Post inguinal hernia repair

[vika bhandari]

Hi Steve,
With post inguinal hernia repair pain referrals, other then ruling out recurrent hernia which is very rare. What are the other areas you look for nerve entrapment?

Thanks
Vika

[Stephen Bird]

Hi Vika,

Great topic to discuss.

I must record a webinar on this topic soon.

But here are my thoughts.

I am lucky enough to do plenty of these scans.

In the immediate post op period they are easy with a simple diagnosis of a haematoma or abscess being the problem.

Down the track 6 months and they usually present to me with a sharp neural pain radiating to the testicle which is very debilitating.

It is most often a nerve entrapment.

Recurrence of hernia is relatively rare with mesh repairs and when I do see a recurrence it is usually a direct hernia through the posterior wall just medial to where the mesh finishes, just lateral to the pubic tubercle in the lower end of the canal not far from the superficial ring.

For neural entrapment there are several options.

The mesh fastening clips can be placed close to the ilioinguinal or iliohypogastric nerve bundles and if the clip is adjacent to the nerve the fibrous capsule that develops around the metallic clip can encase and entrap the nerve stopping it from “flossing” when the patient moves and creating sharp stabbing pain to the ipsilateral testicle.

So I go searching for the mesh fastening clips as they give a nice ring down artifact. When I find a clip I look for a neural structure passing to the location of the clip. The nerve is usually a hypoechoic mono-fascicle linear neural structure and it crashes into the clip or goes very close to it. Then I test with my finger to see if I can re-create the pain at this location (like a positive Tinels test).

If I can recreate the pain we hydro dissect the nerve from the clip with Celestone and Marcaine using plenty of volume and a 22G needle.

Most often it is not actually ilioinguinal or iliohypogastric, but some other random abdominal wall nerve, but it is cranky and entrapped.

This is my most common finding.

They take a fair bit of careful searching and I work closely with the patient to identify the trigger location.

If I cannot find anything you can try injecting the same solution into the inguinal canal. The canal contains the genital branch of the genitofemoral nerve and this can be irritated by the mesh and I suspect also gets entrapped. You cannot see the nerve, so just use plenty of volume and give it a good drink!

I find the gentlemen who suffer this are often fit and active and I suspect the lack of adiposity allows the clip and the nerve to get near each other without the natural insulating properties of adipose between them. Then also as they are fit and active, when they exercise (and it is often bedroom exercise with their partner that is a common trigger for pain, spoiling the moment somewhat) the nerve flosses during the exercise and as it is trapped it stretches and fires off the pain response. They describe it like a red hot poker to the testicle.

I do enjoy these scans,

They are challenging, but can be very rewarding.

Steve

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