Femoral nerve palsy following laparoscopic inguinal herniorrhaphy

Iatrogenic femoral nerve injuries: Analysis of medico-legal issues through a scoping review approach

Purpose

Accidental femoral nerve injury is a well-known iatrogenic complication of orthopaedic, abdominal, and pelvic surgery. Because of the largely transitory nature of the symptoms associated with nerve damage, its true incidence is in all likelihood underestimated. This work aims to illustrate the surgical contexts within which this nerve injury is reported, based on the evidence obtained from a Scoping Review of the literature of the last 20 years, with specific reference to the underlying etiopathogenetic mechanisms and prognostic outcomes, to highlight the evaluation issues of medico-legal interest related to this pathology.

Methods

We conducted a Scoping Review of iatrogenic femoral nerve injuries reported between 2000 and 2021 by searching the electronic databases Pubmed, Scopus, Ovid Medline, Ovid Emcare, and Web of Science.We conducted the review according to the five-step methodology outlined by Arksey and O'Malley.

Results

The literature search identified 104 papers, including case reports, case series, and retrospective studies. Surgical contexts within which iatrogenic femoral nerve injuries were reported include orthopaedic, abdominal, gynaecological, urological, vascular, and plastic surgery, as well as locoregional anaesthesiological procedures. The long-term prognosis was generally favourable.

Conclusions

Because of its frequent iatrogenic genesis, femoral nerve injury is a topic of intense medico-legal interest. From the perspective of estimating the patient's disability, the mostly favourable nature of the prognosis makes the medico-legal assessment, in some respects, complex, thus requiring a precise evaluation methodology.

Current trends in the diagnosis and management of post-herniorraphy chronic groin pain

Inguinodynia (chronic groin pain) is one of the recognised complications of the commonly performed Lichtenstein mesh inguinal hernia repair. This has major impact on quality of life in a significant proportion of patients. The pain is classified as neuropathic and non-neuropathic related to nerve damage and to the mesh, respectively. Correct diagnosis of this problem is relatively difficult. A thorough history and clinical examination are essential, as is a good knowledge of the groin nerve distribution. In spite of the common nature of the problem, the literature evidence is limited. In this paper we discuss the diagnostic tools and treatment options, both non-surgical and surgical. In addition, we discuss the criteria for surgical intervention and its optimal timing.

Treatment Concepts for Idiopathic and Iatrogenic Femoral Nerve Mononeuropathy

Femoral mononeuropathy has many etiologies and is often quite disabling, causing lower extremity paresthesia, anesthesia, pain, or paresis. Despite its morbidity, few therapies have been described to treat the femoral nerve palsy that does not resolve with conservative management or that is refractory to physical therapy. In this report, we present 3 cases of femoral nerve palsy; one as a complication of local nerve block, one as a complication of laparotomy, and one of idiopathic origin. In each case, symptomatic and objective improvement was achieved with femoral neurolysis. We suggest guidelines for the management of those patients who fail to respond to conservative therapy and indications for surgical intervention.

The femoral nerve in the repair of inguinal hernia: well worth remembering

Injury to the nerves after inguinal hernia surgery is uncommon. The femoral nerve may be damaged by suture or staples, tissue scar entrapment, local anesthesia blockade or direct compression. We present a case of a transient lesion of the femoral nerve after mesh hernioplasty for a re-recurrent inguinal hernia, confirmed by radiological studies, electrophysiology and clinical recovery. The diagnosis, mechanism of injury and surgical approach are reviewed. Surgery to a recurrent hernia may be underestimated. The role of electromyography nerve conducting studies is emphasized insisting on the importance of clinical evolution for the successful management of these infrequent injuries.

The role of knee immobilizers in cancer patients with femoral neuropathy

OBJECTIVE

To determine the utility of knee immobilizers for cancer patients with femoral neuropathy.

DESIGN

Retrospective case series with chart reviews and telephone interviews.

SETTING

Teaching hospital, inpatient setting, and 1-year follow-up as outpatients.

PARTICIPANTS

Five cancer patients with femoral neuropathy (4 men, 1 woman; age range, 51-76 y). Inclusion criteria were (1) diagnosis of femoral neuropathy, (2) receipt of knee immobilizer as an inpatient, and (3) ability to discuss opinions about knee orthotics at 1-year follow-up.

INTERVENTION

Knee immobilizer. Main outcome measures Number of falls with and without knee immobilizer, ambulatory distance with and without immobilizer, subjective rating of activity level, and feeling of stability with and without immobilizer.

RESULTS

Patients reported that the knee immobilizer reduced their number of falls by up to 10-fold, increased ambulatory distance between 105 and 420 ft (31.5 and 126 m), improved their feeling of stability, and increased overall activity levels.

CONCLUSIONS

Patients can benefit from knee immobilizers during their rehabilitation efforts: risk of falls decreased, ambulation distance increased, and relative peace of mind was achieved with the orthotic's use.

History of treatment of groin hernia

The history of open surgery for groin hernia has gone through many stages of development, including the ancient era (ancient times to the fifteenth century), the era of the start of herniology (fifteenth to seventeenth centuries), the anatomic era (seventeenth to nineteenth centuries), the era of repair under tension (nineteenth to mid-twentieth century), and the era of tensionless repair (mid-twentieth century to the present). Five principles of modern hernia repair developed through these periods of development: antiseptic/aseptic hernia operation, high ligation of the sac, tightening of the internal ring, reconstruction of the posterior inguinal floor, and tensionless repair. Interestingly, many of the initial attempts at laparoscopic hernia repair did not adhere to the recognized principles of hernia surgery learned from open surgery. It is only when the transabdominal preperitoneal mesh repair and the totally extraperitoneal approach, which adhere to the basic principles, are considered that the results of laparoscopic hernia repair procedures can improve and the recurrence of hernia decrease.

Embryology, anatomy, and surgical applications of the preperitoneal space

The preperitoneal space is presented from an embryologic, anatomic, and surgical standpoint in detail. Because this space is one of the most used areas for the repair of groin hernias, knowledge of its embryology and anatomy is essential.

Laparoscopic extraperitoneal herniorrhaphy

Laparoscopic extraperitoneal (LEP) herniorrhaphy procedures allow direct visualization and repair of many types of hernias (e.g., direct, indirect, femoral, sliding, bilateral). Common complications of open herniorrhaphy procedures are avoided when LEP herniorrhaphy procedures are used because the peritoneum is not entered. The placement of synthetic mesh in the preperitoneal space during LEP herniorrhaphy procedures prevents inadvertent contact with peritoneal contents and minimizes patients' risks of adhesions, bowel obstructions, fistulas, and intraabdominal vascular injuries. Improved anatomic presentation and optimal patient outcomes are achieved with this approach.