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www.jmscr.igmpublication.org Impact Factor (SJIF): 6.379 Index Copernicus Value: 79.54 ISSN (e)-2347-176x ISSN (p) 2455-0450 DOI: https://dx.doi.org/10.18535/jmscr/v6i12.50
Routine Ilionguinal and Iliohypogastric Nerve Excision in Lichenstein Hernia Repair - A Prospective Study of 50 Cases
Authors Dr Harekrishna Majhi1, Dr Bhupesh Kumar Nayak2 1Associate Professor, Department of General Surgery, VSS IMSAR, Burla 2Senior Resident, Department of General Surgery, VSS IMSAR, Burla Email: [email protected], Contact No.: 9437137230
Abstract Chronic inguinal neuralgia is one of the most significant complications following inguinal hernia repair. Subsequent patient disability can be severe & may often require numerous interventions for treatment. The purpose of the study is to evaluate long term outcomes following nerve excision to nerve preservation when performing lichenstein inguinal hernia repairs. A prospective study of cases with excision of illionguinal & illiohypogastric nerve excision during lichenstein hernia repair with post operative groin repair at 6 month & 1 yrs from May 2015-17 was carried out in the Deptt. of General Surgery, VSSIMSAR, Burla. neuralgia reported for Lichtenstein repair of Introduction inguinal hernias range from 6% to 29%. The No disease of human body, belongs to the probable cause of chronic inguiodynia after province of the surgeon, requires its treatment, a hernioplasty due to entrapment, inflammation, better combination of accurate anatomical ligation, neuroma or fibrotic reactions involving knowledge with surgical skill than hernia in all its ilioinguinal, iliohypogastric & genitial branch of variety. This statement made by SIR Astley genito-femoral nerve. Routine ilioinguinal nerve Cooper, 1804 & really a true aphorism to all & iliohypogastric nerve excision has been hernia surgeons. proposed as a means to avoid the troubling In most of the surgical OPDs, Inguinal hernia is a complication of long term postherniorrhaphy common entity. Indirect Inguinal Hernia or neuralgia. This excision would eliminate the Oblique inguinal hernia is the most common of all above mentioned possibilities. forms of hernia. Insult to the nerves may occur inform of In adult males, 65 % of inguinal hernias are Primary indirect & 55% are right sided. The hernia is Partial / complete division bilateral in 12% of cases. Stretching Chronic inguinal neuralgia is one of the most Crushing significant complications following hernia repair. Electrical damage Incidence of long term (≥ 1 year) postoperative
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Secondary 2. All repair had been performed by one Entrapment surgeon & team. Irritation by an adjacent inflammatory 3. Illioypogastric & illioinguinal were: reaction. identified & excised during operation. Adherence & Cicatricial compression with Post operative Assessment:- mesh Through personal interview & clinical Neuroma formation. examination at 1 month routine post- Usually the primary injury is not operative check-up at our surgery OPD. Appreciated at operation, nor is the etiologic Through telephone at 6 month and at 1 lesion, identifiable with certainty after the year Post-Operatively. neuralgia begins. Residual neuralgia deserves Out Comes evaluated are attention because they may result in severe 1. Chronic Post herniorrhapy groin pain morbidity and may become difficult to manage. a. Mild Pain Occasional pain or discomfort Study Group Does not limit activity During this period 50 patient were eligible for the Return to pre hernia life style study. All were admitted to this hospital for b. Moderate Pain inguinal hernia repair (herniorrhaphy or Prevents return to normal hernioplasty) preoperative activities such as Inclusion Criteria sports & lifting 1. Age 20-80 years. Analgesics rarely being needed 2. Males c. Severe Pain Exclusion Criteria Incapacitating I. Recurrent hernia Interferes with activity of daily II. Irreducible/ Strangulated hernia living III. Patients with Frequent need of analgesics Previous h/o stroke 2. Paresthesia (Numness) as told by the Peripheral neuropathy patients. Neuromuscular diseases. In this present study patients Were not aware of Diabetes mellitus excision of ilioinguinal nerve & illiohypogastric As from such patients no definite conclusion nerve. about pain or paresthesia can be made. Evolution of Hernia Surgery IV. Patients having Pre-operative inguinal The earlier record of inguinal hernia dates back to neuralgia. approximately 1500 BC. The ancient Greeks were All the patients were divided in to 2 groups based well aware of inguinal hernias & the term derives on routine excision of ilioinguinal nerve & from the Greek word, meaning an offshoot a illiohypogastic (Group – A) & preservation of building or bulge. ilioinguinal & illiohypogastic. The Latin word ‘hernia’ means a rupture or tear. In the earlier part of first century AD, Celus Principles Followed During the study described the operation in vogue at that time in the 1. All patients received the standard Greco-Roman area. technique of hernia repair i.e. Little information was added to the literature until Lichtenstein’s tension free hernioplasty the beginning of 18th century. From this time until using polypropelene mesh. the 19th century anatomy of inguinal region was described & accurately defined.
