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, Richard H. Rho, MD Departments of Anesthesiology and Pain Management Reprint requests to: Richard H. Rho, MD, Department of Anesthesiology and Pain Management, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224. Tel: (904) 296-5288; Fax: (904) 296-3877; e-mail: rho.richard@mayo.edu. Search for other works by this author on: Oxford Academic Tim J. Lamer, MD Departments of Anesthesiology and Pain Management Search for other works by this author on: Oxford Academic Jack T. Fulmer, MD General Surgery, Mayo Clinic, Jacksonville, Florida Search for other works by this author on: Oxford Academic
Pain Medicine, Volume 2, Issue 3, September 2001, Pages 230–233, https://doi.org/10.1046/j.1526-4637.2001.01032.x
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07 July 2008
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Richard H. Rho, Tim J. Lamer, Jack T. Fulmer, Treatment of Genitofemoral Neuralgia After Laparoscopic Inguinal Herniorrhaphy With Fluoroscopically Guided Tack Injection, Pain Medicine, Volume 2, Issue 3, September 2001, Pages 230–233, https://doi.org/10.1046/j.1526-4637.2001.01032.x
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Abstract
Objective. This report illustrates that genitofemoral neuralgia can result from laparoscopic inguinal herniorrhaphy and offers a management strategy for this pain syndrome.
Design. A patient experienced pain in the distribution of the genitofemoral nerve after laparoscopic herniorrhaphy. Under fluoroscopy, the point of maximal tenderness was elicited and was found to be at the site of a surgical tack placed during the hernia repair. A genitofemoral nerve block was performed at the site of the surgical tack. This resulted in complete resolution of pain symptoms.
Results. The patient's treatment and recovery are described.
Conclusions. Recognition and proper diagnosis of genitofemoral neuralgia after laparoscopic herniorrhaphy may result in appropriate therapy and hasten recovery.
Genitofemoral Neuralgia, Laparoscopic Inguinal Herniorrhaphy
Case Report
A 48-year-old man with a history of bilateral inguinal herniorrhaphies presented with a recurrent right-sided inguinal hernia. He had no other medical problems and no known drug allergies. The laparoscopic herniorrhaphy was performed using Prolene mesh that was secured with several tacks (Figure 1, A and B). The patient tolerated the procedure well without any apparent complications.
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Figure 1
(A) Longitudinal view of surgical tack. (B) Laparoscopic view of mesh and surgical tack.
Two weeks after the procedure, the patient spontaneously developed severe, intermittent, lancinating pain in the right groin area radiating to the anteromedial proximal thigh. There were no symptoms or signs of infection. The patient noted that lateral bending toward the left and abduction of the right leg worsened the pain. A computed tomography showed postoperative changes with no evidence of recurrent hernia or mass. Treatment with nonsteroidal antiinflammatory drugs, muscle relaxants, and ilioinguinal blocks were unsuccessful. Upon examination, a focal point of tenderness was identified at the inferolateral portion of the pubic rami. This was investigated under fluoroscopy and was found to be directly overlying a surgical tack. Palpation over this site produced a positive Tinel's sign, duplicating the patient's presenting pain. An injection using 2 mL of 0.5% bupivacaine was performed under fluoroscopy at the site of the surgical clip (Figure 2, A and B). The patient was pain free for 2 months after the injection. Then, a repeat injection was performed using 2 mL of 0.25% bupivacaine containing 3 mg betamethasone that resulted in long-lasting pain relief.
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Figure 2
Injection of the genitofemoral nerve at the surgical clip. (A) Anteroposterior view. (B) Lateral view.
Discussion
Genitofemoral neuralgia is a well-known complication after conventional open inguinal herniorrhaphy. Painful nerve entrapment syndromes and postoperative neuromas involving the genital branch of the genitofemoral nerve, the ilioinguinal nerve, or the iliohypogastric nerve occur in an estimated 1–2% of conventional herniorrhaphies [1]. In addition, these neuropathic pain syndromes can occur with laparoscopic herniorrhaphy [2]. This case report illustrates the presentation and successful management of a patient who developed pain in the distribution of the genitofemoral nerve after laparoscopic herniorrhaphy.
The genitofemoral nerve originates from the first and second lumbar nerves (Figure 3). The course of this nerve and its branches are similar in males and females. It traverses the psoas muscle and divides into genital and femoral branches at a variable distance proximal to the inguinal ligament. In males, the genital branch passes through the internal inguinal ring and travels with the spermatic cord to supply motor fibers to the cremaster muscle and sensory fibers to the scrotum. In females, the genital branch accompanies the round ligament to supply innervation to the labia majora [3]. The femoral branch is located caudad and lateral to the genital branch and travels on the anterior surface of the external iliac artery under the inguinal ligament to supply the skin of the mid-anterior thigh [4].
Figure 3
Location, course, and cutaneous innervation of the genitofemoral nerve and its branches. Entrapment of the genitofemoral nerve is shown.
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Laparoscopic repair may pose a greater risk to these nerves than does the conventional repair [2]. In the laparoscopic repair, the prosthetic mesh is affixed to the abdominal wall with tacks, which are placed from the symphysis pubis to the anterior superior iliac spine, potentially jeopardizing all the lumbar plexus nerves. Furthermore, in the conventional repair the nerves at risk are generally visible and can be dissected free and avoided during the sutured repair. In contrast, with the laparoscopic repair the staples are placed preperitoneally and the nerves cannot be seen.
Postoperative neuropathic pain may occur as the result of inflammation, neuroma formation, nerve entrapment, or deafferentation. Injection with local anesthetic plus a corticosteroid may be beneficial in treating postoperative neuropathic pain. Corticosteroid injection may reduce inflammation if present [5]. Perineural corticosteroid application has been demonstrated to suppress the “hyperexcitability of neuromas” and may exert a local anesthetic effect upon the nerve [6]. Finally, the mechanical effect of the local injection on the tissue may help to free up an entrapped nerve.
In a patient with suspected neuropathic pain after laparoscopic hernia repair, local injection can be a valuable therapy. Fluoroscopy can be useful during physical exam and as an aid in performing the injection. In addition to its therapeutic effects, an injection of local anesthetic and corticosteroid may offer important diagnostic information regarding the etiology of the pain. If an injection offers complete but transient relief, surgical removal of the tack or rhizotomy may be indicated [7]. The likelihood of benefit from tack or staple removal needs to be weighed against the possibility of damage to the surgical repair or the nerve during reoperation. Although not a panacea, medical therapies, including the use of antiepileptics, tricyclic antidepressants, systemic local anesthetics, N-methyl-d-aspartate antagonists, and opioids, can be useful in treating neuropathic pain [8].
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Blackwell Science, Inc.
Topic:
- fluoroscopy
- laparoscopy
- neuralgia
- pain
- surgical procedures, operative
- diagnosis
- pain disorder
- inguinal hernia repair
- hernia repair
- genitofemoral nerve
- local anesthetic block of genitofemoral nerve
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Case reports
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