Nerve removal – how is this an acceptable procedure?

[Unknown Member]

@alephy I agree.

https://www.researchgate.net/publication/264743520_Neurolysis_Neurectomy_and_Nerve_RepairReconstruction_for_Chronic_Pain

[Alephy]

I find outrageous that some surgeons would cut the nerves no matter what as a precaution…
I think the problem is many people end up having an hernia surgery and the volume of patients and the associated cost are the two main factors that funnel inadequate doctors into the surgery room…also consider the evil tendency of considering only one side of the coin and not the other ie no pain so it’s good, or no recurrence so it’s good…if it was a car you could opt out or choose a different one they would be bust in 1 month

[Unknown Member]

Dr Towfigh the transected branches of the nerves in a neurectomy or neurectomies run deep within the fascia along and within the muscles, not within the surface of the cutaneous level.

I’m sure we have micro cutaneous sensory nerves at the skin level that senses temp and pressure that communicates with the branch however during a neurectomy these micro nerves are not being dissected it’s the branch that’s being dissected…

From testimonial from patients who actually had their nerves resected and how these nerve branches travel anatomically I find it hard to believe there are just sensory only.

Yes we know numbness is expected but numbness seems to have indirect and direct effect on motor capacity.

If it’s just sensory why are so many neurectomy patients having motor deficits in the region of their neurectomy?

As PeterC politely puts his lower abdominal doesn’t exist anymore … how is an athlete who relies on controlling the core to adapt to different movements be able to perform and move properly to their respective sport when they can’t feel and flex their core muscle?

How is a man suppose to hold a proper erection upright when he can’t feel and flex half of the base of his penis root because of it being denervated from a ilioguinal neurectomy on one side?

I think if a neurectomy is being discussed a doctor should be transparent with all its morbidities, not just simply state that it will result in numbness …

[drtowfigh]

Neurolysis involves manipulation of the nerve without actually transecting or cutting it. Neurectomy involves cutting the nerve.

Cutting sensation to the skin does not affect muscle motor function.

[Unknown Member]

@spanish

https://med.nyu.edu/neurosurgery/physicians/a-z-technologies-guide/internal-neurolysis-peripheral-nerve-disorders

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1503540/

[Spanish]

Hi Jerome, thanks! But, then, what is the difference between neurolysis and neurectomy? If neurectomy is removing a nerv, what is neurolysis?

[Unknown Member]

@spanish I think its unrealistic for an athlete to go into a open mesh removal surgery with the belief that they will perform the same level as pre-mesh or better post mesh removal especially a removal that is open and includes neurectomy or neurectomties. I would carefully weigh your current physical activity level, what you can and cannot do and along with what is your personel level of acceptable pain level and make a realistic decision cause this procedure does have trade off and is pretty much a 50/50 coin flip. You maybe trading an existing problem with another problem or problems.

I also think depending on which nerve and how much of it is transected (length cut) will vary your “numbness” level which will indirectly lead to some motor capacity deficit and muscular atrophy despite it being so called purely “sensory”.

I also think the outcome will also depend on the technique of the neurectomy whether its cut tied buried or cut just buried. Some surgeons do not believe in tying prior to burial in muscle some do.

Neurolysis is definitely better than neurectomy, to my understanding it is essentially a nerve block and or removal of damaged portion of the nerve. I am doubtful majority of general surgeon are trained to carefully trim a damaged portion of the nerve skillfully, hence most prefer to simple transect it (neurectomy).

While Neurolysis and decompression should be prioritized over neurectomy, surgeons won’t know till they go in and assess the damage to the nerve whether they can cleanly release the nerve from mesh or scar tissue.

If it’s too much effort and can further damage the nerve they will performn a neurectomy and even if it can be released many prefer to cut it as prophylactic measure as the freed nerve can later get entrapped in scar tissue causing pain and they do not want to deal with the patient coming back with the pain.

If your surgeon says they can perform a neurolysis over neurectomy I think that is a good sign and he or she understand the importance and holistic function of the nerve beyond just the pain factor. However, neurectomy may still be possible cause they don’t know till they’re inside and mesh removal is not a clean procedure.

Best of luck Spaniard and keep us posted!

[Spanish]

I asked and they replied that the neurolysis means “taking care of your nerves and replacing them outside the suture line”. Do you think it makes sense? I’m a bit lost.

Thanks and Regards.

[Spanish]

Good intentions sent me this link from my thread… So neurectomy will lead to numbness and motor functionality decrease, i.e. if you’re an athlete you may recover from pain but you’ll never perform the same… is that correct?