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Irving Lichtenstein (Born 1920) Technique of the Operation Lichtenstein received his medical education & 1. Exploration of Inguinal Canal surgical training at Hahnemann Medical School. 2. Indirect Hernia Sac– separated from the He is a Diploma of the American Board of cord up to neck and inverted into the Surgery (1950) & became a fellow of the abdomen without excision, suture or American College of Surgeons in 1952. ligature. Lichtenstein is the founder & director of the 3. Direct Hernia Sac – if large inverted by Lichtenstein Hernia Institute in Los Angles. means of a single absorbable invaginating Lichtenstein Tension- free Hernioplasty suture. Since the first true herniorrhaphy was performed 4. Monofilament Polypropelene Mesh is by Bassini over 100 year ago, all modifications & Used:- surgical techniques have shared a common Size 8 x 16 cm/5 x 10 cm disadvantages: suture line tension. The anatomic, Surface texture promotes fibroplasias physiologic & pathologic characteristics of hernia Monofilament structure does not recurrence are examined. The prime etiologic perpetuate or harbor infection. factor behind most hernigraphy failure is the Elicit little tissue reaction. suturing together, under tension of structure that is They are not rejected even in the not normally in opposition. presence of infection. With the use of modern mesh prosthetics, it is Fixation of Mesh now possible to repair all hernia without distortion Medical end of mesh made rounded to the of the normal and with no suture line tension. The shape of medical corner of inguinal Canal. technique is simple, rapid, less painful and First Stitch – Rounded corner is sutured with effective. Allowing prompt resumption of polypropelene (1-0) to the aponeurotic tissue unrestricted physical activity with the prosthesis over the pubic bone (periosteum of the bone for the repair of inguinal hernia in mind and is avoided). The mesh should overlap the focusing on the principal of “no tension” bone by 1 to 1.5 cm because failure to cover (considered one of the great principals of surgery this bone can result in recurrence. by Halsted), the Lichtenstein group popularized The Lower Edge is tacked in place by a routine use of mesh in 1984 and coined the term continuous suture to the inguinal ligament up “tension – free hernioplasty”. to a point just lateral to the internal ring. Main Principles in Lichtenstein Repair Suturing the mesh beyond this is unnecessary In the tension free hernioplasty instead of and could injure the femoral nerve. suturing anatomic structures that are not in A slit is made at the lateral end of mesh apposition (conjoint tendon & inguinal creating two tails, a wide one (2/3) above and ligament), the entire inguinal floor is narrower (1/3) below. The cord is placed reinforced by insertion of a sheet of mesh. between two tails near internal ring. The prosthesis, which is placed between the The superior edge of the mesh is loosely transversalis fascia & the external oblique secured by similar continuous suture aponeurosis extend well beyond the (interrupted in our Institution) to the rectus Hesselbach’s triangle to provide sufficient sheath & conjoined muscle & tendon above. mesh/issue interface. The wider upper tail is crossed & placed over On increased intra abdominal pressure the the narrower one. A single polypropelene external oblique aponeurosis applies counter suture approximates the tail of mesh to pressure on the mesh thus using the intra inguinal ligament lateral to the internal rings. abdominal pressure as a positive factor.
