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Benes M, Zido M, Machac P, Kaiser R, Khadanovich A, Nemcova S, Kunc V, Kachlik D. Variations of the extrapsoas course of the lumbar plexus with implications for the lateral transpsoas approach to the lumbar spine: a cadaveric study. Acta Neurochir (Wien) 2024; 166:319. [PMID: 39093448 PMCID: PMC11297108 DOI: 10.1007/s00701-024-06216-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 07/24/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Together with an increased interest in minimally invasive lateral transpsoas approach to the lumbar spine goes a demand for detailed anatomical descriptions of the lumbar plexus. Although definitions of safe zones and essential descriptions of topographical anatomy have been presented in several studies, the existing literature expects standard appearance of the neural structures. Therefore, the aim of this study was to investigate the variability of the extrapsoas portion of the lumbar plexus in regard to the lateral transpsoas approach. METHODS A total of 260 lumbar regions from embalmed cadavers were utilized in this study. The specimens were dissected as per protocol and all nerves from the lumbar plexus were morphologically evaluated. RESULTS The most common variation of the iliohypogastric and ilioinguinal nerves was fusion of these two nerves (9.6%). Nearly in the half of the cases (48.1%) the genitofemoral nerve left the psoas major muscle already divided into the femoral and genital branches. The lateral femoral cutaneous nerve was the least variable one as it resembled its normal morphology in 95.0% of cases. Regarding the variant origins of the femoral nerve, there was a low formation outside the psoas major muscle in 3.8% of cases. The obturator nerve was not variable at its emergence point but frequently branched (40.4%) before entering the obturator canal. In addition to the proper femoral and obturator nerves, accessory nerves were present in 12.3% and 9.2% of cases, respectively. CONCLUSION Nerves of the lumbar plexus frequently show atypical anatomy outside the psoas major muscle. The presented study provides a compendious information source of the possibly encountered neural variations during retroperitoneal access to different segments of the lumbar spine.
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Affiliation(s)
- Michal Benes
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Michal Zido
- Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Neurology, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Petr Machac
- Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Traumatology, University of Szeged, Szeged, Hungary
| | - Radek Kaiser
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic
- Spinal Surgery Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anhelina Khadanovich
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Simona Nemcova
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Vojtech Kunc
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic
- Research Centre, Faculty of Health Studies, Jan Evangelista Purkyne University in Usti Nad Labem, Usti Nad Labem, Czech Republic
| | - David Kachlik
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
- Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic.
- Department of Health Care Studies, College of Polytechnics, Jihlava, Czech Republic.
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Sarıkaya EA, Şen V, Yörükoğlu K, Bozkurt O. Low-cord orchidectomy for testicular cancer: what would be different? World J Urol 2024; 42:421. [PMID: 39028341 PMCID: PMC11271407 DOI: 10.1007/s00345-024-05118-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 06/05/2024] [Indexed: 07/20/2024] Open
Abstract
INTRODUCTION High cord radical orchidectomy (HRCO) is accepted as the standard surgical approach in testicular cancer, however low cord orchidectomy (LCRO) can reduce the morbidity of operation without worsening the oncological outcomes. METHODS We retrospectively re-examined the specimens of men to determine the level of spermatic cord invasion (SCI). Men who had proximal SCI with negative surgical margins after HRCO were assumed to have de-novo residual tumour if LCRO was performed. Others were assumed as oncologically similar. We examined the relation between pre-operative variables and SCI and proximal SCI to determine whether prediction of proximal SCI is possible. RESULTS 196 patients were included. 22 (11%) had SCI and ten (5%) had proximal SCI. Four patients with proximal SCI had positive surgical margins even after HRCO and didn't require additional local treatment. Six patients were assumed to have de-novo residual tumour if LCRO was performed. All six patients were metastatic and had systemic chemotherapy. High platelet count, tumour size, N stage, S stage and M stage were all significantly related with both SCI and proximal SCI (p < 0.05). CONCLUSION Due to low probability of SCI, we think LCRO can safely be performed to reduce morbidity in Stage 1 patients. Although there is a risk for residual tumour in Stage 2-3 patients, currently there is no data that residual tumour would impair the success of systemic chemotherapy. Therefore we can not assume that these patients would be negatively affected. Pre-operative data can be useful to predict the presence of proximal SCI and select appropriate patients for LCRO.
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Affiliation(s)
- Ege A Sarıkaya
- Department of Urology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey.
| | - Volkan Şen
- Department of Urology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Kutsal Yörükoğlu
- Department of Pathology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Ozan Bozkurt
- Department of Urology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
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Sahoo S, Kumar KP, Narayan RK. Genitofemoral Nerve Variation: An Attempt to Explain the Embryological Basis via a Case Report. Cureus 2024; 16:e61763. [PMID: 38975486 PMCID: PMC11226732 DOI: 10.7759/cureus.61763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2024] [Indexed: 07/09/2024] Open
Abstract
The genitofemoral nerve (GFN) presents with a variable course in nearly half of the population. This variation can be seen in its availability, course, and branching. Here, a notable case during a cadaveric dissection revealed an unusually high bifurcation of the GFN on the left side, contrasting with the typical bifurcation observed on the right. This divergence was highlighted using colored markers to aid educational visualization, facilitating a comprehensive learning experience about the nerve's variability and its functional implications, such as the cremasteric reflex. Embryologically, these variations stem from the migratory paths of myotomes during development, influenced by extrinsic signals and growth factors. Despite the high incidence of anatomical variability, the muscular structure remains consistent, suggesting that the nerve's formation is more susceptible to developmental shifts than the muscles it innervates. Clinically, understanding GFN variations is crucial due to the nerve's involvement in conditions like genitofemoral neuropathy, which can arise from surgical procedures. Accurate knowledge of these variations aids in precise diagnostic and therapeutic interventions, reducing complications, and enhancing patient outcomes in lower abdominal and groin surgeries. However, further research is needed to elucidate the exact embryological and genetic underpinnings of these variations.
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Affiliation(s)
- Sanjukta Sahoo
- Anatomy, All India Institute of Medical Sciences, Bhubaneswar, IND
| | | | - Ravi K Narayan
- Anatomy, All India Institute of Medical Sciences, Bhubaneswar, IND
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Lee HN, Cho Y, Park SJ, Lee S, Heo NH. Reply to Letter to the Editor: "Ultrasound-guided genitofemoral nerve block for femoral arterial access gain and closure: a randomized controlled trial". Eur Radiol 2024; 34:1135-1136. [PMID: 37897533 DOI: 10.1007/s00330-023-10375-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 10/07/2023] [Accepted: 10/11/2023] [Indexed: 10/30/2023]
Affiliation(s)
- Hyoung Nam Lee
- Department of Radiology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea.
| | - Youngjong Cho
- Department of Radiology, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung, Korea
| | - Sung-Joon Park
- Department of Radiology, Korea University College of Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Sangjoon Lee
- Vascular Center, The Eutteum Orthopedic Surgery Hospital, Paju, Korea
| | - Nam Hun Heo
- Clinical Trial Center, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
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Barik AK, Mohanty CR, Radhakrishnan RV, Patel RK, Shaji IM. Letter to the Editor: "Ultrasound-guided genitofemoral nerve block for femoral arterial access gain and closure: a randomized controlled trial". Eur Radiol 2024; 34:1132-1134. [PMID: 37930410 DOI: 10.1007/s00330-023-10374-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 08/26/2023] [Accepted: 10/11/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Amiya Kumar Barik
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Chitta Ranjan Mohanty
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhubaneswar, India.
| | | | - Ranjan Kumar Patel
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Ijas Muhammed Shaji
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhubaneswar, India
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Gutiérrez Carrillo G, Garcia Sanz M, de Arriba Alonso M, Gutiérrez Fernandez A, Alonso Prieto MÁ. Robot-assisted laparoscopic triple neurectomy for chronic inguinal pain: Description of the technique, our experience and preliminary results. Actas Urol Esp 2023; 47:605-610. [PMID: 37207986 DOI: 10.1016/j.acuroe.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/28/2023] [Accepted: 03/10/2023] [Indexed: 05/21/2023]
Abstract
INTRODUCTION Chronic inguinal pain or inguinodynia following hernioplasty is a relatively common complication that can be very incapacitating. Surgical treatment by triple neurectomy is a therapeutic option when previous treatments (oral/local therapy or neuromodulation) have failed. OBJECTIVE Retrospective description of the surgical technique and results of laparoscopic and robot-assisted triple neurectomy for chronic inguinodynia. MATERIAL AND METHODS We describe the inclusion/exclusion criteria as well as the surgical technique applied in 7 patients operated on at the University Health Care Complex of León (Urology Department) after failure of other treatment options. RESULTS The patients presented chronic groin pain, reporting a preoperative pain VAS of 7.43 out of 10. After surgery, this score was reduced to 3.71 on the first postoperative day and to 4.2 points one year after surgery. Hospital discharge occurred 24 h after surgery with no relevant complications being reported. CONCLUSIONS Laparoscopic or robot-assisted triple neurectomy is a safe, reproducible, and effective technique for the treatment of chronic groin pain refractory to other treatments.
