Inguinal hernia repair is one of the most routinely performed surgical procedures worldwide, with more than 900,000 surgeries performed each year [1]. It forms a large proportion of general surgical activity and is still evolving with improvements in surgical procedures and materials. Among the several surgical techniques, the tension-free Lichtenstein technique (LT) has been the gold standard for inguinal hernia repair for several decades because of its safety, simplicity, and low recurrence rates [2,3]. In this approach, strengthening of the posterior wall of the inguinal canal with a synthetic mesh has greatly reduced the recurrence rate compared to the usual tissue-based repairs.Lichtenstein repair is widely accepted and successful but not free of difficulties. Chronic groin pain is one of the most critical and problematic surgical consequences and it can considerably impact the patient’s quality of life [4]. Some studies estimated the incidence of prolonged postoperative discomfort after inguinal hernia surgery to be as high as 63% [4]. This pain can continue for months or years after the operation and be so severe that it interferes with everyday activities, occupational performance and general well-being [6,7]. Chronic groin pain is generally refractory to conventional analgesics and may require further procedures including nerve blocks or possibly re-operation [8].

The pathogenesis of persistent groin pain after inguinal hernia repair is multifaceted, with nerve damage being one of the most important reasons. During open mesh repair, nerves in the inguinal area are at risk of injury from dissection, traction, entrapment in sutures, or mesh-related fibrosis, especially the ilioinguinal nerve [5,8]. The ilioinguinal nerve delivers sensation to the groin, upper medial thigh and external genitalia and is therefore particularly relevant in post-operative pain disorders. Irritation or damage to this nerve can lead to neuropathic pain, typically chronic and difficult to treat.Historically, the surgical education has stressed the preservation of the ilioinguinal nerve in hernia surgery to prevent sensory loss and possible neuralgia [9]. Preservation is keeping normal sensory function and avoiding consequences like numbness or dysesthesia. However, newer studies have questioned this strategy, claiming that preventive ilioinguinal neurectomy, the purposeful removal of the nerve during surgery, can decrease the risk of chronic postoperative pain [10]. This is based on the concept that by eliminating the nerve, the risk of entrapment or injury is removed and the development of neuropathic pain prevented.

Many research have reported inconsistent findings on the issue of ilioinguinal nerve preservation versus neurectomy. Some investigations supported nerve preservation, stressing the necessity of normal sensory function and reducing problems connected to nerve excision [9]. In contrast, several studies have shown that prophylactic neurectomy is associated with a significantly decreased incidence of chronic pain without any functional impairment or reduction in quality of life [10,12]. For example, ilioinguinal neurectomy has been reported to leave up to 80% of the patients free from persistent pain after surgery [11]. Similarly, other studies have demonstrated that 96.7% of patients had either minimal or no pain after neurectomy, compared to lower percentages in nerve preservation groups [13].Evidence further suggests that patients receiving nerve preservation can nevertheless experience various degrees of postoperative discomfort. In one study, 36.4% of patients in the nerve preservation group had minor discomfort and 35% had no pain, while patients receiving neurectomy had significantly better outcomes with a greater proportion reporting no pain [14]. In addition, comparative investigations have shown that incidence and severity of pain is higher in the nerve preservation groups than in the neurectomy groups, which supports the potential benefits of preventive nerve excision [18].

Chronic postoperative pain is not only a source of dissatisfaction for the patient but also increases the healthcare burden due to additional therapies and extended recovery. Therefore, it is very important to find an appropriate technique to reduce postoperative discomfort. Prophylactic ilioinguinal neurectomy is a straightforward and successful variation of the normal Lichtenstein procedure and may greatly reduce the occurrence of chronic groin pain [10,12]. Moreover, the sensation loss after neurectomy has been found to be well tolerated in general and does not significantly influence the patient's quality of life [18].Despite the expanding evidence, there is still no consensus about the routine use of ilioinguinal neurectomy in the repair of inguinal hernia. Inconsistent findings have resulted from variability in study designs, patient groups and outcome measures. Furthermore, there is a dearth of recent local evidence on the efficiency of ilioinguinal neurectomy versus nerve preservation in lowering post-operative pain.
This study was designed to assess the degree of postoperative discomfort after ilioinguinal neurectomy versus ilioinguinal nerve preservation after open mesh repair for inguinal hernia. The purpose is to give updated information from local patient data and help guide surgical practice by finding the more effective strategy in minimizing postoperative pain and increasing patient outcome.

 

This randomized controlled experiment was conducted in surgical wards of Lady Reading Hospital, Peshawar for a period of six months from 18th October 2018 to 18th April 2019. A total of 116 individuals with inguinal hernia scheduled for elective open mesh treatment were included in the study. The patients were enrolled after a full clinical assessment which included extensive history, physical examination and regular pre-operative baseline investigations to confirm the diagnosis and to determine the fitness for surgery. Patients were randomly placed into two equal groups of 58 patients each. Group A: Patients who received preventive ilioinguinal neurectomy during open mesh repair Group B: Patients in which the ilioinguinal nerve was detected and preserved during the operation All procedures were performed under proper anesthesia, all using the usual Lichtenstein tension-free mesh repair approach. The surgical method was similar in both groups except for ilioinguinal nerve treatment. All patients were preoperatively assessed for fitness for anesthesia and optimized as appropriate. The inguinal canal was exposed during the operation and the hernia sac was treated according to normal surgical techniques. In Group A the ilioinguinal nerve was found and removed while in Group B it was carefully kept to avoid harm. In all patients the mesh was put over the posterior wall of the inguinal canal and was secured in a suitable way. All patients were followed up post operatively in the surgical ward for a duration of two days. Standard postoperative care was provided for all patients; this included analgesia and wound care. Patients were discharged when clinically stable and able to ambulate without difficulties. All patients were evaluated at the end of first month of post surgery period and follow up was done at regular intervals. The major outcome measure was the level of postoperative pain assessed by Visual Analogue Scale (VAS). Pain scores between 0-3 were deemed as successful pain management and scores between 4-10 were classified as ineffective pain relief. Patients who failed to complete the follow-up period were eliminated from the final analysis. The obtained data were thoroughly registered and evaluated for comparison of the postoperative pain result between both groups in order to determine the efficiency of ilioinguinal neurectomy versus nerve preservation in reduction of chronic groin pain following inguinal hernia repair.