Comparative Study of Preservation versus Elective division of Ileo Inguinal Nerve in Open Repair of Inguinal Hernia.

Transcription

1 International Journal of Current Medical And Applied Sciences.vol.2. Issue: 3, 2014.:14-21 Comparative of reservation versus Elective division of Ileo Inguinal Nerve in Open Repair of Inguinal Hernia. Osman B. Belim *, Nimish J. Shah* & Milind V. atil** *Associate rofessor, **Senior Resident, Department of General Surgery, S.S.G. Medical College & Hospital, Baroda, Gujarat, INDIA. E mail id : drbelim@yahoo.co.in Research Article Subject: General Surgery Abstract: Nerve entrapment is one of the most common causes of chronic pain after inguinal hernia repair. The ilioinguinal nerve is a sensory nerve that innervates the skin over the groin region, the medial aspect of the thigh, the upper part of the scrotum and the penile root. As increasing incidence of chronic neuralgic groin pain has been reported in last 2 decades various studies have been conducted in this concern regarding triple neurectomy, ilioinguinal neurectomy.but, there is no consensus on whether or not to identify and subsequently divide or preserve these three nerves together, or separately, during surgery. This was a prospective study. It was conducted over a period of 8 months from February 2013 to September 2013, at Sir Sayajirao General (S.S.G) Hospital, Vadodara.A total of 126 cases was studied out of which 71 cases with ilioinguinal nerve preservation ( group) 55 cases with elective division of the nerve ( group). Incidence of pain is less in study group compared to control group but it is not statistically significant at 3 month (p =0.82) and at 6 month( p =0.16) Relative risk of incidence of pain in control group is 1.21 at 3 months and 2.74 at six months Mean Severity Score of ain Does not show any Statistically significant difference at 3 months (p=0.19) and at 6 months (p=0.17)there is increased incidence of hypoesthesia in study group but it is not statistically significant at 3 month( p =0.13 )and at 6 month (p=0.93) Relative risk of incidence of hypoesthesia in study group is 0.52 at 3 months and 0.71 at six months There is increased incidence of numbness in study group but it is not statistically significant ( p =0.32 at 3 month and 0.96 at 6 month) Relative risk of incidence of hypoesthesia in study group is 0.60 at 3 months and 0.82 at six months This study showed that pain after open hernia repair with polypropylene mesh is a relevant problem but the overall severity of the pain is less and is unaffected by elective division of the ilioinguinal nerve. Moreover, the transaction of the ilioinguinal nerve was not related to sensory disturbances in the area of distribution of the nerve. Keywords: Ilioinguinal Nerve, Hypoesthesia, Numbness, Inguinal Hernia, ostoperative Groin ain, Neuroectomy Introduction: Of the study of the many operations available in a general surgeon s Armamentarium that of hernia repairs has been written about repeatedly. The rapid changes that have been witnessed in open approach surgeries, prosthetic materials and laparoscopic surgeries has made hernia surgery, a most interesting field of endeavour that demands renewed discipline and dedication. Hernias are among the oldest known afflictions of humankind and surgical repair of inguinal hernias are among the most common general surgical procedures performed today. Despite the high incidence, the technical aspects of hernia repair continue to evolve. Though a variety of procedures are performed, none can be 2014 Logic ublications, IJCMAAS,E-ISSN: ,-ISSN: page I 14

