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.

The study comprised a total of 116 patients and they were separated into two equal groups i.e. Group A (ilioinguinal neurectomy) and Group B (ilioinguinal nerve preservation) with 58 participants in each group . The results are provided in the tables below.

Table 1: Age Distribution of Patients (n=116)

The majority of patients in both groups were between 31–50 years of age.

Table 2: Gender Distribution (n=116)

Male patients were predominant in both groups.

Table 3: Body Mass Index (BMI) Distribution (n=116)

Both groups had comparable BMI distribution.

Table 4: Type of Inguinal Hernia (n=116)

Indirect inguinal hernia was more common in both groups.

Table 5: Postoperative Pain (VAS Score at 1 Month) (n=116)

Effective pain relief (VAS 0–3) was observed in 90% of patients in Group A compared to 73% in Group B, showing better outcomes with ilioinguinal neurectomy.

The findings showed that compared to individuals whose ilioinguinal nerve was preserved, those who received ilioinguinal neurectomy had noticeably improved postoperative pain outcomes. At a one-month follow-up, a greater percentage of patients in the neurectomy group reported no or minimal discomfort, demonstrating the efficacy of preventative ilioinguinal nerve excision in lowering postoperative groin pain.

Inguinal hernia repair is one of the most commonly performed surgical operations. Although the Lichtenstein tension-free mesh repair approach has dramatically reduced the recurrence rates, the chronic postoperative groin pain remains a serious concern [2–4]. The present study was done to examine the efficacy of prophylactic ilioinguinal neurectomy against preservation of ilioinguinal nerve in minimizing the post surgical discomfort. The results of the present study suggest that ilioinguinal neurectomy provides greater post-operative pain alleviation compared to nerve preservation. The average age of patients in Group A (neurectomy) was 33±11.78 years and in Group B (nerve preservation) was 35±12.91 years. Most of the patients in both groups were between 31 and 50 years of age. These findings are similar to earlier studies findings that have indicated inguinal hernia is commonly seen in people of similar age [15]. Significant male preponderance was also noted in both groups, with 88% men in Group A and 90% males in Group B. This is consistent with the known epidemiological trend of inguinal hernia, which is more prevalent in men for anatomical and physiological reasons [1,2]. The primary outcome was postoperative pain at one month measured by the visual analogue scale (VAS). In the neurectomy group, 90% of the patients experienced no or minimal discomfort compared to 73% of patients in the nerve preservation group. This demonstrates significant improvement in postoperative pain alleviation in patients following ilioinguinal neurectomy. These results are consistent with earlier studies that have indicated better pain outcomes with preventive neurectomy. Joshi et al. have found that more patients were free of chronic pain after ilioinguinal neurectomy than those with nerve preservation [15]. In agreement, Gupta et al. reported effective pain relief on 96.7% of patients in the neurectomy group, which also supports the importance of nerve excision in decreasing postoperative problems [16]. Similarly, Nasir et al. found superior pain results in patients who underwent neurectomy with a higher percentage of patients reporting no pain compared to the nerve preservation group [17]. The consistency of these results between the trials further supports the usefulness of ilioinguinal neurectomy in reducing postoperative groin discomfort. Chronic groin discomfort after inguinal hernia surgery is commonly caused by nerve injury, trapping or irritation after surgical dissection or mesh installation [5,8]. The ilioinguinal nerve, if preserved, may be predisposed to these issues, resulting in neuropathic pain that is often difficult to treat. Prophylactic neurectomy, on the other hand, eliminates the danger of nerve entrapment and subsequent neuralgia and may explain the superior outcomes noted in this study and others [10,12].Another aspect is the concern of sensory loss after removal of the ilioinguinal nerve. Traditional surgical instruction has stressed the maintenance of nerve to prevent hypoesthesia and its associated consequences [9]. However, new evidence suggests that the sensory loss after neurectomy is in most cases limited and well tolerated by patients with no substantial effect on quality of life [18]. Sangolagi et al. noted that hypoesthesia may occur but does not add much to patient morbidity and is balanced by the benefits of reduced post-operative discomfort [18]. The present study’s findings add to the increasing body of data that preventive ilioinguinal neurectomy is a useful technique for reducing persistent postoperative pain. The considerable difference in pain outcomes between the two groups emphasizes the potential of neurectomy to increase patient satisfaction and functional recovery. Given that chronic groin pain can result in prolonged disability and increased healthcare utilization, strategies that limit this consequence are of substantial therapeutic value.These results notwithstanding, some publications still promote nerve preservation and suggest that the decision should be personalized according to the features of the patient and the expertise of the surgeon [9]. Differences in findings among studies may be related to differences in surgical technique, patient selection, and methods of pain evaluation. Thus, further large-scale investigations are needed to develop definitive criteria. In conclusion, the results of this study are consistent with the current literature and suggest that ilioinguinal neurectomy is superior to nerve preservation in lowering postoperative discomfort following open mesh repair for inguinal hernia.

The authors of the present study conclude that prophylactic ilioinguinal neurectomy is superior to ilioinguinal nerve preservation in minimizing postoperative groin discomfort after open mesh (Lichtenstein) surgery of inguinal hernia. At one month, a considerably greater proportion of patients in the neurectomy group reported effective pain relief compared with those in whom the nerve was retained.The ilioinguinal neurectomy may be considered a useful modification of the usual surgical method given the effect of prolonged postoperative pain on patient quality of life and rehabilitation. It provides better postoperative comfort without any notable increase in morbidity. Routine ilioinguinal neurectomy may be indicated as the preferred option for open mesh repair for inguinal hernia to get improved pain outcomes.

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