Erratum to: Questioning the favorable influence of nerve identification during open inguinal herniorrhaphy is misleading and may increase the risk of surgeons’ liability

Abstract

It was with great interest that we read the manuscript ‘‘Does nerve identification during open inguinal herniorrhaphy reduce the risk of persistent pain?’’ The question is both a worthy and challenging one and remains one of the most important issues in inguinal hernia repair. This study’s main aim was to correlate intraoperative nerve identification with the risk of nerve damage at 6 months assessed both subjectively and objectively. The authors are to be commended for their work and sound methodology including the use of quantitative sensory testing to help provide some measure of objective data to a complex condition that has primarily been subjectively defined. They report that in their prospective series of 244 patients, despite a high rate of nerve identification, there are still significant signs of nerve damage postoperatively and a risk of persistent pain. Thirty-nine patients (16.0 %) had substantial pain-related functional impairment at 6-month follow-up. They conclude that ‘‘intraoperative nerve identification had no influence on sensory loss in the groin, persistent pain or improvement in functional ability 6 months after surgery.’’ While the data and conclusions presented are accurate in the context of this series, there are several confounding variables and their conclusions regarding intraoperative nerve identification are not necessarily consistent with current evidence and recommendations for best available practice. The main conclusion that chronic pain and nerve injury persist despite a high rate of nerve identification is limited by a low rate of identification of the genital branch of the genitofemoral nerve. Failure to reliably identify anything less than all three nerves renders the findings inconclusive at best, and it would be misleading to conclude that nerve identification does not decrease rates of pain in routine practice. In order to draw a conclusion that contradicts the best available evidence, the design and data of the study must be supportive. The reported 16 % rate of persistent pain with proper nerve identification is higher than that reported in the literature [1, 2]. This may be a function of the time point measured, definitions used, low rates of identification of the genital nerve, the use of heavyweight mesh, or improper nerve handling. These variables illustrate the challenges faced by all investigators seeking to define best available technique and practice with regard to the prevention of chronic pain. It is well known to hernia surgeons that chronic pain has a multifactorial etiology and may develop after hernia operations despite careful handling of nerves and meticulous surgical technique [1, 3–5]. In 2008, the International Consensus Conference was held in Rome with a working group of nine hernia experts and an audience of 200 participants—a group well known to both the authors of this manuscript and the reviewers. This was a culmination of a yearlong review of the best available evidence-based literature with a goal to reach a consensus on several issues related to the prevention and management of chronic pain. While not every answer could be reached with consensus, the issue of nerve identification was well established [1]. Two published studies reporting the results of the role of the identification of all three inguinal nerves (2,305 cases all together) with a long follow-up period (ranging from 1 to 5 years) concluded that identification and preservation D. C. Chen (&) P. K. Amid Division of General Surgery, Lichtenstein Amid Hernia Clinic at UCLA, David Geffen School of Medicine at UCLA, 1304 15th Street, Suite 213, Santa Monica, CA 90404, USA e-mail: dcchen@mednet.ucla.edu