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This creates a new internal ring made of Anterior Wall mesh. 1. External oblique muscle Outcomes of the Operation 2. Internal oblique muscle 1. Post– operative pain: less than other Posterior Wall procedure. 1. Aponeurosis of transverses abdominis 2. Chronic groin pain: 6 % to 29% according muscle to different studies. 2. Fascia transversalis 3. Return to work : 3. Conjoint tendon (formed by aponeurotic 2 – 14 days post-operatively, fibers of internal oblique & transversus depending upon patient’s occupation. abdominis) infront of fascia transversalis. 2 days longer in bilateral inguinal hernias. Roof 4. Recurrence Rate: 1. Lower edge of the internal oblique muscle Uniform results from different 2. The transversus abdominis muscle & studies in different institution < 1% aponeursis. Some hernia recurred at pubic Floor tubercle because of failure to Grooved upper surface of inguinal ligament overlap the bone with mesh. (poupart’s) 5. Infection, hematoma & Seroma: Seen Upper surface of the lacunar ligament approximately < 1% of cases. (Gimbernat’s) Results of different studies 1. Can safely be performed under local Inlet of the Canal i.e. Deep inguinal ring: anesthesia It is a normal defect in the transversalis fascia. It 2. Immediate mobilization of patients. is an oval gap in fascia transversalis about 1.25 3. Early return to work. cm above the mid-inguinal point (mid-point 4. Minimal patient’s discomfort. between anterior superior iliac spine and the 5. Uniformly low recurrence rate <1% symphysis pubis. 6. Gaining increasing acceptance with surgeons around the globe. Structure Passing Through Superficial Ring: 7. 70% British surgeons are now using the IIio-inguinal nerve. Lichtenstein tension free method of hernia Contents of spermatic cord: repair. 1. Vas deferens- Most important structure Anatomy of Inguinal Canal & passes along posterior part of cord. It is a musculo-aponeurotic tunnel about 3.75 cm 2. Arteries long and extends from the deep inguinal ring to a. Testicular artery from abdominal aorta the superficial inguinal ring. The canal is directed b. Cremasteric artery from inferior downwards, forwards & medially above and epigastric parallel with the medial half of the inguinal c. Artery to vas deferens from superior or ligament. inferior vesical artery. Sensory Nerves of Groin Boundaries of Inguinal Canal 1. Iliohypogastric The canal presents anterior & posterior walls, 2. Ilioinguinal roof, floor, inlet & outlet. 3. Genital branch of genitor-femoral
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Iliohypogastric Nerve (L1) the inguinal canal and crossing the This emerges from the upper lateral border of ilioinguinal nerve as they decend to thigh. psoas major, crosses, obliquely behind lower renal Ilioinguinal Nerve (L1) pole and in front of quadritus lumborum (here the It is smaller than iliohypogastric nerve & arises nerve intervenes between the subcostal vessels & with it from the first lumbar ventral ramus. nerve above and the ilioinguinal nerve below) Course Emerges from lateral border of pasoa major, caudal to iliothypogastric At the lateral border of quadratus lumborum the nerve pierces the aponeurotic orgin of transversus Passes obliquely across the quadrates lumborum abdominis & the upper part of iliacus.
Runs between internal oblique and transversus At the anterior end of iliac crest perforates the abdominis & supplies both the muscles transverses abdominis, sometimes connecting with iliohypogastric nerve Close to iliac crest it divides into About 2.5 cm medial to anterior superior iliac spine pierces internal oblique, supplying it and Lateral cutaneous enters inguinal canal. branch Traverses the inguinal canal below the spermatic Pierces the internal & cord or round ligament of uterus. external oblique muscle Leaves the inguinal canal through superficial Crosses behind the inguinal ring with spermatic cord/round ligament tubercele of lilac crest of uterus.
Supplies posterolateral Supplies gluteal skin Upper & medial part of thigh Root of the penis Anterior cutaneous branch Upper part of scrotum Skin covering mons pubic & labium majus Passes forwarded & medially in female. It is encountered in its usual position only Pierces fleshly part of internal anterior superior in 60% of the patients. iliac spine. When aberrant, the course and position of the ilioinguinal nerve are. Then finally becomes cutaneous ny piercing the (a) Behind the cord external oblique apponeurosis (b) Within the cremaster muscle. Ilioninguinal nerve may sometimes do not Supplies suprapubic skin exist and cannot be found.
Iliohypogastric nerve connects with Sometimes exists as very small fibers. subcostal and ilio-inguinal nerves. Occasionally branches and inhibit of the Occasionally branches of the nerve fan out over the spermatic cord and iliohypogastric are seen passing anterior to in an anterior groin hernioplasty.