2 Osman B. Belim, Nimish J. Shah & Milind V. atil termed as an ideal procedure, as each one is accompanied by a variety of early and late complications. Recently, with more attention to patient outcomes, chronic groin pain has replaced recurrence as the primary complication after open inguinal hernia repair. Several large series with systematic follow-up have reported pain rates ranging from 29% to 76% [1]. Chronic pain following surgery has emerged as a common, and sometimes severe, problem that can significantly affect a patient s, health-related, quality of life [2]. Treatment is often difficult and challenging. In our institution, inguinal hernia repair is one of the most common surgeriess erformed. Open inguinal hernia repair is the usual procedure that is followed. This study was undertaken to evaluate long term outcomes of neuralgia and araesthesia following routine ilioinguinal nerve excision, compared to nerve preservation when performing Lichtenstein s inguinal hernia repair and to arrive at a conclusion as to the best modality of treatment after comparison of morbidity and patient satisfaction related to these procedures and in relation to standard published material. Material & Methods: This prospective study entitled Comparative study of preservation versus electivee division of Ilio-inguinal nerve in open repair of inguinal Hernia was conducted over a period of 8 months from February 2013 to September 2013, at Sir Sayajirao General (S.S.G) Hospital, Vadodara.rior approval was obtained from The Scientific and Ethical Research Committee, Medical College Baroda, and S.S.G. Hospital Vadodara, In this present study Comparison was done between and group on the basis of ostoperative ain, hypoesthesia and numbness. atient Selection: Inclusion criteria Male atients admitted with uncomplicated inguinal hernia (Direct& Indirect) above 18 years of age and who are willing to give written & informed Consent. Exclusion Criteria: atients with recurrent hernias atients with Diabetes Mellitus atients with past history of Surgery, trauma in inguinal region Randomization: atients were randomly allocated to one of two groups ( & ) using the envelope method. Fig.5: Intra operative picture of right inguinal region showing iliohypogastric nerve & (B) ilioinguinal nerve The Excised segment of Nerve was sent for The data was collected in prescribed ROFORMA Histopathological examination for its Confirmation. where in it contains, particulars of the patient, atients were assessed for ost operative ain, Clinical history, clinical examination and diagnosis, Hypoesthesia, and Numbness at 14 th Day, 1 Month, 3 Relevant investigations, and details of surgery. Month, and 6 Month.ain assessed using Visual Statistical Analysis: Analogue Scale (VAS:0-10). Hypoesthesia and X 2 test was used to assess associations Numbness were assessed using Multiple between different variables and the presence of post Questionnaire and inprick sensationn operative pain; hypoesthesia and numbness Hypoesthesia defined as a partial loss of Rank sum Wilcoxon s test was used to compare the sensitivity to sensory stimuli [11]. mean severity score between control and study Numbness defined as feeling of loss of sensation group. [12]. Logic publications, IJCMAAS E-ISSN: , -ISSN: , Volume: 2 Issue: 3, 2014 age 15

3 International Journal of Current Medical And Applied Sciences.Volume:2, Issue: 3, Observation & Results: A Total of 108 Male atients of uncomplicated inguinal hernia, who underwent Lichtenstein Mesh Hernioplsty, included for this rospective comparative study. 55 out of 108 patients in and 71 of 108 patients in. Out of 108 patients, 18 patients had bilateral hernia and were considered in both groups. Table: 1 : Age At resentation: Age(yrs.) Total No. of atients (%) U/l B/l Total U/l B/l Total U/l B/l Total < (3.7) 0(0) 4(3.7) (12.3) 0(0) 13(12.3) (14.8) 0(0) 16(14.8) (12.9) 6(5.5) 20(18.4) (17.5) 5(4.6) 24(22.1) > (22.2) 7(6.4) 31(28.6) Total (83.3) 18(16.6) 108(100) The patients included in this study belong to age group.youngest patient was 18 years old and eldest was 84 year old. The Incidence of Hernia is higher in above 60 years of age group. Table : 2 Side Of Inguinal Hernia: Site Total Right Left Bilateral Incidence of Right sided Hernia is higher than Left and Bilateral. Table : 3 Mode Of resentation: Total No. of atient Swelling only Swelling With ain Total % of patients presented with both complain Swelling with ain. Table : 4 Type Of Hernia: Total Type Unilateral Bilateral Unilateral Bilateral Unilateral Bilateral Direct Indirect Indirect Hernia is more common in Unilateral Hernia whereas Direct Hernia is more common in Bilateral Hernia. Logic publications, IJCMAAS E-ISSN: , -ISSN: , Volume: 2 Issue:3, 2014

