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A study to improve identification of the retroperitoneal course of iliohypogastric, ilioinguinal, femorocutaneous and genitofemoral nerves during laparoscopic triple neurectomy

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Abstract

Background

Laparoscopic triple neurectomy is an available treatment option for chronic groin pain, but a poor working knowledge of the retroperitoneal neuroanatomy makes it an unsafe technique.

Object

Describe the retroperitoneal course of iliohypogastric, ilioinguinal, lateral femoral cutaneous and genitofemoral nerves, to guide the surgeon who operates in this region.

Methods

Fifty adult cadavers were dissected resulting in 100 anatomic specimens. Additionally, 30 patients were operated for refractory chronic inguinal pain, using laparoscopic triple neurectomy. All operations and dissections were photographed. Measurements were made between the nerves of the lumbar plexus and various landmarks: interneural distances in a vertical midline plane, posterior or anterior iliac spine and branch presentation model.

Results

The ilioinguinal and iliohypogastric nerves were independent in 78% (Type II) and separated by an average of 2.5 ± 0.8 cm. In surgery study, only 38% were recognized as Type II and at a significantly greater distance (3.5 ± 1.2 cm, p < 0.001). The distance between ilioinguinal and lateral femoral cutaneous nerves was also greater during surgery, with statistical significance (5.1 ± 1.5 versus 4.2 ± 1.5, p < 0.005). The distance of the nerves to their bone references were not statistically different. The genitofemoral nerve emerged from the psoas major muscle in 20% as two separate branches (Type II), regardless of the study. The lateral femoral cutaneous nerve had a mean distance of 0.98 ± 1.6 cm medial to the anterior superior iliac spine.

Conclusion

The identification of the IH, II, FC and GF nerves is essential to reduce the rate of failures in the treatment of CGP. The frequent anatomical variations of the lumbar plexus nerves make knowledge of their courses in the retroperitoneal space essential to ensure safe surgery. The location of the nerves in the LTN is distorted by up to 1 cm. regarding references in the cadavers.

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Abbreviations

IH:

Iliohypogastric

II:

Ilioinguinal

LFC:

Lateral femoral cutaneous

GF:

Genitofemoral

Gb:

Genital branch

Fb:

Femoral branch

P:

Psoas major

I:

Iliacus

TA:

Transversus abdominis

QL:

Quadratus lumborum

Il:

Iliolumbar ligament

PSIS:

Posterior superior iliac spine

ASIS:

Anterior superior iliac spine

References

  1. Ducic I, West J, Maxted W (2008) Management of chronic postoperative groin pain. Ann Plast Surg 60:294–298

    Article  CAS  PubMed  Google Scholar 

  2. Loos MJ, Roumen RM, Scheltinga MR (2007) Classifying post-herniorrhaphy pain syndromes following elective inguinal hernia repair. World J Surg 31:1760–1765

    Article  CAS  PubMed  Google Scholar 

  3. Lee CH, Dellon AL (2000) Surgical management of groin pain of neural origin. J Am Coll Surg 191:137–142

    Article  CAS  PubMed  Google Scholar 

  4. Moreno-Egea A (2016) Surgical management of postoperative chronic inguinodynia by laparoscopic transabdominal preperitoneal approach. Surg Endosc 30(12):5222–5227

    Article  CAS  PubMed  Google Scholar 

  5. Moreno-Egea A (2018) Preperitoneal transabdominal laparoscopic neurectomy as a treatment for inguinodynia. Personal experience and details of the surgical technique. Rev Hispanoam Hernia 6(2):69–74

    Article  Google Scholar 

  6. Klaassen Z, Marshall E, Shane Tubbs R, Robert GL Jr, Wartmann CT, Loukasi M (2011) Anatomy of the ilioinguinal and iliohypogastric nerves with observations of their spinal nerve contributions. Clin Anat 24:454–461

    Article  PubMed  Google Scholar 

  7. Wijsmuller AR, Lange JF, Kleinrensink GJ, van Geldere D, Simons MP, Huygen FJ et al (2007) Nerve identifying inguinal hernia repair: a surgical anatomical study. World J Surg 31:414–420

    Article  CAS  PubMed  Google Scholar 

  8. Rab M, Ebmer J, Dellon AL (2001) Anatomic variability of the ilioinguinal and genitofemoral nerve: implications for the treatment of groin pain. Plast Reconstr Surg 108:1618–1623

    Article  CAS  PubMed  Google Scholar 

  9. Tubbs RS, Salter EG, Wellons JC 3rd, Blount JP, Oakes WJ (2005) Anatomical landmarks for the lumbar plexus on the posterior abdominal wall. J Neurosurg Spine 2(3):335–358

    Article  PubMed  Google Scholar 

  10. Loos MJ, Scheltinga MR, Roumen RM (2010) Tailored neurectomy for treatment of postherniorrhaphy inguinal neuralgia. Surgery 147:275–281