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It is usual to preserve this nerve, but it can neurilemma of a partially or completely interfare with the placement of the mesh and may divided nerve (neuroma formation) be traumatized inadvertently during operation. Compression of nerve by scar or suture. Nerve entrapment is a cause of chronic pain Character following hernia surgery and division of the nerve More or less permanent, varying degree may be required for relief. often burning and without spontaneous Genito-femoral Nerve (L1 L2) paroxysms. Origin: it is formed by the ventral rami of the first Body movements aggravates the pain and second lumbar nerves (L1, L2) while some body position alleviate the discomfort. Femoral Branch: Percussion of neuroma causes a severe Descends lateral to the external iliac artery lancinating pain. Crosses the deep circumflex iliac artery Hyperethesia occur in areas innervated by the nerve. Passes behind the inguinal ligament. Potentially treatable by surgical neurectomy or excision of the offending Enters the femoral sheath lateral to femoral artery lesion. 2. Differentiation (central) chronic pain Pieces the anterior layer of femoral sheath & facia Cause late. Interruption of afferent pathways of the Supplies the skin over the upper part of front of peripheral sensory nerves. thigh Lesions in peripherals nerve &
involvement of CNS. Diagnostic Consideration of Chronic Residual Character Neuralgia Burning type and permanent with Following Open Tension-Free Inguinal Hernia spontaneous paroxysmal exacerbations. Repair Onset of pain is delayed Character of chronic residual of neuralgia. Initially the area of skin involved is Invariably out proportion to the anesthetic, but this is soon replaced by apparent pathology variety of unpleasant sensations like Profound change in mood and hyperesthesia, hyperalgesia, hyperpathia & behavior and a depressive effect allodynia. predominates. Identification of sensory nerve involved Interpersonal relationships are Identifying the nerve by clinical disturbed and patients are unable to distribution of pain is often inaccurate return to work. because the 3 sensory nerves in groin Divided into 2 types on the basis of intermingle. pathogenesis By local anesthesia nerve blocks- 1. Nociceptive (somatic) chronic pain Iliphypogastric & ilioingunial 2. Differentiation (central) chronic pain nerves can be blocked in the groin
Neuralgia from genitofemoral 1. Nociceptive (somatic) chronic pain nerve can be identified by blocking Cause L1 & L2 paravertebrally. Repeated activation of pain fibers by the
proliferation of nerve fibers outside the
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Chronic Post-Herniorrhapht Groin pain completed the questionnaire. 30 % of subjects Lichtenstein et al (1988) described the cause of reported chronic pain and reported pain was severe and persistent pain after hernia surgery is predominantly neuropathic in character. Patients due to sensory nerve crushing. They have at increased risk of chronic pain were under 40 described an operative technique that prevents years old, had day-case surgery, had subsequent inadvertent crushing or division of sensory nerves surgery on the same side and recalled pain to groin with persistent postoperative pain, the operation. offending nerve is usually difficult to identify. Effect of ilionguinal neurectomy on chronic post- They first differentiate whether the pain is due to herniarrhaphy groin pain. ilioinguinal or genitocrural causalgia. When the Ravichandran et al (2000) studied 20 patients with particular nerve is incriminated, its division will primary bilateral hernia. Both sides were repaired ordinarily cure the problem. by a single surgeon under GA using Lichtenstein Charles P. Heise et al (1998) reported 117 tension free hernioplasty. In one side ilioinguinal inguinal reexplorations performed for nerve was divided cleanly lateral to the deep ring inguinodynia and 20 of these patients has primary where it would not interfere or come into contact mesh herniorrhaphy (3 patients had their initial with the mesh and in other side the nerve repair performed Laparoscopically) preserved. Patients were assessed for pain & Chronic groin pain persisted for 12. +_ 1.7 months numbness at 1 day, 1 month and 6 month post- before