4 Osman B. Belim, Nimish J. Shah & Milind V. atil Table : 5 Incidence Of ost-operative Groin ain: Follow up at Value Relative risk 14th OD 65/71(91.54%) 41/55(74.54%) st Month 27/68(39.70%) 19/54(35.18%) rd Month 12/63(19.04%) 8/51(15.68%) th Month 8/33(24.24%) 3/34(8.82%) Incidence of ost-operative Groin ain does not show statistically significant Difference in and. The relative risk of Incidence of ost-operative Groin ain in is Table : 6 Incidence Of Hypoaesthesia: Follow up at Value Relative risk 14th OD 46/71(64.78%) 38/55(69.09%) st Month 19/68(27.94%) 24/54(44.44%) rd Month 9/63(14.28%) 14/51(27.45%) th Month 4/33(6.34%) 3/34(8.82%) Incidence of Hypoesthesia does not show statistically significant Difference in and. The relative risk of Incidence of Hypoesthesia in is Table : 7 Incidence of Numbness Follow up at Value Relative risk 14th OD 22/71(30.98%) 19/55(34.54%) st Month 18/68(26.41%) 17/54(31.48%) rd Month 9/63(14.28%) 12/51(23.52%) th Month 4/33(12.12%) 5/34(14.70%) Incidence of Numbness does not show statistically significant Difference in and group. The relative risk of Incidence of Numbness in is Table: 8 Mean Severity Score Of ain As er Visual Analogue Score: OD ain Score Mean ± SD ain Score Mean Value 14 th OD ± ± Month ± ± Month ± ± Month ± ± Logic publications, IJCMAAS E-ISSN: , -ISSN: , Volume: 2 Issue: 3, 2014 age 17

5 International Journal of Current Medical And Applied Sciences.Volume:2, Issue: 3, Mean Severity Score of ain Does not shows any statistically significant difference. Discussion: In the present study 108 patients were evaluated for pain, hypoesthesia and numbness. atients were divided in two groups i.e 55 patients and 71, 18 patients had bilateral hernia and included in both groups. The patients were followed up for assessment of pain, hypoesthesia, and numbness at 14 th OD, 1, 3 and 6 months after operation. Results are compared with other Studies. Table: 9 Comparison Of Incidence Of Groin ain With Other Studies: Studies Emad Hokkam et al icchio et al Mui et al resent GROUS Value Value Value Value REO * * * 199/ /371 * * * * * * * 1 ST OD 16/26 15/ * * * * * * * * * 7 th OD * * * 258/ /405 * * * * * * * 14 th OD 12/26 8/ * * * * * * 65/71 41/ Month * * * 196/ / /50 37/50 NS 27/68 19/ Month 8/26 4/ * * * * * * 12/63 8/ month 7/26 2/ / / /50 4/ /33 3/ YEAR * * * 71/302 78/ * * * * * * * = were not evaluated at that Follow-up time. The incidence of pain in immediate pain in and does not show significant difference in Emad Hokkam et al [9] study. In Emad Hokkam et al [9] study and Mui et al [7] studies the incidence of pain decreases with time up to six months and the incidence decrease is statistically significant in both the studies while in icchio et al study no statistically significant decrease is noted in incidence of pain.the present study data also doesn t show significant decrease in pain and correlates with the icchio et al study [6]. The relative risk of incidence of pain in is 1.22 at 14 th OD, 1.12 at 1 month, 1.21 at 3 months and 2.74 at 6 months. Table: 10 Comparison Of ain Severity Scores Assessed by VAS : Emad Hokkam et al resent Follow Up Value Value Time 1 st OD 6.3± ± * * * 14 th OD 5.9± ± ± ± Month * * * 0.51± ± month 3.9± ± ± ± month 2.3± ± ± ± * = were not evaluated at that Follow-up time. The mean pain score in Emad et al [9] study is higher at 1 st OD, 14thOD, 3 month and 6 month, And show statistical significant difference in control and study group except at 1 ST OD. In present study the mean pain severity score is less at all follow up i.e. At 14 th OD, 1month, 3month and 6months.And does not show statistically significant difference. In Mui et al [7] study the severity scores did not show any statistical difference at 1month and sixth months, it shows difference in incidence of groin pain at 6 months. In icchio et al [6] incidence pain and pain severity scores were insignificant in study group and control group. Logic publications, IJCMAAS E-ISSN: , -ISSN: , Volume: 2 Issue:3, 2014

