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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 5  |  Issue : 4  |  Page : 204-208

Femoral nerve injury following transabdominal preperitoneal inguinal hernia repair: A case report


1 School of Medicine, Southeast University, Nanjing, China
2 Department of General Surgery, Affiliated Zhongda Hospital, Southeast University, Nanjing, China

Date of Submission12-May-2022
Date of Decision30-May-2022
Date of Acceptance01-Jun-2022
Date of Web Publication24-Dec-2022

Correspondence Address:
Junsheng Li
Department of General Surgery, Affiliated Zhongda Hospital, Southeast University, Nanjing 210009
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijawhs.ijawhs_20_22

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  Abstract 

Chronic postoperative pain is a complication of open and laparoscopic inguinal hernia surgery. The most important factor to the development of postoperative pain is nerve injury. Of all nerve injuries, the damage to the femoral nerve is very rare. Electromyogram and nerve conduction velocity may provide the clue to proper treatment. The authors present a rare case of femoral hernia injury following transabdominal preperitoneal inguinal repair for a primary right inguinal hernia and emphasize the importance of non- or atraumatic mesh fixation during laparoendoscopic inguinal hernia repair.

Keywords: Mesh removal, nerve injury, postoperative pain, TAPP


How to cite this article:
Xu Y, Shao X, Ji Z, Li J. Femoral nerve injury following transabdominal preperitoneal inguinal hernia repair: A case report. Int J Abdom Wall Hernia Surg 2022;5:204-8

How to cite this URL:
Xu Y, Shao X, Ji Z, Li J. Femoral nerve injury following transabdominal preperitoneal inguinal hernia repair: A case report. Int J Abdom Wall Hernia Surg [serial online] 2022 [cited 2023 Jan 28];5:204-8. Available from: http://www.herniasurgeryjournal.org/text.asp?2022/5/4/204/365087




  Key messages: Top


The authors present a rare case of femoral hernia injury following transabdominal preperitoneal inguinal repair for a primary right inguinal hernia and emphasize the importance of non- or atraumatic mesh fixation during laparoendoscopic inguinal hernia repair.


  Introduction Top


Despite proven advantages of tension-free repair with the endoscopic technique, there are potential complications related to mesh implantation, such as chronic postoperative pain, foreign body feeling, and mesh infection.[1],[2] A feared complication following both open and laparoscopic inguinal hernia surgeries is chronic postoperative pain, which was considered a more significant complication than a hernia recurrence, and the most important factor to the development of postoperative pain is nerve injury, which is mostly found in ilioinguinal, iliohypogastric, genital branch of genitofemoral, and lateral femoral cutaneous nerve, whereas the damage to the femoral nerve is very rare. In this report, we present a rare case of femoral hernia injury following transabdominal preperitoneal inguinal repair (TAPP) for a primary right inguinal hernia, and timely reoperation was performed. To our knowledge, no such complication has been reported after TAPP procedure.


  Case History Top


A 52-year-old man, whose body mass index is 19.13, presented with a complaint of the right leg pain after the right inguinal hernia repair, which was performed on November 23, 2021. The patient underwent a TAPP for primary right inguinal hernia, and the procedure went uneventful; a lightweight large pore polypropylene mesh was used. After the surgery, the patient was asked to stay in bed for 3 days; therefore, he did not notice any problem with his leg. However, when he got up of bed on the fourth postoperative day, the patient began to feel severe pain on the right thigh, he showed inability to walk, weakness, and numbness in the right leg, and his leg pain became more severe when he bend his right knees or hips; therefore, to relieve the pain, he had to sat with his right leg stretched straightly. His pain persisted till the eighth postoperative day, and he came to our department. On physical examination, there was no redness or swelling in the right inguinal area; a significant pain could be palpated on the site about 2 cm above the right inguinal ligament. The orthopedist was consulted; the ultrasonography, the electromyography (EMG), and nerve conduction velocity (NCV) were made immediately. The ultrasonography of the right inguinal area was normal, no hematoma and hernia recurrence were found, and the femoral nerve was intact. However, the NCV of the right leg showed a reduction of conduction velocities of 48.8% of compound muscle action potential waves of the femoral nerve compared with the left leg, whereas the F waves were normal. The EMG showed that the right leg muscles were not significantly impaired. Therefore, the EMG and NCV examination indicated that the right femoral nerve was damaged in the early stage [Video 1] [Additional file 1].