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Affiliation(s)
- G Gutiérrez Carrillo
- Complejo Asistencial de León, Complejo Asistencial Universitario de León, León, Spain.
| | - M Garcia Sanz
- Complejo Asistencial de León, Complejo Asistencial Universitario de León, León, Spain
| | - M de Arriba Alonso
- Complejo Asistencial de León, Complejo Asistencial Universitario de León, León, Spain
| | - A Gutiérrez Fernandez
- Complejo Asistencial de León, Complejo Asistencial Universitario de León, León, Spain
| | - M Á Alonso Prieto
- Complejo Asistencial de León, Complejo Asistencial Universitario de León, León, Spain
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Dalili D, Isaac A, Fritz J. Selective MR neurography-guided lumbosacral plexus perineural injections: techniques, targets, and territories. Skeletal Radiol 2023; 52:1929-1947. [PMID: 37495713 DOI: 10.1007/s00256-023-04384-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/02/2023] [Accepted: 06/02/2023] [Indexed: 07/28/2023]
Abstract
The T12 to S4 spinal nerves form the lumbosacral plexus in the retroperitoneum, providing sensory and motor innervation to the pelvis and lower extremities. The lumbosacral plexus has a wide range of anatomic variations and interchange of fibers between nerve anastomoses. Neuropathies of the lumbosacral plexus cause a broad spectrum of complex pelvic and lower extremity pain syndromes, which can be challenging to diagnose and treat successfully. In their workup, selective nerve blocks are employed to test the hypothesis that a lumbosacral plexus nerve contributes to a suspected pelvic and extremity pain syndrome, whereas therapeutic perineural injections aim to alleviate pain and paresthesia symptoms. While the sciatic and femoral nerves are large in caliber, the iliohypogastric and ilioinguinal, genitofemoral, lateral femoral cutaneous, anterior femoral cutaneous, posterior femoral cutaneous, obturator, and pudendal nerves are small, measuring a few millimeters in diameter and have a wide range of anatomic variants. Due to their minuteness, direct visualization of the smaller lumbosacral plexus branches can be difficult during selective nerve blocks, particularly in deeper pelvic locations or larger patients. In this setting, the high spatial and contrast resolution of interventional MR neurography guidance benefits nerve visualization and targeting, needle placement, and visualization of perineural injectant distribution, providing a highly accurate alternative to more commonly used ultrasonography, fluoroscopy, and computed tomography guidance for perineural injections. This article offers a practical guide for MR neurography-guided lumbosacral plexus perineural injections, including interventional setup, pulse sequence protocols, lumbosacral plexus MR neurography anatomy, anatomic variations, and injection targets.
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Affiliation(s)
- Danoob Dalili
- Academic Surgical Unit, Southwest London Elective Orthopaedic Centre (SWLEOC), Dorking Road, Epsom, KT18 7EG, London, UK
- Department of Radiology, Epsom and St Hellier University Hospitals NHS Trust, Dorking Road, Epsom, London, KT18 7EG, UK
| | - Amanda Isaac
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Jan Fritz
- Department of Radiology, New York University Grossman School of Medicine, NY, USA.
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Caragher SP, Khouri KS, Raasveld FV, Winograd JM, Valerio IL, Gfrerer L, Eberlin KR. The Peripheral Nerve Surgeon's Role in the Management of Neuropathic Pain. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5005. [PMID: 37360238 PMCID: PMC10287132 DOI: 10.1097/gox.0000000000005005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/29/2023] [Indexed: 06/28/2023]
Abstract
Neuropathic pain (NP) underlies significant morbidity and disability worldwide. Although pharmacologic and functional therapies attempt to address this issue, they remain incompletely effective for many patients. Peripheral nerve surgeons have a range of techniques for intervening on NP. The aim of this review is to enable practitioners to identify patients with NP who might benefit from surgical intervention. The workup for NP includes patient history and specific physical examination maneuvers, as well as imaging and diagnostic nerve blocks. Once diagnosed, there is a range of options surgeons can utilize based on specific causes of NP. These techniques include nerve decompression, nerve reconstruction, nerve ablative techniques, and implantable nerve-modulating devices. In addition, there is an emerging role for preoperative involvement of peripheral nerve surgeons for cases known to carry a high risk of inducing postoperative NP. Lastly, we describe the ongoing work that will enable surgeons to expand their armamentarium to better serve patients with NP.
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Affiliation(s)
| | - Kimberly S. Khouri
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
| | - Floris V. Raasveld
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jonathan M. Winograd
- From the Harvard Medical School, Boston, Mass
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
| | - Ian L. Valerio
- From the Harvard Medical School, Boston, Mass
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
| | - Lisa Gfrerer
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, N.Y
| | - Kyle R. Eberlin
- From the Harvard Medical School, Boston, Mass
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
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Aggarwal AK, Ottestad E, Pfaff KE, Huai-Yu Li A, Xu L, Derby R, Hecht D, Hah J, Pritzlaff S, Prabhakar N, Krane E, D’Souza G, Hoydonckx Y. Review of Ultrasound-Guided Procedures in the Management of Chronic Pain. Anesthesiol Clin 2023; 41:395-470. [DOI: 10.1016/j.anclin.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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10
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Forlizzi JM, Ward MB, Whalen J, Wuerz TH, Gill TJ. Core Muscle Injury: Evaluation and Treatment in the Athlete. Am J Sports Med 2023; 51:1087-1095. [PMID: 35234538 DOI: 10.1177/03635465211063890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pain in the groin region, where the abdominal musculature attaches to the pubis, is referred to as a "sports hernia,""athletic pubalgia," or "core muscle injury" and has become a topic of increased interest due to its challenging diagnosis. Identifying the cause of chronic groin pain is complicated because significant symptom overlap exists between disorders of the proximal thigh musculature, intra-articular hip pathology, and disorders of the abdominal musculature. PURPOSE To present a comprehensive review of the pathoanatomic features, history and physical examination, and imaging modalities used to make the diagnosis of core muscle injury. STUDY DESIGN Narrative and literature review; Level of evidence, 4. METHODS A comprehensive literature search was performed. Studies involving the diagnosis, treatment, and rehabilitation of athletes with core muscle injury were identified. In addition, the senior author's extensive experience with the care of professional, collegiate, and elite athletes was analyzed and compared with established treatment algorithms. RESULTS The differential diagnosis of groin pain in the athlete should include core muscle injury with or without adductor longus tendinopathy. Current scientific evidence is lacking in this field; however, consensus regarding terms and treatment algorithms was facilitated with the publication of the Doha agreement in 2015. Pain localized proximal to the inguinal ligament, especially in conjunction with tenderness at the rectus abdominis insertion, is highly suggestive of core muscle injury. Concomitant adductor longus tendinopathy is not uncommon in these athletes and should be investigated. The diagnosis of core muscle injury is a clinical one, although dynamic ultrasonography is becoming increasingly used as a diagnostic modality. Magnetic resonance imaging is not always diagnostic and may underestimate the true extent of a core muscle injury. Functional rehabilitation programs can often return athletes to the same level of play. If an athlete has been diagnosed with athletic pubalgia and has persistent symptoms despite 12 weeks of nonoperative treatment, a surgical repair using mesh and a relaxing myotomy of the conjoined tendon should be considered. The most common intraoperative finding is a deficient posterior wall of the inguinal canal with injury to the distal rectus abdominis. Return to play after surgery for an isolated sports hernia is typically allowed at 4 weeks; however, if an adductor release is performed as well, return to play occurs at 12 weeks. CONCLUSION Core muscle injury is a diagnosis that requires a high level of clinical suspicion and should be considered in any athlete with pain in the inguinal region. Concurrent adductor pathology is not uncommon.
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Affiliation(s)
| | - Mark B Ward
- New England Baptist Hospital, Boston, Massachusetts, USA
| | - James Whalen
- New England Patriots, Foxboro, Massachusetts, USA
| | - Thomas H Wuerz
- New England Baptist Hospital, Boston, Massachusetts, USA
| | - Thomas J Gill
- New England Baptist Hospital, Boston, Massachusetts, USA
- St Elizabeth's Medical Center, Brighton, Massachusetts, USA
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Aravind P, Tiongco RFP, McNichols CH, Williams EH. Ultrasound as a Useful Tool for a Peripheral Nerve Surgeon: Examples in Clinical Practice. J Reconstr Microsurg 2022. [PMID: 36584694 DOI: 10.1055/s-0042-1759526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Peripheral nerve surgeons often require additional imaging for examination, diagnostic testing, and preoperative planning. Point-of-care ultrasound (US) is a cost-effective, accessible, and well-established technique that can assist the surgeon in diagnosing and treating select peripheral nerve pathologies. With this knowledge, the properly trained surgeon may perform US-guided nerve blocks to help accurately diagnose and treat causes of neuropathic pain. We offer this paper, not as an exhaustive review, but as a selection of various peripheral nerve pathologies, which the senior author treats, and their associated US examination findings. Our goal is to encourage other peripheral nerve surgeons to incorporate US into their practices. METHODS We provide various cases from our outpatient peripheral nerve clinic demonstrating relevant US anatomy. We also review techniques for US guided nerve blocks with relevant anatomic landmarks. RESULTS US imaging successfully assisted in identification and injection techniques for various peripheral nerve pathologies in a surgeon's practice. Examples were presented from the neck, trunk, upper extremity, and lower extremity. CONCLUSION Our review highlights the use of US by a peripheral nerve surgeon in an outpatient private practice clinic to diagnose and treat select peripheral nerve pathologies. We encourage reconstructive surgeons to add US to their arsenal of diagnostic tools.