reexplorations 4 patients underwent plus operatively. inguinal reexploration & mesh nurectomy. After There is no evidence that elective division of remedial surgery, patients were followed up for ilioninguinal nerve is associated with any 15.9 +- 3.1 months. The 10 of 16 patients who had significant improvement in post-operative mesh removal plus neurectomy reported good to symptoms, but he limited sample size precludes excellent results (62 %) compared with 2 of 4 ant firm conclusions. reporting the same with mesh removal only George W. Dittrick et al (2004) published the (50%). incidence of postoperative neuralgia was Lastly they concluded that Mesh inguinodynia i.e. significantly lower in ilionguinal Neurectomy (Mesh herniorrhaphy with chronic groin pain) is a group versus the nerve preservation group at 1 definite symptom for patients. Remedial inguinal month 5% Vs 21 % at 6 months: 3 % Vs 25%. surgery with mesh removal and neurectomy will There was no significant difference in the cure this problem. incidence of postoperative neuralgia at 3 years i.e. George. E. Wantz (1993), performed about 1882 6% Vs 8%. anterior hernioplasries since 1970, the ilioinguinal Observations nerve was intentionally devided in 546 patients. Patient Profile Chronic groin pain was not seen in neurectomy 1 Total no. of patients 50 group, but was seen in whom nerve had been 2 Sex (all males) 50 3 Age 20-80 Years carefully preserved. So according to some 4 Number of patients available 25 (group A), surgeons routine excision of ilioinguinal nerve At. 1 month follow up 25 (group B) prevent the development of inguinal neuralgia. 5 Number of patients available 24 (group A), At 6 month follow up 22 (group B) Poobalan as et al (2001), reported the frequency 6 Number of patients available 24 (group A), and characteristics of chronic pain following open At 1 year follow up 22 (group B) inguinal hernia repair and identified certain risk factors for its development. In this study 351 patients underwent surgery for inguinal hernia by open methods. Out of these 226 patients (64%)
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At. 1 year Post-operative follows up standard technique every time. All repairs S. Authors Postoperative Post- were done under spinal anesthesia. No. groin pain operative Paresthesia In one group of 25 patients i.e. (Gr – A) Gr. A Gr. B Gr. A Gr. Ilioinguinal nerve illiohypogestric was B indentified and excised. 1 George. 3% 25% 13% 5% W. In another group of 25 patients i.e. (Gr – B) Dittrick et illioinguinal nerve illiohypogestic & al (20014) preserved. In 4 patients the nerve could not be 2 Tsakayanis 0% - 6.28% - et al (2004) identified & were included in nerve 3 Marcello 24% 27% 6% 4% preservation group. Picchio et al (2004) In all cases, early post-operative period was Incidence of Post-herniorrhaphy groin pain uneventful, during the hospital stay. In few and numbness in our present study: patients urinary retention was a problem on st 1 day of operation and was managed by Overall incidence of chronic groin pain in our bladder catheterization. prospective study. During hospital stay they were administered. Follow up Nerve Nerve Injectable antibiotics for first 2 days & period excision gr. A preservation gr. B injectable analgesic on 1st day. 6 month 12.4% 22.7% 1 year 4.16% 22.7% Then the patients were switched over to oral antibiotics. Incidence of postoperative paresthesia Stiches were removed on 7th post operative (numbness) over groin day and were discharged with a scrotal Follow up Gr. A Gr. B support. period nerve excision Nerve - In all cases wounds were healthily Preservation At. 6 month 4/24 16.64% 2/22 9.08% - No residual scrotal edema in any cases. At 1 year 3/24 12.48% 2/22 9.08% The present study has several limitations 1. Unable to perform clinical neurological Incidence of post-operative groin at 1 year examination at 6 month & 1 year for loss Pain Gr. A,n=24 Gr. B,n=22 of pain & touch sensation. nerve excision Nerve grp Preservation 2. Long term effort of ilionguinal neurectomy Presence of 1 4.16% 5 22.7% was not followed up. pain Mild pain 1 4.16 % 4 18.16% 3. Able to show that prophylactic neurectomy Moderate 0 0% 1 4.54% decreases the incidence of chronic groin pain pain, the exact reasoning behind this Severe pain 0 0% 0 0% phenomenon remains unknown.