Therefore, the femoral nerve injury was suspected to be the most likely cause of the patient’s neuropathic pain and inability to walk. Eventually, an exploratory laparoscopic procedure was performed as soon as possible. Under general anesthesia in the supine position, three trocars were placed, and a disposable 10-mm Optiview trocar accommodating the camera was placed above the umbilicus. Another 10-mm trocar and 5-mm trocar were placed lateral to the bilateral rectus muscle for grasping instruments.

There is a dense small intestine adhesion on the peritoneum suture line of previous TAPP procedure [Figure 1]; therefore, the open of the peritoneum was made a little bit above the previous suture line, and the mesh was exposed. The mesh was carefully dissected by sharp and blunt dissection, from lateral to medial, from cranial to caudal; most of the dissection could be accomplished by blunt dissection because of the short duration after previous surgery. On the lower border of the mesh, in the triangle of doom, a mesh fixation suture was found [Figure 2] and removed [Figure 3]. Finally, the mesh was removed completely [Figure 4], and the peritoneum was closed again with absorbable suture [Figure 5].
Figure 1: Dense adhesion was found on the peritoneum of the previous suture line

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Figure 2: The lower border of the mesh was fixed with suture

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Figure 3: The mesh fixation suture was removed

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Figure 4: The mesh was completely removed

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Figure 5: After mesh and fixation was removed, the peritoneum was closed with suture

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Right after the operation in the anesthesia recovery room, the patient can move the right leg freely without pain. And on the second postoperative day, he could walk and bend his knee without difficulty and pain. His EMG and NCV on postoperative day 4 were normal on the right leg as compared to the left leg, which indicated the functional recovery of the femoral nerve. Although the patient had no pain at all, he still has slight numbness on the inner side of the right thigh on the 10th postoperative day.


  Discussion Top


Laparoscopic inguinal hernia repair is increasingly preferred over open techniques because of diminished recovery time, improved cost effectiveness, and less postoperative pain.[3] The postoperative chronic pain rates after open repair are between 11% and 16.8%[4],[5],[6],[7]; in contrast, a rate of 6%–12.4% was reported after endoscopic inguinal hernia repair.[4],[7] There is a significantly reduced incidence of persistent postherniotomy pain after laparoscopic versus open herniotomy.[31] The high percentage of chronic pain after open mesh repair may be related to direct damage of the inguinal nerves intraoperatively.[30] Although a low postoperative pain was observed in patients received endoscopic repair, the mesh placed in preperitoneal space poses a different problem compared with the open anterior repair, since the nerves in front of the transversalis fascia are at risk of entrapment by mesh-fixating devices.[8],[9] The common nerve injuries seen with laparoscopic inguinal repairs are lesions of the genitofemoral nerve and lateral femoral cutaneous nerve. However, in total, in large series, the frequency of damage to these nerves is not higher than 0.3%.[29] Although the most vulnerable nerves are iliohypogastric nerve, ilioinguinal nerve, and genitofemoral nerve, rarely, the femoral nerve injury could occur after inguinal hernia repair.[10],[11]