6 Osman B. Belim, Nimish J. Shah & Milind V. atil Table: 11 ain Scores at the Follow-up Visits in icchio et al : Variable 1 Month 6 Months 1 year ain Score Absent 195(50) 184(48) (63) 238(66) (76) 213(73) 0.56 Mild 108(28) 128(34) 89(25) 93(26) 55(18) 60(21) Moderate 66(17) 49(13) 32(9) 21(6) 11(4) 9(3) Severe 22(6) 19(5) 11(3) 6(2) 5(2) 9(3) The icchio et al [6] study did not show statistically difference regarding pain at telephonic follow up ranging (12 months to 65 months). Table: 12 ain Score at Telephone Follow-Up in icchio et al : ain Score [n=391] [n=380] [n=344] value [n=354] [n=334] - Value Absent 262 (76) 249(75) 0.22 Mild 53 (15 67 (20) Moderate 20 (6) 12 (4) Severe 9 (3) 6 (2) [n=358] value [n=302] [n=291] value The present study statistics correlate with icchio et al [6] study statistics Now, for consideration of triple neurectomy, Alferi et al [10] conducted rospective Multicentric of Chronic ain for Influence of reservation Versus Division of Ilioinguinal, Iliohypogastric, and Genital Nerves During Open Mesh Herniorrhaphy. He suggested that the identification and preservation of ilioinguinal nerve, iliohypogastric nerve and genito-femoral nerve decreases the incidence of pain. In this study the 380 hernioplasties with all nerves identified, in 310 patients (81.6%) had all nerves preserved, 10 (2.6%) had all nerves dissected, and the remaining 60 (15.8%) had at least 1 or 2 nerves injured or divided. The overall incidence of pain in this group was 5.5% at 6 months, mild in 16 cases (4.2%) and moderate to severe in 5 cases (1.3%). Briefly, moderate to severe pain occurred in 4 (40%) of 10 hernioplasties with all nerves divided and in 1 (1.7%) of 60 hernioplasties with 1or 2 nerves injured or divided. In none of the cases of hernia repair with all nerves preserved was chronic moderate to severe pain reported. The Higher incidence of post operative groin pain in triple neurectomy patients can be explained by the fact that resection of the nerve has generally been performed distal to its origin, leaving the site of the injured nerve intact to continue to generate the pain signal and exposed to neuroma formation [10]. But when one nerve is excised, there is no significant increase in incidence of pain. The nerve should be cut sharply and as proximal as possible. Table: 13 Comparison Of Incidence Of Hypoesthesia With Other Studies: Studies Emad et al icchio et al Mui Et Al resent s value value value value 1 st OD 2/26 10/ * * * * * * * * * 7 th OD * * * * * * * * * 14 th OD 1/26 8/ * * * * * * 46/71 38/ Month * * * 84/ / /50 26/ /68 24/ Month 1/26 4/ * * * * * * 9/63 14/ Month 1/26 2/ / / /50 21/50 Ns 4/33 3/ Year * * * 13/302 33/ * * * * * * * = were not evaluated at that Follow-up time. Logic publications, IJCMAAS E-ISSN: , -ISSN: , Volume: 2 Issue: 3, 2014 age 19

