Although advances in inguinal hernia repair have markedly reduced recurrence rates, chronic pain after hernia repair is a continuing concern. In earlier reports, we have described the causes and prevention of chronic pain and emphasized the key features of groin neuroanatomy and the vulnerability of the intramuscular segment of the iliohypogastric nerve. We also have identified “meshoma” as a pathologic cause of inguinodynia and demonstrated the effectiveness of “triple neurectomy” as the surgical treatment for postherniorrhaphy pain that has not responded to non-surgical pain management.

“Triple Neurectomy,” pioneered in our institute in 1995, consists of resection of the ilioinguinal, iliohypogastric, and inguinal segment of the genital branch of the genitofemoral nerves. The procedure is performed through the incision of the original hernia repair and does not require mobilization of the spermatic cord. Originally, the iliohypogastric nerve was resected from its emergence from the internal oblique muscle to its point of exit from the external oblique aponeurosis. In 2004, realizing that the intramuscular segment of the iliohypogastric nerve can be injured when the lower edge of the internal oblique muscle (the so-called conjoined tendon) is sutured to the inguinal ligament during tissue repair, or due to fixation of a plug during plug repair, the operation was extended to include the intramuscular segment of the nerve. In 2005, a patient was referred with groin and testicular pain (to be distinguished from scrotal skin pain) and MRI evidence of entrapment of vas deferens within a plug. Since the patient had an earlier vasectomy, the affected segment of the vas was resected during the triple neurectomy. Postoperatively, the patient’s chronic groin pain and orchialgia disappeared, which was contrary to our experience with other patients with both orchialgia and inguinodynia.

Histologic analysis showed fibrosis and foreign-body reaction around the paravasal nerves within the lamina propria of the vas. In 18 subsequent patients with inguinodynia and orchialgia, a 2 cm segment of lamina propria was resected (without resecting the vas) as proximal to the inguinal ring as possible. Histology showed perineural fibrosis in these patients as well.

The incision is made through the original hernia repair and the external oblique aponeurosis is opened. The ilioinguinal nerve (Fig. 13.1) is identified between the internal ring (or the lateral part of the mesh if any was previously placed) and the anterior superior iliac spine. The nerve can be attached to the inguinal ligament or the upper leaf of the external oblique aponeurosis and blocked from the view by a retractor. The nerve can also be hidden within the fat-filled grooves of the internal oblique muscle; therefore, all superficial fat should be wiped from the internal oblique muscle to reveal the hidden nerve. The cut ends of the nerve are ligated to close the neurilemma of the nerve thus avoiding traumatic neuroma formation. The ligated proximal end of the nerve is buried within the internal oblique muscle to keep the stump of the nerve from being incorporated in future scarring of the surgical field.

The iliohypogastric nerve (Fig. 13.1) is located between the external and internal oblique aponeurotic layers. To identify the nerve, the anatomic cleavage between these two layers is opened. The visible part of the nerve over the internal oblique aponeurosis is identified and held by a vessel loop. A slit is made in the internal oblique muscle fibers to locate the intramuscular segment of the nerve (Fig. 13.2), which is then severed as proximal to the surgical field as possible. The cut ends of the nerve are ligated and the proximal cut end is buried within the internal oblique muscle. In fewer than 5% of patients, the normally visible part of the iliohypogastric nerve is under the internal oblique aponeurosis, therefore hidden from the surgeon’s view. In these patients, the subaponeurotic course of the nerve must be determined by noting the small point of its simultaneous exit from both external and internal oblique aponeuroses (Fig. 13.3). In these instances the internal oblique aponeurosis, under the above nerve exit point is incised to expose, trace, and resect the hidden nerve as laterally as possible.