    Article  PubMed  Google Scholar 

  11. Andresen K, Rosenberg J (2018) Management of chronic pain after hernia repair. J Pain Res 11:675–681

    Article  PubMed  PubMed Central  Google Scholar 

  12. HerniaSurge Group (2018) International guidelines for groin hernia management. Hernia 22(1):1–165

    Article  Google Scholar 

  13. Chen DC, Hiatt JR, Amid PK (2013) Operative management of refractory neuropathic inguinodynia by a laparoscopic retroperitoneal approach. JAMA Surg 148(10):962–967

    Article  PubMed  Google Scholar 

  14. Moore AM, Bjurstrom MF, Hiatt JR, Amid PK, Chen DC (2016) Efficacy of retroperitoneal triple neurectomy for refractory neuropathic inguinodynia. Am J Surg 212(6):1126–1132

    Article  PubMed  Google Scholar 

  15. Song JW, Wolf JS, McGillicuddy JE, Bhangoo S, Yang LJ (2011) Laparoscopic triple neurectomy for intractable groin pain: technical of 3 cases. Neurosurgery 68:339–346

    PubMed  Google Scholar 

  16. Madura JA, Madura JA II, Copper CM, Worth RM (2005) Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patients. Am J Surg 189:283–287

    Article  PubMed  Google Scholar 

  17. Bjurström MF, Nicol AL, Amid PK, Lee CH, Ferrante FM, Chen DC (2017) Neurophysiological and clinical effects of laparoscopic retroperitoneal triple neurectomy in patients with refractory postherniorrhaphy neuropathic inguinodynia. Pain Pract 17(4):447–459

    Article  PubMed  Google Scholar 

  18. Engelen M, Dilen K, Baten E (2017) Laparoscopic treated neuralgia after inguinal hernia repair: case report and literature review. Acta Chir Belg 117(5):283–289

    Article  CAS  PubMed  Google Scholar 

  19. Karampinis I, Weiss J, Pilz L, Post S, Herrle F (2017) Transabdominal laparoscopic retroperitoneal neurectomy for chronic pain after inguinal hernia repair and appendicectomy—a matched-pair study. BMC Surg 17(1):85

    Article  PubMed  PubMed Central  Google Scholar 

  20. George T, Williams EH, Franklin R, Lee Dellon A (2019) Two team surgical approach to improve retroperitoneal nerve identification in the treatment of groin pain. Ann Plast Surg 82(1):82–84

    Article  CAS  PubMed  Google Scholar 

  21. Al-dabbagh AKR (2002) Anatomical variations of the inguinal nerves and risks of injury in 110 hernia repairs. Surg Radiol Anat 24:102–107

    Article  CAS  PubMed  Google Scholar 

  22. Moreno-Egea A, Moreno Latorre A. (2019) Triple neurectomy versus selective neurectomy in the laparoscopic approach to chronic inguinal pain? Anatomo-surgical response. Rev Hispanoam Hernia 7(1):35–40

    Article  Google Scholar 

  23. Ndiaye A, Diop M, Ndoye JM, Konaté I, Ndiaye AI, Mané L et al (2010) Anatomical basis of neuropathies and damage to the ilioinguinal nerve during repairs of groin hernias (about 100 dissections). Surg Radiol Anat 29(8):675–681

    Article  Google Scholar 

  24. Whiteside JL, Barber MD, Walters MD, Falcone T (2003) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions. Am J Obstet Gynecol 189(6):1574–1578

    Article  PubMed  Google Scholar 

  25. Cirocchi R, Henry BM, Mercurio I, Tomaszewski KA, Palumbo P, Stabile A et al (2019) Is it possible to identify the inguinal nerves during hernioplasty? A systematic review of the literature and meta-analysis of cadaveric and surgical studies. Hernia 23(3):569–581

    Article  CAS  PubMed  Google Scholar 

  26. Reinpold W, Schroeder AD, Schroeder M, Berger C, Rohr M, Wehrenberg U (2015) Retroperitoneal anatomy of the iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve: consequences for prevention and treatment of chronic inguinodynia. Hernia 19:539–548

    Article  CAS  PubMed  Google Scholar 

  27. Moritz T, Prosch H, Berzaczy D, Happak W, Lieba-Samal D, Bernathova M, Auff E, Bodner G (2013) Common anatomical variation in patients with idiopathic meralgia paresthetica: a high resolution ultrasound case-control study. Pain Phys 16(3):E287–293

    Google Scholar 

  28. Mattera D, Martínez F, Soria V, Verdier V, Salle F, Saibene A, Rapalini J, Cúneo A, Silveri C, Acevedo D (2008) Surgical anatomy of the lateral femoral cutaneous nerve in the groin region. Eur J Anat 12(1):33–37

