AbstractMinimally invasive approaches have become standard for pediatric appendectomy. The laparoscopic assisted single port approach, also known as the “all-in-one” appendectomy, has gained recent popularity [1]. We describe a child who suffered meralgia paresthetica (a neuropathy in the distribution of the lateral femoral cutaneous nerve) after a laparoscopic assisted single port appendectomy, perhaps secondary to mobilization of the cecum

Dolgin, Stephen E.

Fike, Frankie B.

Hong, Andrew R.

Ng, Andrew M.

Schneider, Steven J.

Journal of Pediatric Surgery Case Reports

Minimally invasive approaches have become standard for pediatric appendectomy. The laparoscopic assisted single port approach, also known as the “all-in-one” appendectomy, has gained recent popularity [1]. We describe a child who suffered meralgia paresthetica (a neuropathy in the distribution of the lateral femoral cutaneous nerve) after a laparoscopic assisted single port appendectomy, perhaps secondary to mobilization of the cecum

Ng, A. M.

Hong, A. R.

Dolgin, S. E.

Hofstra Northwell Academic Works (Hofstra Northwell School of Medicine)

Meralgia paresthetica after “all-in-one” appendectomy

Andrew M. Ng

Frankie B. Fike

Steven J. Schneider

Andrew R. Hong

Stephen E. Dolgin

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Elsevier - Publisher Connector 