[Unknown Member]

[Unknown Member]

Dr. Towfigh, How can muscle spindles in the groin muscles function properly when it’s “numb”,denervated? Muscles rely on sensory feedbacks to properly contract both voluntarily and involuntarily to changes in movement, pressure, and temperature. Just because its denervated at the cutaneous level doesn’t mean there is no direct or indirect impact to motor function. We need our muscles to contract properly for our locomotion to be dynamic as well be static. Without proper contraction it also atrophies. Without sensory there is a loss in motor control cause there is no feeling that initiates the feed back loop to the brain…

[drtowfigh]

Allow me to provide some of my own perspective, as a surgeon who ha does mostly chronic pain and revisional hernia repair and thus also performs neurectomies as needed:

– neurectomy should not be taken lightly and the nerves should be preserved as much as is possible.
– though the ilioinguinal and iliohypogastric nerves have both motor and sensory components upon its origin, they lose their motor component as they extend anteriorly in the groin. Thus, anterior neurectomy of these nerves has sensory side effects in most patients (ie numbness), but should not provide any motor dysfunction. This is why I am not an advocate of laparoscopic radical neurectomy except in extreme situations.
– the genital nerve branch does have motor function to the cremaster muscle in addition to sensory function.
– Neurolysis is an option in an i damaged nerve entrapped in, eg, scar tissue.
– in the case of a neuroma, there is no option other than neurectomy.
– neurosurgeons have little to no experience in how to handle peripheral nerves. At my institution, I am referred the peripheral (small) nerve pain, including meralgia paresthetica, as our neurosurgeons do not handle these.

[Unknown Member]

@peterc Thanks for sharing your experience and bringing attention to this topic.
I’ve been wondering the same for while doing a lot of research on neurectomy as someone experiencing complication with hernia mesh.

I’ve had my fair share of consults and yes surgeons are not truthful and honest about neurectomy and its full morbidity regardless whether its single, double or triple.

From a legal perspective a patch of “numbness” is sufficient enough, the minimum to cover the grounds of an informed consent. It’s not in a surgeon’s interest to explain the science behind numbness and its morbidity to a patient in its full extent.

Why would they? That would most certainty dissuade those that are on the fence and dampen the hope for those who are really suffering immensely looking for some sort of relief.

For a surgeon its very black and white. They’ll solve your chronic pain (neuropathic or nociceptive) with numbness, the following morbidity is not really their problem, especially when your damaged good already from their perspective.

Majority of surgeons are also not specialized to deal with nerves especially when their not a neurosurgeon.

For a general surgeon it’s not worth their time, effort, nor are they trained with the technical skills required to perform a decompression or neurolysis successfully.

It is more of a risk for them to further damage the nerve attempting the latter especially if a mesh is also involved.

There is a consensus that a damaged nerve isn’t worth saving, which is debatable given the circumstance and the extent of the damage. Nerves have the ability to heal and a neurectomy should not be a git go even if it’s damaged from an entrapment.

In my opinion nerves should be attempted to be saved at all cost and surgeons should do all they can do so, especially if that is the patient’s wish. There’s a reason why they preserve it in the original surgery, same should apply during a revision.

Unfortunately, in short for many surgeons cutting is easier and the expected outcome will yield to what was informed to the patient; numbness.

In addition to the aforementioned, there is the sad reality of the financial aspect. Non-profit or not, healthcare is a business after all and that entails maximizing revenue.

Hernia surgeries have the lowest reimbursement rates, a revision surgery even lower despite it being arduous, so adding neurectomy is another method to pad an already low reimbursement procedure. A provider can charge $5k or even more per neurectomy…you can do the math…

There’s been some proposal for multidisciplinary approach, however unless it’s a private pay by a VIP patient, it’s rare a neuro, vascular, and hernia surgeon to be in the same OR treating a hernia complication patient…

Lastly, there is a research aspect to neurectomy as well especially at the academic medical centers. With the ongoing research on nerves on individuals anatomical variations, demographics, and social factors surgeons at these leading institutes are performing experimental surgeries masked as medicine as sad to say.

They don’t really know what will happen as it varies from individual, most it seems don’t do well and it is proven 100% recovery is unrealistic. What started from anterior approach research has lead to development of laparoscopic preperitoneal and retro-peritoneal techniques, which tends to be on a extreme.

So is this all acceptable?
I think that is up to the individual patient at the end of the day. If one is faced with this unfortunate circumstance that is their decision to accept the procedure or not and in my opinion surgeons should be honest and forthright with the entire repercussion and especially do all they can to honor the patient’s wish provide the best chance of quality of life for those suffering.

[Alephy]

I am with you 100%! This is the problem ie doctors and surgeons do not see the whole body but just their bit…they may work together but in a assembly line fashion. Surgery is deemed successful if the patient doesn’t go back to the surgeon….never mind if they have to be followed for chronic pain by another doctor for the rest of their lives….I bet if your surgeon were required to follow you after the surgery in case of complications the whole process would be very different….the main point of hernia surgery is avoiding a recurrence….recurrence recurrence recurrence…divide and conquer cam lead to catastrophe in medicine

[PeterC]

I can’t find the edit button on the mobile version of these new forums but Id like to add – I understand in some cases of major nerve damage this procedure may be the only resort.

I’m talking about how this is has become a standard procedure – the first thing that was offered to me by a top surgeon whos the director of the board of surgeons in my city was the nerve removal and how hes done it to other athletes/olympians/hockey players – regardless of symptoms.

[PeterC]

Definitely appreciate the insight doc.