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Affiliation(s)
- Pathik Aravind
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael Felix P Tiongco
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Colton H McNichols
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric H Williams
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,The Dellon Institutes for Peripheral Nerve Surgery, Towson, Maryland
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Sinha MK, Barman A, Tripathy PR, Shettar A. Nerve identification in open inguinal hernioplasty: A meta-analysis. Turk J Surg 2022; 38:315-326. [PMID: 36875277 PMCID: PMC9979557 DOI: 10.47717/turkjsurg.2022.5882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/26/2022] [Indexed: 01/11/2023]
Abstract
Objectives In open inguinal hernioplasty, three inguinal nerves are encountered in the surgical field. It is advisable to identify these nerves as careful dissection reduces the chances of debilitating post-operative inguinodynia. Recognizing nerves during surgery can be challenging. Limited surgical studies have reported on the identification rates of all nerves. This study aimed to calculate the pooled prevalence of each nerve from these studies. Material and Methods We searched PubMed, CENTRAL, CINAHL, ClinicalTrials.gov and Research Square. We selected articles that reported on the prevalence of all three nerves during surgery. A meta-analysis was performed on the data from eight studies. IVhet model from the software MetaXL was used for preparing the forest plot. Subgroup analysis was performed to understand the cause of heterogeneity. Results The pooled prevalence rates for Ilioinguinal nerve (IIN), Iliohypogastric nerve (IHN), and genital branch of genitofemoral nerve (GB) were 84% (95% CI 67-97%), 71% (95% CI 51-89%) and 53% (95% CI 31-74%), respectively. On subgroup analysis, the identification rates were higher in single centre studies and studies with a single primary objective as nerve identification. The heterogeneity was significant in all pooled values, excluding the subgroup analysis of IHN identification rates in single-centre studies. Conclusion The pooled values indicate low identification rates for IHN and GB. Significant heterogeneity and large confidence intervals reduce the importance of these values as quality standards. Better results are observed in single-centre studies and studies which are focused on nerve identification.
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Affiliation(s)
- Mithilesh Kumar Sinha
- Department of General Surgery, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Apurba Barman
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Bhubaneswar, India
| | | | - Ankit Shettar
- Department of General Surgery, All India Institute of Medical Sciences, Bhubaneswar, India
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Manolakos K, Zygogiannis K, Mousa C, Demesticha T, Protogerou V, Troupis T. Anatomical Variations of the Iliohypogastric Nerve: A Systematic Review of the Literature. Cureus 2022; 14:e24910. [PMID: 35698694 PMCID: PMC9186473 DOI: 10.7759/cureus.24910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2022] [Indexed: 11/19/2022] Open
Abstract
Several anatomical variations of the iliohypogastric nerve branches have been observed in earlier studies. Knowledge of these variations is useful for the improvement of peripheral nerve blocks and avoidance of iatrogenic nerve injuries during surgeries. The purpose of this study was to perform a systematic review of the literature about the anatomical topography and variations of the iliohypogastric nerve. An extensive search on PubMed, Scopus, and Web of Science electronic databases was conducted by the first author in November 2021, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Anatomical or cadaveric studies about the origin, the course, and the distribution of the iliohypogastric nerve were included in this review. Thirty cadaveric studies were included for qualitative analysis. Several anatomical variations of the iliohypogastric nerve were depicted including its general properties, its origin, its branching patterns, its course, its relation to anatomical landmarks, and its termination. Among them, the absence of the iliohypogastric nerve ranged from 0 to 34%, its origin from L1 ranged from 62.5 to 96.5%, and its isolated emergence from psoas major ranged from 47 to 94.5%. Numerous anatomical variations of the iliohypogastric nerve exist but are not commonly cited in classic anatomical textbooks. The branches of the iliohypogastric nerve may be damaged during spinal anesthesia and surgical procedures in the lower abdominal region. Therefore, a better understanding of the regional anatomy and its variations is of vital importance for the prevention of iliohypogastric nerve injuries.
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Affiliation(s)
| | | | | | - Theano Demesticha
- Department of Anatomy and Surgical Anatomy, Medical School, National and Kapodistrian University of Athens, Athens, GRC
| | - Vasileios Protogerou
- Department of Anatomy and Surgical Anatomy, Medical School, National and Kapodistrian University of Athens, Athens, GRC
| | - Theodore Troupis
- Department of Anatomy and Surgical Anatomy, Medical School, National and Kapodistrian University of Athens, Athens, GRC
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Drakonaki EE, Adriaensen MEAPM, Al-Bulushi HIJ, Koliarakis I, Tsiaoussis J, Vanderdood K. Sonoanatomy of the ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves: a practical guide for US-guided injections. J Ultrason 2022; 22:e44-e50. [PMID: 35449704 PMCID: PMC9009344 DOI: 10.15557/jou.2022.0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/13/2021] [Indexed: 11/22/2022] Open
Abstract
The ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves are the major sensory nerves that may be involved in chronic groin and genital pain with a significant impact on the quality of life of patients. The diagnosis remains clinical, and US-guided diagnostic injections using an anesthetic may aid in confirming the clinical suspicion. The anatomy of the peripheral nerves can be successfully studied using imaging. High-resolution ultrasound is increasingly used in the clinical setting for visualizing small peripheral nerves, and magnetic resonance imaging provides an anatomical overview of the relationship between small nerves and surrounding structures. In this pictorial assay, we review the anatomy and clinical relevance of the ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves. We summarize the various techniques for ultrasound identification, and present the ultrasound-guided infiltration techniques for injecting the ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves. Corresponding magnetic resonance images and clinical photos of the probe placement technique are provided for anatomical correlation. This paper is aimed to serve as a practical technical guide for physicians to familiarize themselves with the ultrasound anatomy of the major inguinal sensory nerves and to enable successful ultrasound identification and ultrasound-guided diagnostic or therapeutic infiltrations for pain management of the ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves.
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Affiliation(s)
- Elena E Drakonaki
- Department of Anatomy, School of Medicine, University of Crete, Greece.,Department of MSK imaging, Diagnostic and Interventional Ultrasound Practice, Greece
| | | | | | | | - John Tsiaoussis
- Department of Anatomy, School of Medicine, University of Crete, Greece
| | - Kurt Vanderdood
- Department of Medical Imaging, Zuyderland Medical Center, Netherlands
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15
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Sun HH, Tay KS, Jesse E, Muncey W, Loeb A, Thirumavalavan N. Microsurgical Denervation of the Spermatic Cord: A Historical Perspective and Recent Developments. Sex Med Rev 2022; 10:791-799. [PMID: 37051952 DOI: 10.1016/j.sxmr.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/15/2021] [Accepted: 11/16/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The management of chronic scrotal pain is long and varied, with historical treatment algorithms typically ending with orchiectomy. Microsurgical denervation of the spermatic cord (MDSC) is a testicle-sparing option for patients who have failed conservative treatment options and over its forty-year history has seen many technical refinements. OBJECTIVES To review the history and development of MDSC and discuss the outcomes of different surgical techniques. METHODS A literature review using PubMed and Google Scholar was conducted to identify studies pertaining to surgical treatment of CSP, MDSC, and outcomes. Search terms included "chronic," "scrotal pain," "orchialgia," "spermatic cord," "denervation," and "microsurgery." RESULTS We included 21 case reports and series since the first seminal paper describing MDSC technique in 1978. Additional studies that challenged existing conventions or described novel techniques are also discussed. The current standard procedure utilizes a subinguinal incision and a surgical microscope. Open, robotic, and laparoscopic approaches to MDSC have been described, but access to minimally invasive instruments may be limited outside of developed nations. Pain reduction following preoperative spermatic cord predicts success of MDSC. Methods for identifying and preserving the testicular and deferential arteries vary depending on surgeon preference but appear to have comparable outcomes. Future developments in MDSC involve targeted denervation, minimizing collateral thermal injury, and alternative techniques to visualize arterial supply. CONCLUSION For patients suffering from CSP, MDSC is a well-studied technique that may offer appropriately selected patients' relief. Future investigation comparing targeted vs full MDSC as well as in vivo study of new techniques are needed to continue to improve outcomes. Sun HH, Tay KS, Jesse E, et al. Microsurgical Denervation of the Spermatic Cord: A Historical Perspective and Recent Developments. Sex Med Rev 2022;XX:XXX-XXX.
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Affiliation(s)
- Helen H Sun
- Urology Institute, University Hospitals/Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Kimberly S Tay
- Urology Institute, University Hospitals/Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Erin Jesse
- Urology Institute, University Hospitals/Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Wade Muncey
- Urology Institute, University Hospitals/Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Aram Loeb
- Urology Institute, University Hospitals/Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Nannan Thirumavalavan
- Urology Institute, University Hospitals/Case Western Reserve University School of Medicine, Cleveland, OH, USA
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16
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Zhou Z, Yan L, Li Y, Zhou J, Ma Y, Tong C. Embryonic developmental process and clinical anatomy of the preperitoneal fascia and its clinical significance. Surg Radiol Anat 2022; 44:1531-1543. [PMID: 36404360 PMCID: PMC9734211 DOI: 10.1007/s00276-022-03046-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 11/10/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE Many researchers have different views on the origin and anatomy of the preperitoneal fascia. The purpose of this study is to review studies on the anatomy related to the preperitoneal fascia and to investigate the origin, structure, and clinical significance of the preperitoneal fascia in conjunction with previous anatomical findings of the genitourinary fascia, using the embryogenesis of the genitourinary system as a guide. METHODS Publications on the preperitoneal and genitourinary fascia are reviewed, with emphasis on the anatomy of the preperitoneal fascia and its relationship to the embryonic development of the genitourinary organs. We also describe previous anatomical studies of the genitourinary fascia in the inguinal region through the fixation of formalin-fixed cadavers. RESULTS Published literature on the origin, structure, and distribution of the preperitoneal fascia is sometimes inconsistent. However, studies on the urogenital fascia provide more than sufficient evidence that the formation of the preperitoneal fascia is closely related to the embryonic development of the urogenital fascia and its tegument. Combined with previous anatomical studies of the genitourinary fascia in the inguinal region of formalin-fixed cadavers showed that there is a complete fascial system. This fascial system moves from the retroperitoneum to the anterior peritoneum as the preperitoneal fascia. CONCLUSIONS We can assume that the preperitoneal fascia (PPF) is continuous with the retroperitoneal renal fascia, ureter and its accessory vessels, lymphatic vessels, peritoneum of the bladder, internal spermatic fascia, and other peritoneal and pelvic urogenital organ surfaces, which means that the urogenital fascia (UGF) is a complete fascial system, which migrates into PPF in the preperitoneal space and the internal spermatic fascia in the inguinal canal.