Meralgia paresthetica after “all-in-one” appendectomy 

Contents lists available at ScienceDirect
J Ped Surg Case Reports 3 (2015) 521e522Journal of Pediatric Surgery CASE REPORTS
journal homepage: www.jpscasereports .comMeralgia paresthetica after “all-in-one” appendectomy
Andrew M. Ng a,*, Frankie B. Fike b, Steven J. Schneider c, Andrew R. Hong b,
Stephen E. Dolgin b
aHofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA
bDepartment of Surgery, Cohen Children’s Medical Center, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
cDepartment of Pediatric Neurosurgery, Cohen Children’s Medical Center, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USAa r t i c l e i n f o
Article history:
Received 14 August 2015
Received in revised form
8 October 2015
Accepted 10 October 2015
Key words:
Meralgia paresthetica
Laparoscopic assisted single port
appendectomy
Lateral femoral cutaneous nerve* Corresponding author. Hofstra North Shore-LIJ Sch
University, Hempstead, NY 11549, USA. Tel.: þ1 516 46
E-mail address: ang5@pride.hofstra.edu (A.M. Ng).
2213-5766/ 2015 The Authors. Published by Elsevier
http://dx.doi.org/10.1016/j.epsc.2015.10.007a b s t r a c t
Minimally invasive approaches have become standard for pediatric appendectomy. The laparoscopic
assisted single port approach, also known as the “all-in-one” appendectomy, has gained recent popu-
larity [1]. We describe a child who suffered meralgia paresthetica (a neuropathy in the distribution of the
lateral femoral cutaneous nerve) after a laparoscopic assisted single port appendectomy, perhaps sec-
ondary to mobilization of the cecum.
 2015 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).1. Case report
A 12 year old female presented to the emergency room 6 days
after undergoing an uneventful “all-in-one” appendectomy for
uncomplicated appendicitis, a diagnosis conﬁrmed by histopa-
thology. The patient complained after discharge of persistent pain
in the right lower quadrant associated with nausea. She also was
suffering numbness over the anterior and lateral right thigh. The
patient’s mother stated that her daughter’s gait had been limited by
pain when she bore weight on the right leg. The patient denied
fevers, sick contacts, and vomiting. She had been tolerating a reg-
ular diet, passing ﬂatus, and having bowel movements. She had
been generally well prior to the episode of appendicitis.
Initial abdominal exam was normal except for mild tenderness
in the right lower quadrant without signs of peritonitis. The single
umbilical trocar site was healing without infection. The patient
demonstrated limited right lower extremity strength on ﬂexion and
decreased sensation to light touch over the lateral and anterior
right thigh.
Laboratory studies revealed a normal complete blood count,
basic metabolic panel and urinalysis. Abdominal and hipool of Medicine, 500 Hofstra
3 7516; fax: þ1 516 463 5631.
Inc. This is an open access article uultrasounds were normal, with no evidence of intra-abdominal
abscess or hip joint effusion, respectively. An abdomen and pelvis
CT scan was also negative. An MRI of the lumbosacral plexus and
pelvis revealed post surgical inﬂammation with no collection.
Based on the clinical ﬁndings, meralgia paresthetica was sus-
pected. A lateral femoral cutaneous nerve block was performed
using 10 cc of .25% ropivicaine by the anesthesia pain service with
pain relief for 12e16 h. The pain and paresthesia then returned. The
patient was evaluated and treated by physical therapy throughout
her hospital course and was able to ambulate independently with a
walker at discharge. Two months later, the patient reported the
ability to ambulate independently but continued to experience
groin and hip pain, subjective right leg weakness and right lateral
lower thigh numbness despite twice week therapy. At six months,
the sensory deﬁcit in the anterolateral thigh was improving and
there were no motor ﬁndings.2. Discussion
Meralgia paresthetica (MP) is a mononeuropathy of the lateral
femoral cutaneous nerve, a sensory branch of the lumbar plexus
originating from the dorsal roots of the second and third lumbar
ventral rami [1,2]. The nerve then emerges from the lateral border
of the psoas major muscle and crosses the iliac muscle toward the
anterior superior iliac spine (ASIS) [3]. MP has a reported incidencender the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A.M. Ng et al. / J Ped Surg Case Reports 3 (2015) 521e522522of 4.3 per 10,000 person years [4]. MP is classically caused by
compression of the nerve as it passes through or under the inguinal
ligament [5]. The occurrence is typically idiopathic, but can be
secondary to trauma or surgical procedures, most commonly hip
joint replacement and spine operations [6]. Moritz et al. demon-
strated that a shorter distance between the lateral femoral cuta-
neous nerve and the ASIS is associated with development of MP,
mostly secondary to mechanical stress [7]. MP has been reported in
the literature as a rare complication of laparoscopic appendectomy,
inwhich the lateral femoral cutaneous nervewas injured secondary
to the insertion of a trocar in the right abdominal quadrant [8].
Since our patient underwent placement of a single umbilical trocar
that mechanism is not pertinent to this case. We speculate that
injury to the nerve did not occur in the typical location at the
inguinal ligament, but occurred in the retroperitoneum during the
mobilization of the cecum, a routine feature of the “all-in-one”
appendectomy [9]. However, we have not found examples in the
literature of meralgia paresthetica attributed to this mechanism.
While obesity is a contributing factor to the development of MP, our
patient had a BMI of 16.6 kg/m2. Other etiologies seen in the adult
population include positioning or compression by safety belt; the
later may be related to seat belt trauma seen in the literature [10].
MP presents with a sensory deﬁcit in the distribution of the
lateral femoral cutaneous nerve, speciﬁcally the anterolateral
aspect of the thigh and does not extend below the knee. Patients
typically complain of sharp pain, numbness, burning, and even a
sensation similar to a cell phone vibrating. In idiopathic cases, MP
can present with the tenderness over the lateral femoral cutaneous
nerve at the origin of the inguinal ligament at the anterior superior
iliac spine [11]. There are no motor deﬁcits as this nerve contains
purely sensory nerve ﬁbers.
There are various conditions that present similarly to MP,
including lumbar radiculopathy, trochanteric bursitis, and primary
hip disease. Patients with lumbar radiculopathy have back pain
associated with reﬂex, motor and sensory changes. On the other
hand, patients with MP do not complain of back pain and do not
have motor or reﬂex changes. We speculate that this child’s
weakness was secondary to pain. In order to rule out more common
pathologies, various clinical tests can also be performed to narrow
the differential diagnosis. A pelvic compression test involves posi-
tioning a patient in lateral decubitus with the symptomatic side
facing up. A downward force is applied and sustained to the pelvis
for 45 s. Alleviation of pain is considered positive [12]. In addition, a
Tinel sign may be present, which can be elicited over the lateral
femoral cutaneous nerve as it passes under the inguinal ligament.
Lastly, a nerve block can be utilized, which is both diagnostic and
therapeutic [13].
Laboratory tests and studies can help diagnose MP. Electromy-
ography can distinguish between lumbar radiculopathy, diabetic
femoral neuropathy and MP. Plain radiographs of the back, hip and
pelvis can help rule out bony disease. Blood tests like a complete
blood cell count, uric acid, sedimentation rate, and antinuclear
antibody testingmay be performed in order to determine a primary
cause.MP can be initially treated with a short course of analgesics. If
the pain and other symptoms persist, nerve-block can be employed
[14]. The injection technique involves a local anesthetic at times
coupled with a steroid medial to the anterior superior iliac spine,
just inferior to the inguinal ligament [15]. MP can also be treated
surgically when other steps fail. Neurolysis may provide relief, but
has a probability of recurrence. According to one study, symptoms
can recur within 1e9months [16]. In those cases, a resection can be
performed.
MP is a rare complication of laparoscopic appendectomy. This
case represents the ﬁrst reported case after “all-in-one” appen-
dectomy. Because the nerve is not visible during the operation, it
may be quite susceptible to injury. The diagnosis should be sus-
pected in patients with post-operative symptoms similar to our
patient. Of course, other etiologies must ﬁrst be ruled out. But if
suspected, a nerve block is both diagnostic and therapeutic. First-
line treatment should be conservative, with neurolysis and nerve
resection as options if non-surgical management fails.
Conﬂicts of interest statement
The authors report no conﬂict of interests.
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Meralgia paresthetica after “all-in-one” appendectomy

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