(222) Treatment of Genitofemoral Neuralgia After Laparoscopic Inguinal Herniorrhaphy with Fluoroscopically-Guided Tack Injection

Abstract

Nerve entrapment syndromes involving the genital branch of the genitofemoral nerve, the ilioinguinal nerve, or the iliohypogastric nerve occur in an estimated 1–2% of conventional, open herniorrhaphies [3], and can also occur with laparoscopic herniorrhaphies [1]. A 48-year-old man with a recurrent right-sided inguinal hernia underwent a laparoscopic hernia repair using Prolene mesh and titanium tacks. Two weeks post-operatively, the patient spontaneously developed severe, intermittent, lancinating pain in a genitofemoral nerve distribution. Infection and recurrent hernia were ruled out. Treatment with non-steroidal anti-inflammatory drugs, muscle relaxants and ilioinguinal nerve blocks using traditional anatomic landmarks were unsuccessful. A focal point of tenderness at the inferolateral portion of the pubic ramus was investigated under fluoroscopy and was found to be directly overlying a surgical tack. Palpation over this site produced a Tinel's sign reproducing the patient's pain. A diagnostic injection using local anesthetic was performed at this site. The patient was pain-free for two months following the injection. When the pain returned, the injection was repeated using local anesthetic with corticosteroid, using the same fluoroscopically-guided technique. The patient has been asymptomatic since that time. Laparoscopic hernia repair may pose increased risk of nerve injury than conventional hernia repair [1]. With a conventional repair the nerves at risk are generally visible and may be dissected free, thus avoiding nerve injury. In contrast, with the laparoscopic repair the staples are placed preperitoneally and the nerves cannot be visualized. In a patient with suspected nerve entrapment syndrome following laparoscopic hernia repair, injection therapy may be effective treatment. As illustrated in this paper, fluoroscopy can be useful during physical exam and as an aid in localizing and for performing the injection. If an injection offers significant but transient relief, surgical removal of the staple or neurectomy at a site proximal to the lesion may be indicated [2].