Chapter 210: Postherniorrhaphy Inguinodynia: Causes, Prevention, and Surgical Treatment: Triple-Neurectomy 2149

layers covered and protected from mesh by

the investing fascia of the internal oblique
muscle (Fig. 3). The key step to expose the
iliohypogastric nerve is opening the ana-
tomic cleavage between the internal and
external oblique layers high enough to ex-
pose the internal oblique aponeurosis. This
step that takes only a few seconds easily and
automatically exposes the iliohypogastric
nerve. The iliohypogastric nerve has an eas-
ily visible part over the internal oblique
aponeurosis; however, below the point
marked by the arrow in Figure 4, the nerve
has a hidden segment that runs inferiorly and
laterally within the internal oblique muscle
(Figs. 4 and 6). This segment of the
iliohypogastric nerve is the most vulnerable
Fig. 1. Ilioinguinal nerve is located over the cord, covered and protected by the investing neural structure of the inguinal area because
fascia of the internal oblique fascia (pointed to by the arrow). it is not visible within the operative field.
Passing suture through the internal oblique
muscle, or the so-called conjoined tendon, for
its fixation to the inguinal ligament, flat
mesh, or plug has the potential risk of injur-
ing the intramuscular segment of the nerve
with the needle, or entrapping it by the su-
ture. In less than 5% of patients, the iliohypo-
gastric nerve runs under the internal oblique
aponeurosis in a subaponeurotic location. In
these cases the location of the nerve must be
determined by noting the point of its si-
multaneous exit from the external and inter-
nal oblique layers (Fig. 5). Furthermore, in
these instances, no suture or fixating device
should be inserted into the internal oblique
aponeurosis below the area marked by the
“xs” in Figure 5 to avoid injuring the nerve
that runs inferiorly and laterally underneath
the internal oblique aponeurosis (Fig. 6).

CAUSES OF NEUROPATHIC PAIN

Fig. 2. Inguinal segment of the genital branch of the genitofemoral nerve is located under the Neuropathic pain can be caused by (a) struc-
cord (pointed to by the arrow), covered and protected by the deep cremasteric fascia.
tural injuries such as axonotmesis (disrup-
tion of axon and myelin sheath with preser-
vation of the connective tissue covering of
the nerve), neurotmesis (partial or complete
severance of a nerve, with disruption of the
axon and its myelin sheath and the connec-
tive tissue elements) due to cutting, thermal, Nongastrointestinal Transabdominal Surgery
or traction injuries leading to traumatic
neuromaformation,andmyelindegeneration
and separation, axon crystallization due to
direct contact of nerves with mesh; (b) en-
trapment injuries by suture, fixating devices,
or wrinkled mesh or meshoma.

SURGICAL TREATMENT
OF NEUROPATHIC PAIN

Fig. 3. Iliohypogastric nerve is located between the external and internal oblique layers, covered and Triple neurectomy, advocated by us in 1995,
protected by the investing fascia of the internal oblique muscle. The arrow shows the junction of the is currently a universally accepted surgical
visible and hidden (intramuscular) segment of the nerve. treatment for neuropathic pain refractory