Inguinal Hernia Management: Focus on Pain

In the Netherlands approximately 31,000 inguinal hernias are corrected yearly, making it one of the most frequently performed operations in surgery. The majority of inguinal hernia repairs is conducted in male patients older than 50 years. Since recurrence rates have been reduced to a few per cent after mesh repair, nowadays morbidity associated with open inguinal hernia repair is mainly related to chronic pain. The incidence of chronic pain has been reported to be up to 53%, however reported incidences are variable due to different defnitions of chronic pain. A working group that recently developed the European Hernia Society (EHS) guidelines for treatment of inguinal hernia estimated the overall incidence of moderate to severe chronic pain after hernia surgery to be around 10-12%. The primary endpoint in studies regarding inguinal hernia repair has been recurrence up to now. Currently, such studies have also focused on chronic pain. The choice for surgical treatment of an inguinal hernia is based on dissolving pain and discomfort associated with the hernia. Additionally, this prevents an emergency operation necessary in case of incarceration and/or strangulation of the previous harmless hernia that is associated with higher morbidity and mortality compared to elective surgery. However, the indication for elective surgery should not only depend on consideration of mortality rates that are associated with emergency and elective repair. The rate of incarceration and/or strangulation of a conservatively treated hernia, the rate of recurrence of a hernia postoperatively, contra-indications, preoperative pain and discomfort associated with the hernia, the natural course of pain and the incidence of chronic postoperative pain should also be taken into account

A step towards stereotactic navigation during pelvic surgery: 3D nerve topography

Background: Long-term morbidity after multimodal treatment for rectal cancer is suggested to be mainly made up by nerve-injury-related dysfunctions. Stereotactic navigation for rectal surgery was shown to be feasible and will be facilitated by highlighting structures at risk of iatrogenic damage. The aim of this study was to investigate the ability to make a 3D map of the pelvic nerves with magnetic resonance imaging (MRI). Methods: A systematic review was performed to identify a main positional reference for each pelvic nerve and plexus. The nerves were manually delineated in 20 volunteers who were scanned with a 3-T MRI. The nerve identifiability rate and the likelihood of nerve identification correctness were determined. Results: The analysis included 61 studies on pelvic nerve anatomy. A main positional reference was defined for each nerve. On MRI, the sacral nerves, the lumbosacral plexus, and the obturator nerve could be identified bilaterally in all volunteers. The sympathetic trunk could be identified in 19 of 20 volunteers bilaterally (95%). The superior hypogastric plexus, the hypogastric nerve, and the inferior hypogastric plexus could be identified bilaterally in 14 (70%), 16 (80%), and 14 (70%) of the 20 volunteers, respectively. The pudendal nerve could be identified in 17 (85%) volunteers on the right side and in 13 (65%) volunteers on the left side. The levator ani nerve could be identified in only a few volunteers. Except for the levator ani nerve, the radiologist and the anatomist agreed that the delineated nerve depicted the correct nerve in 100% of the cases. Conclusion: Pelvic nerves at risk of injury are usually visible on high-resolution MRI w