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Affiliation(s)
- Zheqi Zhou
- grid.440288.20000 0004 1758 0451Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, 710068 China ,grid.440747.40000 0001 0473 0092Yan’an University, Yan’an, China
| | - Likun Yan
- grid.440288.20000 0004 1758 0451Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, 710068 China
| | - Yi Li
- grid.440288.20000 0004 1758 0451Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, 710068 China
| | - Jinsong Zhou
- grid.43169.390000 0001 0599 1243Department of Human Anatomy, Histology and Embryology, School of Basic Medical Sciences, Xi’an Jiaotong University Health Science Center, Xi’an, 710061 Shaanxi China
| | - Yanbing Ma
- grid.43169.390000 0001 0599 1243Department of Human Anatomy, Histology and Embryology, School of Basic Medical Sciences, Xi’an Jiaotong University Health Science Center, Xi’an, 710061 Shaanxi China
| | - Cong Tong
- grid.440288.20000 0004 1758 0451Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, 710068 China
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Farquharson BJ, Sivarajah V, Mahdi S, Bergman H, Jeyarajah S. Where is the nerve? Review of operation note documentation practice for inguinal hernia repair. Ann R Coll Surg Engl 2021; 103:651-655. [PMID: 34412537 DOI: 10.1308/rcsann.2021.0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Careful identification and management of inguinal nerves during inguinal hernia repair is important to avoid iatrogenic injury. Documentation of this practice may inform postoperative clinical management. We set out to investigate how often surgeons identify inguinal nerves and document findings and management in their operation notes. METHODS We carried out a retrospective review of operation notes at a single district general hospital. We analysed operation notes for documentation of identification and intraoperative management (preservation or sacrifice) of the inguinal nerves (iliohypogastric, ilioinguinal, genital branch of genitofemoral nerve). We collected data on the baseline characteristics of the patients, hernia characteristics and primary operating surgeons for subgroup analysis. RESULTS A total of 100 patients were included in the analysis. Identification of any inguinal nerves (generic 'nerve') was documented in 17% of operation notes. Documentation in the operation notes of named individual nerves was limited. No documentation of intraoperative management of inguinal nerves was found in 83% of operation notes. Preservation of the inguinal nerves (generic 'nerve') was recorded in 8% and sacrifice recorded in 9% of cases. Subgroup analysis revealed similar incidence of documentation of identification and management of inguinal nerves across grades of primary surgeon, with overall incidence low for all grades. CONCLUSION This study reveals a lack of appreciation of the importance of documenting identification and management of inguinal nerves in operation notes. Further consideration of the potential implications of poor documentation would be beneficial to improve standards.
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Affiliation(s)
| | | | - S Mahdi
- East and North Hertfordshire NHS Trust, UK
| | - H Bergman
- East and North Hertfordshire NHS Trust, UK
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18
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Surgical Treatment of Abdominal Wall Neuromas. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3585. [PMID: 34046291 PMCID: PMC8143781 DOI: 10.1097/gox.0000000000003585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/27/2021] [Indexed: 12/11/2022]
Abstract
Neuromas are an under-recognized contributor to chronic abdominal pain. Other than after mesh inguinal hernia repair, surgical management of painful abdominal wall neuromas has not been well established in the literature.
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19
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Beamer MR, Pinkhasov A, Kravchick S. Preoperative Modified Spermatic Cord Block Predicts Success in Candidates for Microscopic Spermatic Cord Denervation. Urology 2021; 156:31-36. [PMID: 33961892 DOI: 10.1016/j.urology.2021.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/07/2021] [Accepted: 04/04/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the utility of a modified spermatic cord block (MSCB) that targets known contributors to refractory chronic scrotal content pain (CSCP) at predicting postoperative pain relief following a microscopic spermatic cord denervation (MSCD). METHODS A MSCB was performed in all patients with refractory CSCP. This was performed by injecting anesthetic circumferentially around the vas deferens and over the external ring. Patients with >50% pain reduction were offered MSCD. Baseline, post-block, and postoperative pain was assessed. Age, prior groin surgery, and post-block pain free period were recorded. A multivariate linear regression model was used to determine predictors of surgical success. RESULTS Fifty-two patients underwent a MSCB. Forty-six (88%) had an adequate response and underwent MSCD. All patients saw improvement in pain postoperatively with an average reduction of 80% (4 < 50%; 7 50-69%; 35 ≥ 70%). On multivariate linear regression analysis, pain reduction following MSCD was an independent predictor of postoperative improvement (P < 0.001). No other factors, including post-block pain free period or prior surgery predicted success. CONCLUSIONS The described MSCB can be utilized as an independent predictor of success following MSCD. Post-block pain free period was not associated with postoperative pain level. The MSCB may help identify candidates for MSCD that would be missed with the traditional block.
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Affiliation(s)
- Matthew R Beamer
- Department of Urology, SUNY Upstate Medical University, Syracuse, NY.
| | | | - Sergey Kravchick
- Department of Urology, SUNY Upstate Medical University, Syracuse, NY; Department of Urology, United Health Services, Johnson City, NY
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20
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Nayak SB, Vasudeva SK. Innervation of the scrotum by the anterior division of the obturator nerve - a rare variation. Morphologie 2021; 106:128-131. [PMID: 33875370 DOI: 10.1016/j.morpho.2021.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 11/28/2022]
Abstract
The scrotum is supplied by ilioinguinal, genital branch of genitofemoral, perineal branch of the posterior cutaneous nerve of the thigh and the posterior scrotal branches of the pudendal nerve. We report an extremely rare innervation of the anterior part of the scrotum by the anterior division of the right obturator nerve. The genital branch of genitofemoral nerve did not reach the scrotum. The ilioinguinal nerve did not supply the scrotum. The anterior division of the obturator nerve gave a branch which ascended superomedially in the thigh, crossed superficial to the spermatic cord and communicated with the right ilioinguinal nerve. As it crossed the spermatic cord, it gave a scrotal branch which descended over the spermatic cord and ramified to supply the anterior part of the scrotum. Knowledge of this variation could be important to anaesthesiologists, urologists and surgeons in general.
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Affiliation(s)
- S B Nayak
- Melaka Manipal Medical College (Manipal Campus), Manipal Academy of Higher Education, Madhav-Nagar, Manipal, Karnataka State, India
| | - S K Vasudeva
- Department of Mathematics, Manipal Institute of Technology, Manipal Academy of Higher Education, Madhav-Nagar, Manipal, Karnataka State, India.
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21
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Daniels SP, Xu HS, Hanna A, Greenberg JA, Lee KS. Ultrasound-guided microwave ablation in the treatment of inguinal neuralgia. Skeletal Radiol 2021; 50:475-483. [PMID: 33000286 DOI: 10.1007/s00256-020-03618-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 09/09/2020] [Accepted: 09/17/2020] [Indexed: 02/02/2023]
Abstract
Chronic groin pain can be due to a variety of causes and is the most common complication of inguinal hernia repair surgery. The etiology of pain after inguinal hernia repair surgery is often multifactorial though injury to or scarring around the nerves in the operative region, namely the ilioinguinal nerve, genital branch of the genitofemoral nerve, and the iliohypogastric nerve, is thought to be a key factor in causing chronic post-operative hernia pain or inguinal neuralgia. Inguinal neuralgia is difficult to treat and requires a multidisciplinary approach. Radiologists play a key role in the management of these patients by providing accurate image-guided injections to alleviate patient symptoms and identify the pain generator. Recently, ultrasound-guided microwave ablation has emerged as a safe technique, capable of providing durable pain relief in the majority of patients with this difficult to treat condition. The objectives of this paper are to review the complex nerve anatomy of the groin, discuss diagnostic ultrasound-guided nerve injection and patient selection for nerve ablation, and illustrate the microwave ablation technique used at our institution.