    Google Scholar 

  29. Ray B, D'Souza AS, Kumar B, Marx C, Ghosh B, Gupta NK, Marx A (2010) Variations in the course and microanatomical study of the lateral femoral cutaneous nerve and its clinical importance. Clin Anat 23(8):978–984

    Article  PubMed  Google Scholar 

  30. Majkrzak A, Johnston J, Kacey D, Zeller J (2010) Variability of the lateral femoral cutaneous nerve: an anatomic basis for planning safe surgical approaches. Clin Anat 23:304–311

    CAS  PubMed  Google Scholar 

  31. Tomaszewski KA, Popieluszko P, Henry BM, Roy J, Sanna B, Kijek MR, Walocha JA (2016) The surgical anatomy of the lateral femoral cutaneous nerve in the inguinal region: a meta-analysis. Hernia 20(5):649–657

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Iwanaga J, Simonds E, Schumacher M, Kikuta S, Watanabe K, Shane Tubbs R (2019) Revisiting the genital and femoral branches of the genitofemoral nerve: suggestion for a more accurate terminology. Clin Anat 32:458–463

    Article  PubMed  Google Scholar 

  33. Geh N, Schultz M, Yang L, Zeller J (2015) Retroperitoneal course of iliohypogastric, ilioinguinal, and genitofemoral nerves: a study to improve identification and excision during triple neurectomy. Clin Anat 28(7):903–909

    Article  PubMed  Google Scholar 

  34. Avsar FM, Sahin M, Arikan BU, Avsar AF, Demirci S, Elhan A (2002) The possibility of nervus ilioinguinalis and nervus iliohypogastricus injury in lower abdominal incisions and effects on hernia formation. J Surg Res 107:179–185

    Article  PubMed  Google Scholar 

  35. van Schoor A-N, Marius C, Bosman MC, Bosenberg AT (2013) Revisiting the anatomy of the ilio-inguinal/iliohypogastric nerve block. Pediatr Anesth 23:390–394

    Article  Google Scholar 

  36. Sürücü HS, Tanyeli E, Sargon MF, Karahan ST (1997) An anatomic study of the lateral femoral cutaneous nerve. Surg Radiol Anat 19:307–310

    Article  PubMed  Google Scholar 

  37. Hospodar PP, Ashman ES, Traub JA (1999) Anatomic study of the lateral femoral cutaneous nerve with respect to the ilioinguinal surgical dissection. J Orthop Trauma 13:17–19

    Article  CAS  PubMed  Google Scholar 

  38. Grothaus MC, Holt M, Mekhail AO, Ebraheim NA, Yeasting RA (2005) Lateral femoral cutaneous nerve: an anatomic study. Clin Orthop Relat Res 437:164–168

    Article  Google Scholar 

  39. Mischkowski RA, Selbach I, Neugebauer J, Koebke J, Zöller JE (2006) Lateral femoral cutaneous nerve and iliac crest bone grafts—anatomical and clinical considerations. Int J Oral Maxillofac Surg 35:366–372

    Article  CAS  PubMed  Google Scholar 

  40. Bjurlin MA, Davis KE, Allin EF, Ibrahim DT (2007) Anatomic variations in the lateral femoral cutaneous nerve with respect to pediatric hip surgery. Am J Orthop (Belle Mead NJ) 36:143–146

    Google Scholar 

  41. Doklamyai P, Agthong S, Chentanez V, Huanmanop T, Amarase C, Surunchupakorn P, Yotnuengnit P (2008) Anatomy of the lateral femoral cutaneous nerve related to inguinal ligament, adjacent bony landmarks, and femoral artery. Clin Anat 21:769–774

    Article  PubMed  Google Scholar 

  42. Bodner G, Bernathova M, Galiano K, Putz D, Martinoli C, Felfernig M (2009) Ultrasound of the lateral femoral cutaneous nerve: Normal findings in a cadaver and in volunteers. Reg Anesth Pain Med 34:265–268

    Article  PubMed  Google Scholar 

  43. Sim IW, Webb T (2004) Anatomy and anaesthesia of the lumbar somatic plexus. Anaesth Intensive Care 32:178–187

    Article  CAS  PubMed  Google Scholar 

  44. Anloague PA, Huijbregts P (2009) Anatomical variations of the lumbar plexus: a descriptive anatomy study with proposed clinical implications. J Man Manip Ther 17(4):e107–114

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Hernia Clinic, La Vega University Hospital, Avda Primo de Rivera 7, 5ºD, 3008, Murcia, Spain

    Alfredo Moreno-Egea

  2. School of Medicine, San Antonio University, Murcia, Spain

    Alfredo Moreno-Egea

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Correspondence to Alfredo Moreno-Egea.

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Moreno-Egea, A. A study to improve identification of the retroperitoneal course of iliohypogastric, ilioinguinal, femorocutaneous and genitofemoral nerves during laparoscopic triple neurectomy. Surg Endosc 35, 1116–1125 (2021). https://doi.org/10.1007/s00464-020-07476-w

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