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It’s not long (my summary is barely shorter, but for the sake of not violating copyright…)
It’s a letter to the editor from S. Huerta, Department of Surgery, VA North Texas Health Care System, University of Texas Southwestern Medical Center
– Best estimate of incidence of inguinodynia is 10%, but widely ranges between institutions (0-64%).
– Has done 1805 open (tissue and mesh) inguinal repairs in his practice since 2005, which is in a VA hospital with a closed system, so complications are dealt with in-house.
– Patients are all older vets, around 60yrs old with little variation in age, and he cites a rate of inguinodynia of 1.7%.He does the following to keep that rate low:
1. Watchful waiting, especially for younger patients, because many with inguinal pain don’t have a hernia, so surgery should only be done when hernia presents itself over time.
2. Elective ilioinguinal neurectomy. Cites meta-analysis of 16 RCTs comparing it with nerve preservation that found a significant reduction of inguinodynia at 6 months (9% vs. 25%), but no statistically significant difference at 12 months (9% vs. 18%). He electively resects the nerve, particularly in young patients, but elects to preserve it in cases where it is not readily identified (i.e. not typically located).
3. Cuts mesh to fit the inguinal canal of each patient, as it is possible (but not confirmed) that inguinodynia results from nerve entrapment following inflammatory reaction to mesh…less mesh, less likely to have reaction. He has used the same proline mesh since 2005.
4. Tissue repair. No one strategy fits all. Does Shouldice repair on young patients, with recurrence no different than mesh, because even if risk of recurrence was greater, can do posterior recurrence repair when they are older.
5. Smoking cessation – cites study that smoking is predictive of inguinodynia, so highly recommends his patients to stop six weeks prior to repair.
– notes that while intro of mesh has reduced recurrence rates overall, tissue repair is still appropriate for some cohorts.
– notes Desarda has similar recurrence to Lichetenstein, but carries lower inguinodynia risk.
– Can’t release his data due to privacy/legal reasons.