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Affiliation(s)
- Steven P Daniels
- Department of Radiology, NYU Langone Heath, 660 First Avenue, New York, NY, 10016, USA.
| | - Helen S Xu
- Department of Radiology, New York Presbyterian Hospital-Weill Cornell Medical Center, 525 East 68th Street, Box 141, New York, NY, 10065, USA
| | - Amgad Hanna
- Department of Neurosurgery, University of Wisconsin School of Medicine and Public Health, 600 E. Highland Avenue, Madison, WI, 53792, USA
| | - Jacob A Greenberg
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, 600 E. Highland Avenue, Madison, WI, 53792, USA
| | - Kenneth S Lee
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 E. Highland Avenue, Madison, WI, 53792, USA
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22
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Oh PJ, Bajic P, Lundy SD, Ziegelmann M, Levine LA. Chronic Scrotal Content Pain: a Review of the Literature and Management Schemes. Curr Urol Rep 2021; 22:12. [PMID: 33447905 DOI: 10.1007/s11934-020-01026-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Chronic scrotal content pain (CSCP) is a complex condition with multiple etiologies that requires a thorough understanding of its pathophysiology, workup, and treatment options. We performed a comprehensive and contemporary review to augment our current understanding of CSCP. RECENT FINDINGS We discuss new advances in CSCP-specific pain questionnaires, modern studies of microscopic spermatic cord denervation and its variations, and novel techniques including electric nerve stimulation and cryoablation in addition to randomized control trials with significant negative findings. We also present literature focusing on the prevention of CSCP secondary to surgical iatrogenic causes. The constantly evolving literature of CSCP has led to the significant evolution in its diagnosis and treatment, from oral medications to salvage options after microscopic spermatic cord denervation. With each advance, we come closer to developing a more thorough, evidence-based algorithm to guide urologists in treatment of CSCP.
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Affiliation(s)
- Paul J Oh
- Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Ave, Building Q10-1, Cleveland, OH, 44195, USA
| | - Petar Bajic
- Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Ave, Building Q10-1, Cleveland, OH, 44195, USA.
| | - Scott D Lundy
- Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Ave, Building Q10-1, Cleveland, OH, 44195, USA
| | | | - Laurence A Levine
- Division of Urology, Rush University Medical Center, Chicago, IL, USA
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Kim S, Josephs S, Tsui BCH. Successful postoperative analgesia with ilio-inguinal nerve block following sclerotherapy for a labial venous malformation. Anaesth Rep 2020; 8:e12069. [PMID: 33210092 DOI: 10.1002/anr3.12069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2020] [Indexed: 11/08/2022] Open
Abstract
Though ilio-inguinal nerve block has been commonly utilised in male urologic surgery, a single injection ilio-inguinal nerve block alone has not previously been reported for analgesia of the vulva. In this report, we describe the case of a 14-year-old girl undergoing sclerotherapy of a venous malformation affecting the labia majora and minora. After induction of anaesthesia, we performed an ultrasound-guided ilio-inguinal nerve block using a total volume of 15 ml of ropivacaine 0.2% with 1 μg.ml-1 dexmedetomidine which provided effective postoperative analgesia. Though the patient received intravenous analgesia intra-operatively and had an inpatient bed reserved in anticipation of severe postoperative pain, she required no further analgesia and was discharged home following 2 hours in the postoperative anaesthesia care unit. With the additional use of dexmedetomidine resulting in prolonged efficacy of the block, the patient reported effective postoperative relief for approximately 30 hours, solely using ibuprofen for pain relief. This case reminds clinicians that the ilio-inguinal nerve block may provide benefit not only for male urologic surgery but also for procedures involving the external female genitalia, with extended analgesia with the use of dexmedetomidine.
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Affiliation(s)
- S Kim
- Department of Anesthesiology, Perioperative, and Pain Medicine Lucile Packard Children's Hospital at Stanford Stanford California USA
| | - S Josephs
- Department of Interventional Radiology and Diagnostic Radiology Lucile Packard Children's Hospital at Stanford Stanford California USA
| | - B C H Tsui
- Department of Anesthesiology, Perioperative, and Pain Medicine Lucile Packard Children's Hospital at Stanford Stanford California USA
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Ahuja V, Thapa D, Nandi S, Gombar S, Dalal A, Bansiwal RK. To evaluate the effect of quadratus lumborum block on the tramadol sparing effect in patients undergoing open inguinal hernia surgery: A randomised controlled trial. Indian J Anaesth 2020; 64:S198-S204. [PMID: 33162602 PMCID: PMC7641059 DOI: 10.4103/ija.ija_545_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 05/26/2020] [Accepted: 06/14/2020] [Indexed: 11/04/2022] Open
Abstract
Background and Aims An ultrasound-guided quadratus lumborum (QL) block provides both somatic and visceral analgesia in abdominal surgeries. We aimed to evaluate the postoperative tramadol sparing effect of single-shot anterior QL block in inguinal hernia surgery patients. Methods This prospective, randomised controlled trial was conducted in a single tertiary care centre over a period of 1 year. A total of 50 patients, American Society of Anaesthesiologists (ASA) physical status I-II of both sexes aged 18-80 years with body mass index (BMI) ≥20 to ≤35 kg/m2 undergoing uncomplicated unilateral inguinal hernia surgery under spinal anaesthesia (SA) were randomly allocated to either of the two groups. The block group (n = 25) received single-shot anterior QL block with 20 ml of 0.5% ropivacaine and the control group (n = 25) received no block. Postoperatively, patients received intravenous (IV) paracetamol 1g every 6 h and tramadol patient-controlled analgesia up to 24 h. Primary outcome was total tramadol consumption at 24 h postoperatively. Results The total tramadol consumption mean ± SD [95% CI (range)] at 24 h in the block group was 84.00 ± 37.86 [68.37-99.63 (20-160)] mg versus 93.60 ± 34.99 [79.16-108.04 (20-160)] mg in control group, (p value = 0.36). Postoperative VAS score, haemodynamics, and patient satisfaction score were similar in both the groups. No adverse events were reported. Conclusion A single-shot anterior QL block did not establish a postoperative tramadol-sparing effect at 24 h as compared to no block in patients undergoing inguinal hernia surgery under SA.
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Affiliation(s)
- Vanita Ahuja
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Deepak Thapa
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Souvik Nandi
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Satinder Gombar
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Ashwani Dalal
- Department of General Surgery, Government Medical College and Hospital, Chandigarh, India
| | - Rajesh Kumar Bansiwal
- Department of General Surgery, Government Medical College and Hospital, Chandigarh, India
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25
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Anderson E, Pascoe C, Sathianathen N, Katz D, Murphy D, Lawrentschuk N. Subinguinal orchiectomy—A minimally invasive approach to open surgery. BJUI COMPASS 2020; 1:160-164. [PMID: 35475209 PMCID: PMC8988733 DOI: 10.1002/bco2.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/08/2020] [Accepted: 07/12/2020] [Indexed: 11/10/2022] Open
Affiliation(s)
- Elliot Anderson
- Department of Surgery Monash University Clayton VIC Australia
- Department of Urology Western Health Footscray VIC Australia
| | - Claire Pascoe
- Division of Cancer Surgery Peter MacCallum Cancer Centre East Melbourne VIC Australia
| | - Niranjan Sathianathen
- Division of Cancer Surgery Peter MacCallum Cancer Centre East Melbourne VIC Australia
| | - Darren Katz
- Department of Urology Western Health Footscray VIC Australia
- Men’s Health Melbourne Melbourne VIC Australia
| | - Declan Murphy
- Division of Cancer Surgery Peter MacCallum Cancer Centre East Melbourne VIC Australia
- Sir Peter MacCallum Department of Oncology University of Melbourne Parkville VIC Australia
| | - Nathan Lawrentschuk
- Division of Cancer Surgery Peter MacCallum Cancer Centre East Melbourne VIC Australia
- Department of Urology Royal Melbourne Hospital Melbourne VIC Australia
- Department of Surgery The University of Melbourne Melbourne VIC Australia
- EJ Whitten Centre for Prostate Cancer Research Richmond VIC Australia
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26
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Sengul G, Ertekin C. Human cremaster muscle and cremasteric reflex: A comprehensive review. Clin Neurophysiol 2020; 131:1354-1364. [DOI: 10.1016/j.clinph.2020.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 02/28/2020] [Accepted: 03/09/2020] [Indexed: 11/28/2022]
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Moreno-Egea A. A study to improve identification of the retroperitoneal course of iliohypogastric, ilioinguinal, femorocutaneous and genitofemoral nerves during laparoscopic triple neurectomy. Surg Endosc 2020; 35:1116-1125. [PMID: 32430523 DOI: 10.1007/s00464-020-07476-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/19/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Laparoscopic triple neurectomy is an available treatment option for chronic groin pain, but a poor working knowledge of the retroperitoneal neuroanatomy makes it an unsafe technique. OBJECT Describe the retroperitoneal course of iliohypogastric, ilioinguinal, lateral femoral cutaneous and genitofemoral nerves, to guide the surgeon who operates in this region. METHODS Fifty adult cadavers were dissected resulting in 100 anatomic specimens. Additionally, 30 patients were operated for refractory chronic inguinal pain, using laparoscopic triple neurectomy. All operations and dissections were photographed. Measurements were made between the nerves of the lumbar plexus and various landmarks: interneural distances in a vertical midline plane, posterior or anterior iliac spine and branch presentation model. RESULTS The ilioinguinal and iliohypogastric nerves were independent in 78% (Type II) and separated by an average of 2.5 ± 0.8 cm. In surgery study, only 38% were recognized as Type II and at a significantly greater distance (3.5 ± 1.2 cm, p < 0.001). The distance between ilioinguinal and lateral femoral cutaneous nerves was also greater during surgery, with statistical significance (5.1 ± 1.5 versus 4.2 ± 1.5, p < 0.005). The distance of the nerves to their bone references were not statistically different. The genitofemoral nerve emerged from the psoas major muscle in 20% as two separate branches (Type II), regardless of the study. The lateral femoral cutaneous nerve had a mean distance of 0.98 ± 1.6 cm medial to the anterior superior iliac spine. CONCLUSION The identification of the IH, II, FC and GF nerves is essential to reduce the rate of failures in the treatment of CGP. The frequent anatomical variations of the lumbar plexus nerves make knowledge of their courses in the retroperitoneal space essential to ensure safe surgery. The location of the nerves in the LTN is distorted by up to 1 cm. regarding references in the cadavers.