7 International Journal of Current Medical And Applied Sciences.Volume:2, Issue: 3, The incidence of hypoesthesia in present study does not show statistically significant difference in at 14 th OD, 1 month 3 month and 6 month follow up s. Table : 14 Comparison Of Incidence Of Numbness With Other Studies: Studies icchio Et Al Mui Et Al resent s Value Value Value 14 th OD * * * * * * 22/71 19/ Month 46/391 54/ /50 9/ /68 17/ Month * * * * * * 9/63 12/ Month * * * * * * 4/33 5/ Year 17/302 11/ * * * * * * * = were not evaluated at that Follow-up time. Incidence of numbness in study group in nerve is statistically insignificant and correlates with previous studies. We found no evidence to support the benefit of ilioinguinal nerve division with respect to post operative pain within the limitation of a small sample size. Our data confirm that ilioinguinal nerve division does not affect postoperative pain after mesh repair of the inguinal hernia. In particular, considering the primary end point of our study, after 6 month there was no difference in the rates of patients free from pain in both groups, and the 95% Confidence Interval for the difference was so low that it is was without clinical importance. After repair, sensory changes are common. In the study by Ravichandran et al [5], loss of Sensation in the territory supplied by the ilioinguinal nerve occurred in 40% to 45% of patients when the nerve was divided and in 5% to 25% of cases when it was preserved after 6 months. Our data confirm that elective transection of the ilioinguinal nerve leads to relative increase in the proportion of patients who complain of numbness in the post-operative period with respect to those with preserved nerve. But these data was statistically insignificant at all follow-up visits. In conclusion, our study showed that pain after open hernia repair with polypropylene mesh is a relevant problem but the overall severity of the pain is less and is unaffected by elective division of the ilioinguinal nerve. Moreover, the transection of the ilioinguinal nerve was not related to sensory disturbances in the area of distribution of the nerve. But compared to previous similar studies in which results show ain incidence in study group and control group was statistically insignificant but there was a statistically significant difference in incidence of sensory disturbances like hypaesthesia and numbness, which is higher in elective division of nerve group. These fallacies in our study can be explained by much smaller sample size than other studies and higher drop-out rates at 6 month of follow-up. Limitations of : The sample size was this study was relatively small The duration of follow up was short hence long term results could not be commented upon The surgeries in this study was not carried out by the same surgical team instead they were carried out under 7 surgical units operating at S.S.G. hospital. References: 1. Janu G, Sellers KD, Mangiante EC. Recurrent inguinal hernia. referred Operative approach. Am Surg 1998; 64: Nienhuijs SW, Van Oort I, Keemers-Gel s M. Randomized trial comparing the rolene Hernia System, mesh plug repair and Lichenstein method for openinguinal hernia repair. Br J Surg 2005;92(1): Amid K. Causes, prevention and surgical treatment of postherniorrhaphy neuropathic inguinodynia: Triple neurectomy Logic publications, IJCMAAS E-ISSN: , -ISSN: , Volume: 2 Issue:3, 2014

8 Osman B. Belim, Nimish J. Shah & Milind V. atil 4. Wantz GE. Complications of inguinal hernia repair. Surg,Clin North Am1984;64: Ravichandran D, Kalambe BG, ain JA. ilot randomized controlled study of preservation or division of ilioinguinal nerve in open mesh repair of Inguinal hernia.british Journal of Surgery 2000;87: icchio M, alimento D, Attanasio U, Matarazzo F, Bambini C, Caliendo A. Randomized controlled trial of preservation or elective division of ilioinguinal nerve on open inguinal hernia repair with polypropylene mesh. ArchSurg 2004;139: Mui WL, Ng CS, Fung TM, Cheung FK, Wong CM, Ma THet al. rophylactic ilioinguinal neurectomy in open inguinal hernia repair: a double-blind randomized controlled trial.ann Surg2006;244: Mohamed G. Ibrahim, Wagdy I Fayed, Khaled E. Soliman, Alaa M. Hamza A Randomized led To Compare The Effect of Ilio- Inguinal Neurectomy or reservation of The Ilio-Inguinal Nerve in Lichtenstein Tension Free Hernioplsty For Inguinal Hernia Medical Research Institute, Alexandria. University. Journal of the Medical Research Institute JMRI 2006; Vol. 27 No.4: (283-8) 9. Hokkam E, The Effect Of Ilioinguinal Neurectomy In Elective Inguinal Hernia Repair On Chronic ostoperative ain. Egypt Journal of Surgery October,2009 Vol. 28, No. 4, Alfieri S, Rotondi F, Di Giorgio A, Fumagalli U, Salzano A, Di Miceli D et al. Influence of preservation versus division of ilioinguinal, iliohypogastric, and genital nerves during open mesh herniorrhaphy: prospective multicentric study of chronic pain. Ann Surg2006;243: com/hypoesthesia com/numbness Logic publications, IJCMAAS E-ISSN: , -ISSN: , Volume: 2 Issue: 3, 2014 age 21