Operative Management of Refractory Neuropathic Inguinodynia by a Laparoscopic Retroperitoneal Approach

IMPORTANCE: With the technical success of tension-free inguinal herniorrhaphy, chronic groin pain has far surpassed recurrence as the most common long-term complication. OBJECTIVE: To evaluate laparoscopic triple neurectomy of the ilioinguinal, iliohypogastric, and genitofemoral nerve trunks in the retroperitoneal lumbar plexus for treatment of refractory inguinodynia. DESIGN: Prospective study. SETTING: University hernia center. PARTICIPANTS: Twenty consecutive patients with chronic inguinodynia (14 male; mean age, 46 years; all failing pain management; prior neurectomy in 4 patients) and follow-up to 180 days (minimum, 90 days). MAIN OUTCOMES AND MEASURES: Groin pain (Numeric Rating Scale score), dermatomal mapping, hernia recurrence, histologic confirmation, and complications. RESULTS: There were no intraoperative complications. All patients had histologic confirmation of neurectomy and clinical confirmation with dermatomal mapping. Mean numeric pain scores were significantly decreased (baseline score, 7.8) on postoperative days 1 (score, 2.9; P < .001), 7 (score, 2.2; P < .001), 30 (score, 1.7; P < .001), and 90 (score, 1.9; P < .001). Narcotic dependence decreased and activity level increased. Five patients reported transient hypersensitivity consistent with deafferentation. All had numbness in the distribution of neurectomy without complaint. Four had residual meshoma pain, with 2 undergoing subsequent reoperation to remove mesh. Orchialgia was not improved. CONCLUSIONS AND RELEVANCE: This represents the largest series of laparoscopic retroperitoneal triple neurectomies for treatment of inguinodynia. The rate of successful intervention was better than reported for standard triple neurectomy and open extended triple neurectomy. The procedure allows access proximal to all potential sites of peripheral neuropathy and overcomes many of the limitations of open triple neurectomy. In the absence of recurrence or meshoma, it is the preferred technique for definitive management of chronic inguinal neuralgia.