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Affiliation(s)
- Alfredo Moreno-Egea
- Hernia Clinic, La Vega University Hospital, Avda Primo de Rivera 7, 5ºD, 3008, Murcia, Spain.
- School of Medicine, San Antonio University, Murcia, Spain.
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Medina Velázquez R, Marchena Gómez J, Luque García MJ. Chronic postoperative inguinal pain: A narrative review. Cir Esp 2020; 99:80-88. [PMID: 32386729 DOI: 10.1016/j.ciresp.2020.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/29/2020] [Accepted: 03/16/2020] [Indexed: 11/30/2022]
Abstract
Inguinodynia or chronic postoperative inguinal pain is a growing problem between patients who undergo surgical repair of an inguinal hernia. The change in results measurement proposed by many authors towards Patient Reported Outcome Measurement has underlined the importance of chronic postoperative inguinal pain, because of the great limitations in everyday life and the huge socioeconomic impact that it causes. In this article a narrative review of the available literature in PUBMED, EMBASE and Cochrane Library is performed and the most relevant aspects about epidemiology, etiology prevention, diagnosis and treatment of chronic postoperative inguinal pain are discussed. A new management algorithm is also proposed. The variability in its incidence and clinical presentation makes diagnosis of chronic postoperative inguinal pain a very challenging issue. There is no standardized therapy and an adequate etiological diagnosis is key point for a successful treatment. There are many treatment options that have to be sequentially used and adjusted to each patient and their clinical features.
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Affiliation(s)
- Raúl Medina Velázquez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, España.
| | - Joaquín Marchena Gómez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, España
| | - María José Luque García
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, España
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George T, Williams EH, Franklin R, Lee Dellon A. Two-Team Surgical Approach to Improve Retroperitoneal Nerve Identification in the Treatment of Groin Pain. Ann Plast Surg 2020; 82:82-84. [PMID: 30540586 DOI: 10.1097/sap.0000000000001662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND An estimated 700,000 groin hernia repairs are performed in the United States each year. Studies have shown that up to 50% of patients who undergo groin hernia repair are affected by persistent pain beyond the first few days after surgery. At 2 to 5 years after either open or laparoscopic, mesh or without mesh, 10% to 12% of these patients will have persistent and disabling pain. If the ilioinguinal, iliohypogastric, or genitofemoral nerves are injured below the transversalis muscle layer, the traditional external, open approach to nerve resection will not help these patients. The traditional internal, laparoscopic, approach to the retroperitoneum can be used for nerve resection, but identification of the correct nerve is difficult. Therefore, we have developed a 2-team, dual approach, combining open and endoscopic approaches to solve this problem. METHODS A retrospective review of the electronic medical records was performed to identify all patients who underwent a dual approach for groin denervation after persistent postherniorraphy pain. This dual approach included an external incision paired with a laparoscopic, retroperitoneal approach to identify and/or transect the ilioinguinal, iliohypogastic, lateral femoral cutaneous, and genital branch of the genitofemoral nerve. Inclusion criteria are persistent groin pain with alleviation after preoperative nerve block and either a failed attempt at an external approach groin denervation or pain after a primary laparotomy/laparoscopy procedure. RESULTS Thirteen patients met the inclusion criteria. All patients underwent a dual approach, and nerves were identified and confirmed in both the external groin and laparoscopic approaches. When placed on a scale from excellent/good to fair/poor relief of pain, 10 patients (77%) described excellent/good relief and 3 (23%) continued to have persistent pain. CONCLUSIONS A combined open surgical procedure, to identify the lateral femoral cutaneous nerve, and a laparoscopic procedure in the retroperitoneum have demonstrated the feasibility of this approach to identify correctly the nerve to be resected to relieve disabling groin pain.
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Konschake M, Zwierzina M, Moriggl B, Függer R, Mayer F, Brunner W, Schmid T, Chen DC, Fortelny R. The inguinal region revisited: the surgical point of view : An anatomical-surgical mapping and sonographic approach regarding postoperative chronic groin pain following open hernia repair. Hernia 2019; 24:883-894. [PMID: 31776877 PMCID: PMC7395915 DOI: 10.1007/s10029-019-02070-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/11/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Inguinodynia or chronic post-herniorrhaphy pain, defined as pain lasting longer than 3 months after open inguinal hernia repair, has become the most important complication after inguinal surgery and therefore compromises the patient´s quality of life. A major reason for inguinodynia might be the lack of neuroanatomical knowledge and suboptimal "management" of the nerves during surgery. METHODS We present a detailed neuroanatomic mapping of the inguinal region by dissection including the most important surgical landmarks with all nerves confirmed by immunohistochemistry, ultrasound guided visualization of the iliohypogastric, ilio-inguinal, and genital branch of the genitofemoral nerve, and a practical (preoperative) algorithm for clinical management. RESULTS Surgically and ultrasonographically relevant structures ("landmarks") in open hernia repair are the anterior-superior iliac spine, pubic tubercle, Camper´s fascia (superficial layer of the superficial abdominal fascia), External oblique aponeurosis, Internal oblique muscle, Transversus abdominis muscle, superficial inguinal ring, external spermatic fascia, cremasteric fascia with cremaster muscle fibers, internal spermatic fascia, cremasteric vein (=external spermatic vein = "blue line"), ductus deferens, pampiniform plexus, inguinal ligament and the inferior epigastric vessels. CONCLUSION A detailed understanding of inguinal anatomy is an indispensable basic requirement for all surgeons to perform inguinal ultrasonography as well as open inguinal hernia repair, avoiding complications, especially postoperative inguinodynia.
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Affiliation(s)
- M Konschake
- Department of Anatomy, Histology and Embryology, Division of Clinical and Functional Anatomy, Medical University of Innsbruck, Müllerstr. 59, 6020, Innsbruck, Austria.
| | - M Zwierzina
- Department of Plastic, Reconstructive and Aesthetic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - B Moriggl
- Department of Anatomy, Histology and Embryology, Division of Clinical and Functional Anatomy, Medical University of Innsbruck, Müllerstr. 59, 6020, Innsbruck, Austria
| | - R Függer
- Department of Surgery, Elisabethinen Hospital, Linz, Austria
| | - F Mayer
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - W Brunner
- Department of Surgery, Kantonspital St. Gallen, St. Gallen, Switzerland
| | - T Schmid
- Department for Visceral-, Transplantation- and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - D C Chen
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Lichtenstein Amid Hernia Clinic, Santa Monica, CA, USA
| | - R Fortelny
- Department of General-, Visceral- and Oncological Surgery, Wilhelminenspital, Vienna, Austria
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Hanwright P, Yang R, Chopra K, Dorafshar A, Dellon AL, Williams E. A Surgical Approach to Treat Painful Neuromas of the Supraorbital and Supratrochlear Nerves with Implantation of the Proximal Stump into the Orbit. Craniomaxillofac Trauma Reconstr 2019; 12:305-308. [PMID: 31719956 DOI: 10.1055/s-0039-1688697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 03/08/2019] [Indexed: 10/26/2022] Open
Abstract
Frontal neuralgia causally related to trauma to the supraorbital and supratrochlear nerves remains a difficult problem to resolve. A peripheral nerve approach to this problem would involve neuroma resection and relocation of the proximal nerve stump to a location away from the vulnerable supraorbital ridge. A retrospective chart review was done to identify patients with frontal pain related to supraorbital trauma who underwent operative interventions to solve this problem by neuroma resection and relocation of the proximal stumps into the orbit. Eight patients were identified for inclusion in this study. At a mean of 16 months after surgery, there was a significant change in the visual analog score from a mean of 9.4 to 2.8 ( p < 0.05), with 88% of the patients reporting a >50% reduction in pain postoperatively. There was one treatment failure. There were no postoperative complications. The strategy of relocating the proximal end of the supraorbital and supratrochlear nerves into the posterior orbit after resecting the painful neuromas can successfully manage posttraumatic craniofacial pain related to these injured nerves.
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Affiliation(s)
- Philip Hanwright
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robin Yang
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Karan Chopra
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amir Dorafshar
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, Illinois
| | - A Lee Dellon
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric Williams
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Evaluation of Ultrasound-guided Genitofemoral Nerve Block Combined with Ilioinguinal/iliohypogastric Nerve Block during Inguinal Hernia Repair in the Elderly. Curr Med Sci 2019; 39:794-799. [PMID: 31612398 DOI: 10.1007/s11596-019-2107-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/28/2019] [Indexed: 12/16/2022]
Abstract
To evaluate the anesthetic effect of ultrasound-guided (USG) ilioinguinal/iliohypogastric nerve (II/IHN) block combined with genital branch of genitofemoral nerve (GFN) block in the elderly undergoing inguinal hernia repair, 54 old patients (aged 60-96years, ASA I-III) with indirect hernia were enrolled and scheduled for unilateral tension-free herniorrhaphy. Patients were grouped randomly to receive either USG II/IHN plus GFN block (Group G) or USG II/IHN block alone (Group I). The intraoperative visual analogue scale (VAS) scores were recorded at skin incision, at spermatic cord/round ligament traction and at sac ligation. The resting and dynamic VAS scores were recorded postoperatively. The requirements of extra sedatives and analgesics for intra- and postoperative analgesia were assessed. Occurrence of complications of the block, postoperative nausea and vomiting and femoral nerve palsy was also reported. Both groups showed similar sensory block. When stretching spermatic cord/round ligament, the patients in group G had significantly lower VAS scores than in group I. And group G used much fewer adjuvant sedatives and analgesics to achieve adequate anaesthesia. In addition, group G was presented with better intraoperative anaesthesia and lower postoperative dynamic VAS scores at all time points tested. No significant difference was found in the postoperative requirement of rescue medication. Both groups showed no complications related to the block and group G reported no femoral nerve palsy. The addition of GFN block to II/IHN block improves the quality of perioperative anesthesia and analgesia in the elderly and reduces the consumption of extra sedatives and analgesics during the surgery.