The femoral nerve is the largest branch of the lumbar plexus. It is formed from the posterior divisions of the ventral rami of L2–L4 roots, after those roots issue branches to the iliopsoas muscle. It passes down the pelvis between the psoas and iliacus muscle in the deep surface of the iliac fascia and passes under the inguinal ligament at the lateral to the femoral artery.[10],[11],[12],[13] Before it passes under the inguinal ligament to the thigh, it innervates a portion of the psoas muscle and Sartorius.[14] Then, it divides into the terminal motor and sensory branches; these branches supply the extensor muscle and the skin of the anterior and medial aspects of the thigh and leg. The frequent symptoms of the femoral nerve damage after inguinal hernia repair usually presented burning or stabbing pain in the inguinal area and anterior thigh.[11],[15],[16] Other patients may present quadriceps weakness, presented as difficulty with extension movement of the knee and altered sensation in the sensory distribution of the nerve. In our present case, the clinical presentation was pain in the right groin area and the right anterior aspect of the thigh, and this pain was increased by hand pressing, and the patient refused to walk and bend his knee.

The most frequent causes of femoral nerve injury are iatrogenic, including hip arthroplasty,[17] vaginal birth,[18] and femoral angiography.[19] Although rare, several mechanisms of femoral nerve damage after hernia surgery have been reported, including either open hernia repair[16],[20],[21] or total-extraperitoneal-herniorrhaphy (TEP)[10]; the mechanisms of femoral nerve may be either direct nerve entrapment,[22],[23] evacuation of postoperative hematoma, or compression,[14] especially when dealing with multiple recurrent hernias.[13] Studies reported significantly less acute pain after fibrin glue compared with stapled fixation.[32] The international guideline recommends no fixation or using glue for inguinal hernia repair, to avoid acute and chronic postoperative pain, especially for reducing the risk of neurogenic origin[3]; therefore, any fixation point with suture or tacks during laparoscopic hernia repair should be kept away from the pain triangle.[24] In fact, most patients after both open and laparoscopic inguinal hernia would develop some types of nerve lesion with secondary sensory disturbances or postoperative pain,[25] since even the suspected neuropathic pain is very unspecific.[26] Although most nerve entrapment syndromes respond to nonsteroidal analgesics and resolve with time, however, severe chronic groin neuralgia sometimes persists.[27],[28] A key question is to identify patients who suffered from severe neuropathic pain, which should be operated as soon as possible from those only requiring pharmacological treatment.

Our present case had typical severe pain and difficulty to walk, which is much different from the commonly observed cases with postoperative pain after inguinal hernia repair, and 8 days after the initial inguinal hernia repair, the patient’s symptoms persisted, with both significant motor and sensory impairments. Therefore, acute nerve injury was suspected. And this was confirmed by the EMG report, which indicated that almost a reduction of conduction velocities of waves of the femoral nerve by 50%, which indicated the direct damage to the axons. Consequently, a direct nerve injury was our first impression. In this circumstance, we decided to do the surgical revision. Although negative exploration was reported,[12] we believe that an early exploration is necessary.

In the present study, we removed both the mesh and the mesh fixations. Although one may argue that since injury was most likely due to the suture fixation in the inferior border to the iliac fascia, the mesh could be saved. Actually, laparoscopic mesh removal is not advised as the first step in postoperative chronic pain patient, because of the feasibility and safety of mesh removal procedure; therefore, surgeons may decide to waive the complete mesh removal in case of firm adhesions in the vicinity of doom triangle, to avoid the potential serious complications, whereas, in our case, we decided to completely remove the mesh for two reasons: first, the revision procedure was performed shortly after the hernia repair (8 days) and the mesh could be relatively easily removed without firm adhesion, and second, to assure the successful treatment, any risk factors associated with the possibility of development of nerve injury and pain were minimized.

Femoral nerve injury during laparoscopic inguinal hernia repair is uncommon, but do occur. EMG and NCV may provide the clue to proper treatment; in case a sustained iatrogenic injury is diagnosed, an early exploration is warranted. The present study also emphasizes the importance of non- or atraumatic mesh fixation during laparoendoscopic inguinal hernia repair.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicting of interest

There are no conflicts of interest.

Ethical approval

This report did not require ethical approval of any kind.

Human and animal rights

This report does not contain any study with animals performed by any of the authors.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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