Results Conclusion A total of 50 patients were admitted for This present study was conducted to evaluate the primary inguinal hernia repair (unilateral or effect of excision of ilionguinal nerve and bilateral), satisfying all the inclusion criteria illiohypogastric nerve tension free hernioplasty on in the study. postoperative chronic groin pain and parethesia in All were evaluated properly with preoperative the department of General Surgery, VSS IMSAR, minimum routine investigations. Burla during the period from May 2015 to 2017. All patients were polypropelene mesh, by a A total of 50 patients were admitted for primary single surgeon (operated with), with the inguinal hernia repair (unilateral or bilateral)
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satisfying all the inclusion criteria in the study. All Reference patients were treated with Lichtenstein tension 1. Georg. E, Wantz, MD, FACS, Testicular free hernioplasty with polypropelene mesh by atrophy and chronic residual neuralgia as a asingle surgeon with the standard technique every risk of inguinal hernioplasty surg. Clin time. North A M. 1993; 73:571-81. In 4 patients the nerve could not be identified & 2. Gray’s Anatomy. 38th edition. 1995. were included in nerve preservation group. In all 3. Irying L. Lichtenstein, MD , Aley G. cases early post-operative period was uneventful, Shulman, MD, parviz, K. Amid, MD, during the hospital stay. Michele M, Montllor, MD Los Angles, Post operative assessment for chronic groin pain California. Lichtenstein Tension free and numbness was carried out at 6 month and 1 Herioplasty. Am. J. Surg. 1989 (Feb): 157. year. At the end of the study both the group of 4. Lee CH, Dellon AL. Surgical management patients i.e. nerve excision group (Grp – A) and of groin pain of neural origin J Am Coll. nerve preservation group pain (Grp – B) were Surg. 2000 Aug; 191(2): 137-42. compared for (i) incidence of post herniorrhapy 5. Bower S. Moore BB, Weiss Sm. Neuralgia groin pain (ii) incidence of post herniorrhaphy after inguinal hernia repair. Am Surg. groin numbness. 1996; 62: 664-667 This prospective study showed a satisfactory 6. Bailey & Love’s. Short practice of significant decrease in the incidence of post surgery, 24th edition 2004 operative groin pain at 6 months and 1 year for 7. Aasvang E, Kehlet 4. Surgical patients in the ilioinguinal nerve & iliohypogastric management of chronic pain after inguinal excision group versus nerve preservation group. hernia repair. Br. J. Surg.2005 Jul: 92(7): This study also clearly demonstrated that elective 795-801. excision of ilioinguinal nerve and iliohypogastric 8. Bartlett DC, porter C, Kingsnorth AN. A nerve were not accompanied by a significant Pragmatic approach to cutaneous nerve increase in post-operative groin numbness. division during open inguinal hernia Furthermore, there was a consistence decrease in repair. Hernia 2007 Jun; 11(3): 243-6. incidence of post – operative numbness with 9. Bay-Nielsen M. Nilsson E, Nordin P, increasing time period in nerve excision group. Kehlet H, Chronic Pain after open mesh & The result of this prospective trial demonstrate sutured repair of indirect inguinal hernia in that prophylactic excision of illiohypogastric young males. Br. J. Surg. 2004 Oct; nerve ilioinguinal nerve during Lichtenstein 91(10):1372-6 tension free hernioplasty: 10. Courtney CA, Duffy K, Serpell MG, 1. Significantly decrease the incidence of O’Dwyer P.J. Outcomes of patients with chronic groin pain after surgery. severe chronic pain following repair of 2. Not associated with additional morbidities groin hernia. Br. J. Surg. 2002; 89:1310- in term of local cutaneous neurosensory 1314. disturbances. 11. Csontos Z, Kassai M, Lukais L, Barais J, 3. Safe to perform Horvath Po, Weber G. The results of 4. Well tolerated by the patients Lichtenstein Operation for groin hernias- 5. High patient satisfaction in terms of no Prospective multicenter study. Magy Seb. recurrence & no pain. 20015 Aug; 58(4) : 219-24. So ilionguinal and iliohypogestric neurectomy 12. D. Ravichandra, B.G. Kalmbe & J.A. Pain. should be considered as a routine surgical step Pilot randomized controlled study of during open mesh hernia repairs. preservation or division of ilioinguinal
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nerve in open mesh repair of inguinal hernia. Br. J. Surg. 2000; 87: 1166-1177. 13. D.E. Tsakayannis, A.C. Kiriakopoulous D.A. Linos. Elective nurectomy during open, “tension free”inguinal hernia repair. Hernia 2004 Feb; 8(1): 67-69. 14. Dennis R, O’ Riordan D. Risk factors for chronic pain after inguinal hernia repair. Ann R coll surg Engl. 2007 Apr; 89(3): 218-20. 15. Farquharson’s Text Book of Operative General Surgery. 9th edition. 2005. 16. Madura JA 2nd, Cooper CM, worth RM. Inguinal neurectomy for inguinal nerve entrapment: and experience with 100 patients. Am J. Surg. 2005 Mar; 189 (3) 283-7. 17. Schwart’z Principle of Surgery, 8th edition 2005.
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