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Riff AJ, Movassaghi K, Beck EC, Neal WH, Inoue N, Coleman SH, Nho SJ. Surface Mapping of the Musculotendinous Attachments at the Pubic Symphysis in Cadaveric Specimens: Implications for the Treatment of Core Muscle Injury. Arthroscopy 2019; 35:2358-2364. [PMID: 31395170 DOI: 10.1016/j.arthro.2019.02.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 02/18/2019] [Accepted: 02/19/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To characterize the 3-dimensional muscular, musculotendinous, and neurovascular anatomy about the pubic symphysis relevant to core muscle injury (CMI). METHODS Ten cadaveric hips were dissected to characterize the musculotendinous insertion of the rectus abdominis and inguinal ligament, origins of the adductor longus and adductor brevis, and the pubic cartilage plate. A 3-dimensional coordinate measuring system and data acquisition software were used to calculate structure cross-sectional area, and the landmark anatomical relationships to 1 another and relevant neurovascular structures. RESULTS All specimens were male with an average age of 62 ± 2 years. The mean footprints of the rectus abdominis, inguinal ligament, adductor longus, and adductor brevis were 8.4 ± 3.1, 1.2 ± 0.5, 3.8 ± 1.6, and 2.9 ± 1.3 cm2, respectively. The mean pectineus and gracilis footprints were 6.3 ± 2.4 and 3.4 ± 0.9 cm2, respectively. The mean cross-sectional area of the cartilage plate was 24.8 ± 5.6 cm2. The adductor longus was an average 1.5 ± 0.25 cm from the adductor brevis and 0.69 ± 0.52 cm from the rectus abdominis. The genital branch of the genitofemoral nerve was an average of 4.3 cm (range, 2.8-6.4) lateral to the insertion of the inguinal ligament. The femoral vein and artery were 3.0 cm (range, 2.5-3.6) and 3.7 cm (range, 2.5-5.9) lateral to the inguinal ligament footprint. The obturator nerve was 2.5 cm (range, 1.6-3.4) lateral to the adductor longus. CONCLUSIONS Familiarity with the anatomy of the pubic symphysis is essential for surgeons treating patients with CMI. We have shown that this relatively small area is the site of many muscular, musculotendinous, and neurovascular structures with various sized footprints and described the 3-dimensional anatomy of the anterior pubic symphysis. The origin of the adductor longus lies in close proximity to other structures, such as the adductor brevis, the insertion of the rectus abdominis, and the obturator nerve. These findings should be considered when operating in this region and treating patients with chronic groin pain. CLINICAL RELEVANCE The anatomy of the pelvic region and pubic symphysis has not been well characterized. Intimate knowledge of relevant anatomy is essential to treating CMI, also known as athletic pubalgia or sports hernia.
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Affiliation(s)
- Andrew J Riff
- Department of Orthopaedic Surgery, Indiana University Health, Indianapolis, Indiana, U.S.A
| | - Kamran Movassaghi
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Edward C Beck
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A..
| | - William H Neal
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Nozomu Inoue
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Struan H Coleman
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Shane J Nho
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
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Iwanaga J, Simonds E, Schumacher M, Kikuta S, Watanabe K, Tubbs RS. Revisiting the genital and femoral branches of the genitofemoral nerve: Suggestion for a more accurate terminology. Clin Anat 2019; 32:458-463. [PMID: 30592097 DOI: 10.1002/ca.23327] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 12/22/2018] [Indexed: 11/11/2022]
Abstract
The genitofemoral nerve is a branch of the lumbar plexus originating from the ventral rami of the first and second lumbar spinal nerves. During routine dissections of this nerve, we have occasionally observed that the genital branch of the genitofemoral nerve gave rise to the femoral branch, and the femoral branch of the genitofemoral nerve gave rise to the genital branch. Therefore, this study aimed to investigate the aforementioned distributions of the genitofemoral nerve in a large number of cadaveric specimens. Twenty-four sides from fourteen fresh-frozen cadavers derived from nine males and five females were used in this study. For proximal branches of the genitofemoral nerve, that is, as they first arise from the genitofemoral nerve, the terms "medial branch" and "lateral branch" were used. For the final distribution, the terms "genital branch" and "femoral branch" were used. On eight sides (33.3%) with nine branches, one or two branch(s) from either the medial or lateral branch became coursed as the femoral or genital branches (five became femoral and four became genital branches). Our study revealed that the distribution of the genitofemoral nerve is more complicated than previously described. The "medial branch" and "lateral branch" that we have used in the present study for describing the proximal branches of the genitofemoral nerve are more practical terms to describe the genitofemoral nerve. Clin. Anat. 32:458-463, 2019. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Joe Iwanaga
- Seattle Science Foundation, Seattle, Washington.,Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine, Kurume, Japan
| | | | | | | | - Koichi Watanabe
- Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine, Kurume, Japan
| | - R Shane Tubbs
- Seattle Science Foundation, Seattle, Washington.,Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
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Role of MR Neurography in Groin and Genital Pain: Ilioinguinal, Iliohypogastric, and Genitofemoral Neuralgia. AJR Am J Roentgenol 2019; 212:632-643. [PMID: 30620677 DOI: 10.2214/ajr.18.20316] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Chronic neuralgia of the border nerves (ilioinguinal, iliohypogastric, and genitofemoral) is difficult to diagnose and treat clinically. We examined the role of MR neurography (MRN) in the evaluation of border nerve abnormalities and the results of treatments directed at the MRN-detected nerve abnormalities. MATERIALS AND METHODS This retrospective cross-sectional study included 106 subjects with groin or genital pain (mean [± SD] age, 50.7 ± 15.4 years) who showed mono- or multifocal neuropathy of the border nerves at 3-T MRN. Subjects who underwent CT-guided perineural injection were assessed for pain response. Injection responses were categorized as positive, possible positive, and negative. Subjects who received hyaluronidase, continuous radiofrequency ablation, or surgery were also evaluated for treatment outcomes. RESULTS One hundred forty abnormal nerves were positive for neuropathy in 106 studies. Eighty of 106 subjects had single neuropathy, and 26 had multifocal neuropathy. Fifty-eight subjects underwent CT-guided perineural injections, with five receiving bilateral injections (63 injections). Improvement in subjective pain was seen in 53 of 63 cases (84.2%). A statistically significant improvement in pain response was noted in the isolated ilioinguinal nerve block group as compared with the isolated genitofemoral nerve block group (p = 0.0085). Thirteen of 58 subjects received multiple nerve injections at the same sitting. Both groups receiving single or multiple nerve injections had similar improvement in pain scores of 84% and 85%, respectively, although this difference was not statistically significant. CONCLUSION Our retrospective analysis showed improved pain relief in subjects who underwent CT-guided nerve blocks on the basis of a positive MRN.
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Cirocchi R, Henry BM, Mercurio I, Tomaszewski KA, Palumbo P, Stabile A, Lancia M, Randolph J. Is it possible to identify the inguinal nerves during hernioplasty? A systematic review of the literature and meta-analysis of cadaveric and surgical studies. Hernia 2018; 23:569-581. [PMID: 30570686 PMCID: PMC6586705 DOI: 10.1007/s10029-018-1857-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 11/08/2018] [Indexed: 11/27/2022]
Abstract
Purpose Patients who undergo inguinal hernioplasty may suffer from persistent postoperative pain due to inguinal nerve injuries. The aim of this systematic review and meta-analysis was to provide comprehensive data on the prevalence (identification rates), anatomical characteristics, and ethnic variations of the ilioinguinal (IIN), the iliohypogastric (IHN) and the genital branch of the genitofemoral (GNF) nerves. Methods The systematic literature search was conducted using the PubMed, Scopus and Web of Science databases. Results A total of 26 articles (5265 half-body examinations) were included in this study. The identification rate of the IIN was 94.4% (95% CI 89.5–97.9) using a random-effects model. Unweighted multiple regression analysis showed that study sample size (β = − 0.74, p = .036) was the only statistically significant predictor of lower prevalence. The identification rates of the IHN and GNF was 86.7% (95% CI 78.3%–93.3%) and 69.1% (95% CI 53.1%–83.0%) using a random-effects model, respectively. For those outcomes, a visual analysis of funnel and Doi plots indicated irregularity and provided evidence that larger studies tended to have lower identification rates. In terms of the synthesis of anatomical reference points, there was a large and statistically significant amount of heterogeneity for most outcomes. Conclusions The identification rates of the inguinal nerves in our study were lower than reported in literature. The lowest was found for GNF, suggesting that this nerve was the most difficult to identify. Knowledge regarding the anatomy of the inguinal nerves can facilitate their proper identification and reduce the risk of iatrogenic injury and postoperative pain.
