JMSCR Vol||06||Issue||12||Page 318-327||December 2018 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 Dr Harekrishna Majhi et al JMSCR Volume 06 Issue 12 December 2018 Page 318 JMSCR Vol||06||Issue||12||Page 318-327||December 2018 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. Dr Harekrishna Majhi et al JMSCR Volume 06 Issue 12 December 2018 Page 319 JMSCR Vol||06||Issue||12||Page 318-327||December 2018 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. Dr Harekrishna Majhi et al JMSCR Volume 06 Issue 12 December 2018 Page 320 JMSCR Vol||06||Issue||12||Page 318-327||December 2018 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