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Affiliation(s)
- R Cirocchi
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - B M Henry
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika Street, 31-034, Kraków, Poland.
| | - I Mercurio
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - K A Tomaszewski
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika Street, 31-034, Kraków, Poland
| | - P Palumbo
- Department of Surgical Sciences, The University of Rome "La Sapienza", Rome, Italy
| | - A Stabile
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - M Lancia
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - J Randolph
- Tift College of Education, Mercer University, Atlanta, GA, USA
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A step up therapeutic regimen for chronic post-Pfannenstiel pain syndrome. Eur J Obstet Gynecol Reprod Biol 2018; 231:248-254. [DOI: 10.1016/j.ejogrb.2018.10.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 10/21/2018] [Accepted: 10/23/2018] [Indexed: 01/04/2023]
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Abstract
Chronic postoperative inguinal pain has become a primary outcome parameter after elective inguinal hernia repair with significant consequences affecting patient productivity, employment, and quality of life. A systematic and thorough preoperative evaluation is important to identify the etiologies and types of pain. Owing to the complex nature of chronic pain, a multimodal and multidisciplinary treatment approach is recommended. Patients with chronic pain refractory to conservative measures may be considered for surgical intervention. Triple neurectomy remains the most definitive and accepted remedial operation performed and provides effective relief in the majority of patients.
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Affiliation(s)
- Q Lina Hu
- Department of Surgery, University of California at Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - David C Chen
- Department of Surgery, University of California at Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA.
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Abstract
INTRODUCTION Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery. METHODS An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients. CONCLUSIONS The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.
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Chen D, Graham D, MacQueen I. Inguinal neuroanatomy: Implications for prevention of chronic postinguinal hernia pain. INTERNATIONAL JOURNAL OF ABDOMINAL WALL AND HERNIA SURGERY 2018. [DOI: 10.4103/ijawhs.ijawhs_6_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Fritz J, Dellon AL, Williams EH, Rosson GD, Belzberg AJ, Eckhauser FE. Diagnostic Accuracy of Selective 3-T MR Neurography–guided Retroperitoneal Genitofemoral Nerve Blocks for the Diagnosis of Genitofemoral Neuralgia. Radiology 2017; 285:176-185. [DOI: 10.1148/radiol.2017161415] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jan Fritz
- From the Russell H. Morgan Department of Radiology and Radiological Science (J.F.), Department of Plastic and Reconstructive Surgery (A.L.D., E.H.W., G.D.R.), Department of Neurosurgery (A.J.B.), and Department of Surgery (F.E.E.), The Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287
| | - A. Lee Dellon
- From the Russell H. Morgan Department of Radiology and Radiological Science (J.F.), Department of Plastic and Reconstructive Surgery (A.L.D., E.H.W., G.D.R.), Department of Neurosurgery (A.J.B.), and Department of Surgery (F.E.E.), The Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287
| | - Eric H. Williams
- From the Russell H. Morgan Department of Radiology and Radiological Science (J.F.), Department of Plastic and Reconstructive Surgery (A.L.D., E.H.W., G.D.R.), Department of Neurosurgery (A.J.B.), and Department of Surgery (F.E.E.), The Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287
| | - Gedge D. Rosson
- From the Russell H. Morgan Department of Radiology and Radiological Science (J.F.), Department of Plastic and Reconstructive Surgery (A.L.D., E.H.W., G.D.R.), Department of Neurosurgery (A.J.B.), and Department of Surgery (F.E.E.), The Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287
| | - Allan J. Belzberg
- From the Russell H. Morgan Department of Radiology and Radiological Science (J.F.), Department of Plastic and Reconstructive Surgery (A.L.D., E.H.W., G.D.R.), Department of Neurosurgery (A.J.B.), and Department of Surgery (F.E.E.), The Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287
| | - Frederick E. Eckhauser
- From the Russell H. Morgan Department of Radiology and Radiological Science (J.F.), Department of Plastic and Reconstructive Surgery (A.L.D., E.H.W., G.D.R.), Department of Neurosurgery (A.J.B.), and Department of Surgery (F.E.E.), The Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287
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Karampinis I, Weiss J, Pilz L, Post S, Herrle F. Transabdominal laparoscopic retroperitoneal neurectomy for chronic pain after inguinal hernia repair and appendicectomy -a matched-pair study. BMC Surg 2017; 17:85. [PMID: 28728601 PMCID: PMC5520326 DOI: 10.1186/s12893-017-0282-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 07/14/2017] [Indexed: 11/10/2022] Open
Abstract
Background Chronic debilitating pain is a rare but significant cause of postoperative morbidity after inguinal surgery. Such pain is usually of neuropathic origin and frequently caused by intraoperative nerve damage. In this retrospective matched-pair study we analysed results of a minimal-invasive approach to neurectomy on quality of life and pain relief. Methods From March 2010 to January 2012, 9 patients developing chronic neuropathic pain after inguinal hernia repair (8 patients) or open appendicectomy (one patient) were operated using a laparoscopic transabdominal approach in our department. Clinical examinations and specific questionnaires on pain and quality of life (PainDetect, SF-36) were completed 6 months to 3 years after neurectomy. Every patient was matched with one patient without chronic pain. Results Seven of nine patients had severe or very severe pain before neurectomy, two had mild pain but refused a conservative treatment. Four patients were free of pain after neurectomy, three described an improved pain status, whereas two did not observe any change in pain. Within a follow-up period of 14,3 months, no deterioration of pain or other complications were observed. Patients who underwent neurectomy had significantly lower quality of life compared to the control group. No postoperative complications were observed. Conclusions Laparoscopic transabdominal neurectomy represents a possible surgical approach in treating patients with chronic disabling postoperative groin pain requiring surgery. This technique was feasible, safe, and effective in our series to relieve chronic debilitating pain in the majority of our patients with comparable results to other published approaches.
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Affiliation(s)
- Ioannis Karampinis
- Department of Surgery, Mannheim University Medical Centre, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Johannes Weiss
- Department of Surgery, GRN-Klinik Schwetzingen, Schwetzingen, Germany
| | - Lothar Pilz
- Department of Statistics, Mannheim University Medical Centre, University of Heidelberg, Mannheim, Germany
| | - Stefan Post
- Department of Surgery, Mannheim University Medical Centre, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Florian Herrle
- Department of Surgery, Mannheim University Medical Centre, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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Schwarz GM, Hirtler L. The cremasteric reflex and its muscle - a paragon of ongoing scientific discussion: A systematic review. Clin Anat 2017; 30:498-507. [DOI: 10.1002/ca.22875] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 03/06/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Gilbert M. Schwarz
- Division of Anatomy; Center for Anatomy and Cell Biology, Medical University of Vienna; Vienna Austria
| | - Lena Hirtler
- Division of Anatomy; Center for Anatomy and Cell Biology, Medical University of Vienna; Vienna Austria
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Belanger GV, VerLee GT. Diagnosis and Surgical Management of Male Pelvic, Inguinal, and Testicular Pain. Surg Clin North Am 2016; 96:593-613. [PMID: 27261797 DOI: 10.1016/j.suc.2016.02.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Pain occurs in the male genitourinary organs as for any organ system in response to traumatic, infectious, or irritative stimuli. A knowledge and understanding of chronic genitourinary pain can be of great utility to practicing nonurologists. This article provides insight into the medical and surgical management of subacute and chronic pelvic, inguinal, and scrotal pain. The pathophysiology, diagnosis, and medical and surgical treatment options of each are discussed.
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Affiliation(s)
- Gabriel V Belanger
- Division of Urology, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA
| | - Graham T VerLee
- Maine Medical Partners Urology, 100 Brickhill Avenue, South Portland, ME 04106, USA.
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Sakai T, Murata H, Hara T. A case of scrotal pain associated with genitofemoral nerve injury following cystectomy. J Clin Anesth 2016; 32:150-2. [DOI: 10.1016/j.jclinane.2016.02.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 01/27/2016] [Accepted: 02/16/2016] [Indexed: 10/21/2022]
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A cadaveric study of the anatomical variations of the lumbar plexus with clinical implications. J ANAT SOC INDIA 2016. [DOI: 10.1016/j.jasi.2016.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Oka S, Shiraishi K, Matsuyama H. Microsurgical Anatomy of the Spermatic Cord and Spermatic Fascia: Distribution of Lymphatics, and Sensory and Autonomic Nerves. J Urol 2016; 195:1841-7. [DOI: 10.1016/j.juro.2015.11.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Shintaro Oka
- Department of Urology, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Koji Shiraishi
- Department of Urology, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Hideyasu Matsuyama
- Department of Urology, Yamaguchi University School of Medicine, Yamaguchi, Japan
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Khan JS, Rai A, Sundara Rajan R, Jackson TD, Bhatia A. A scoping review of perineural steroids for the treatment of chronic postoperative inguinal pain. Hernia 2016; 20:367-76. [DOI: 10.1007/s10029-016-1487-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 03/19/2016] [Indexed: 11/25/2022]
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Aasvang E, Werner M, Kehlet H. Referred pain and cutaneous responses from deep tissue electrical pain stimulation in the groin. Br J Anaesth 2015; 115:294-301. [DOI: 10.1093/bja/aev170] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2015] [Indexed: 12/12/2022] Open
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