165. Neurectomy Pros and Cons

This week, the topic of discussion was:
-Neurectomy
-Triple Neurectomy
-Laparoscopic Neurectomy
-Nerve Pain
-Neuralgia
-Neuropathy
-Neuroma
-Ablation
-Hydrodissection
-Chronic Pain
-Mesh Pain

Welcome to HerniaTalk LIVE, a Q&A hosted by Dr. Shirin Towfigh, hernia and laparoscopic surgery specialist who practices at the Beverly Hills Hernia Center. This is the only Q&A of its kind, aimed at educating and empowering patients about all things related to hernias and hernia-related complications. For a personal consultation with Dr. Towfigh: +1-310-358-5020, info@beverlyhillsherniacenter.com.

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Transcript

Speaker 1 (00:10):

Hey everyone, it’s Dr. Towfigh. We’re doing this on my Beverly Hills Hernia Center page. I hope you’re well. I am really excited to be with you today because it’s again, another Tuesday and I’ve had a really great day this week. And in addition, we’re going to be talking about nerve stuff and I of course picked it. I usually tend to pick my topics based on what you all are interested in and what you ask for. And if you’re on hernia talk.com, which I highly recommend, I’ve had this web page for so many years. Since 2013, we have thousand, thousand people that have been helped with hernia talk.com. It’s a free discussion forum, but some great topics came on. Thank you everyone for joining me. My name is Dr. Shirin Towfigh. I am your Hernia and laparoscopic surgery specialist. Those of you that are joining me on Facebook, you’re either at Dr.

Speaker 1 (01:12):

Towfigh or at Beverly Hills Hernia Center and also many of you follow me on Twitter X or Instagram at hernia Doc. As always, this and all prior episodes will be on YouTube so you can watch, share, like subscribe, and we are over 160, I think 165 episodes now, which is super exciting. And of course, as you know, we’ve also started a whole podcast. So if you’d like to do the podcast, I highly recommend that you also watch this as a podcast because I like podcasts. We just had a whole two hours of driving. I had to do for a meeting and listened to podcasts for the two hours of traffic I was in. We had the Pacific Coast Surgical Association meeting this year, which was in Ranch Mirage, which is kind of like Palm Springs, but it’s just on the outskirts of Palm Springs. But in California everything is Palm Springs, and then there’s Rancho Mirage and all the different subs of Palm Springs. There’s Palm Desert, et cetera. Rancho Road is kind of like the nice area. So we had a great meeting there called Pacific Coast Surgical Association. My team presented our data on mesh implant illness, which I thought was very well done.

Speaker 1 (02:51):

I thought it was very well done. And in talking about mesh implant illness, we reviewed all the outcomes that we see after the Mesh is removed. So the question was once the Mesh is removed, how do people react? Do they get better? What percentage get better? We found 86% actually get better. Actually, I take that back. 56% were cured once all of their mesh and sutures and tax and whatever were removed. So that’s good because it shows that mesh removal is a good treatment for mesh and platinums, but it’s bad because there’s still 44% people that weren’t cured. Many of them got better, but many also, maybe they didn’t have Mesh plan illness. So we’re trying to learn. The point was that we’re learning about this. Going back to what I was saying earlier, sometimes I’m inspired by what is discussed on my discussion forum, which is hernia talk.com, which of course is free to anyone who wants to use it.

Speaker 1 (03:58):

You just have to go on the website. You can lurk it and kind of go through all the questions, see if there’s anyone that shares your own questions. But what you can also do is register to for free and also ask questions and interact. So what I was impressed upon was there are several recent questions about neurectomy, and so I thought maybe it’ll be good to talk about neurectomy and everything you want to know about ectomies as a dedicated topic. Now, I have had multiple episodes in the past when we talked about nerves, we talked about nerve pain, nerve injections, neuromas, et cetera. However, I don’t recall ever having a full episode on neurectomy itself, the actual surgical neurectomy. So let’s kind of dive into that. Of course, as usual, if you have any questions that you want to ask, I’m happy to answer them that I can just relate to hernias obviously.

Speaker 1 (05:06):

But what I will say is that the topic of neurectomy, let’s just first of all, let’s get this clear. What is a neurectomy? Neurectomy is a cutting of the nerve. Now, usually we don’t like to cut nerves because there’s implications like cutting off a limb, right? There’s implications, but sometimes it’s necessary. So why would anyone want to cut a nerve? Well, first of all, we usually don’t cut nerves unless the nerve is causing a sensory problem. What does that mean? Burning hypersensitivity, what we call painful numbness. So it’s numb, which means it’s not working, the nerve’s not working, but it’s painful, which means the nerve has been injured and so causing pain, so those are really like hot poker sensation, painful numbness, severe pain usually of a burning quality or shooting quality, and you can wrap around your back or shoot into wherever this nerve causes sensation.

Speaker 1 (06:17):

Now if you’re numb from a nerve, usually we don’t do surgery because numbness is not considered a sensation abnormality that requires an intervention. And of course neurectomy is the surgical cutting of a nerve and we only cut in my specialty at least these small peripheral nerves, not the nerves in your back, but nerves that have eventually made their way toward the front where your hernias are. Usually when we talk about neurectomy, we talk about nerves in the groin area for inguinal hernia, but there are other nerves in your flank area, your Rives, and also nerves in the abdominal wall, usually to the sides called anterior cutaneous nerves, which we may also address.

Speaker 1 (07:21):

The thing that we talked about before has been, you may have heard the term triple neurectomy, selective neurectomy, pragmatic neurectomy. These are all different ways of addressing nerve problems by cutting the nerve. So when you cut the nerve, any nerve, you will get numbness as a result of that. So don’t expect to feel like you did before the nerve was ever injured. However many people say, that’s fine. I’m okay being numb as long as it’s burning pain. This hot poker pain, this sizzling, this shooting hypersensitivity goes away. So the consequence of cutting a nerve is you’ll be numb in that area. We don’t like to cut nerves that have what’s called a motor sensation. What does motor? Motor means? Like the engine motor, so it works. So muscle function, those are called motor nerves, so a nerve that feeds a muscle that has a function.

Speaker 1 (08:26):

We don’t like to cut those nerve cheer like we don’t want to cut those nerves because then you’ll be paralyzed. Most of the nerves that we deal with do not have a motor function. They are there because there is a sensation problem. So the skin is hypersensitive. You can’t wear certain underwear because anything that touches it causes pain. Women tend to wear dresses and with no underwear sometimes if it’s a very severe problem because anything that touches the skin becomes really irritating and discomforting or elicits that triggers that nerve pain. Men may prefer really loose boxers and prefer not to have constricting briefs. They prefer not to wear belts or jeans. They’ll wear jeans because any of that kind of stiffness or pain, external pressure will kind of cause ’em to have a worsening of their pain. So before you get to neurectomy where you have to cut the nerve and the purpose being to halt any of that nerve pain by just cutting it first, understand what a nerve is.

Speaker 1 (09:42):

So the nerve starts at the brain and then the nerve are basically like electrical cables, right? Starts in the brain, goes down to your spine, leaves the spine and goes to wherever it’s supposed to do its work. So let’s talk about groin. Hernias starts in brain, goes down your spine in the upper part of your lumbar T 12, L 1, L 2, the nerves come out and then wrap around your abdominal wall. They travel through the abdominal wall down to the groin. There’s a pudendal nerve, goes down the sacrum out through your pelvic floor and gets to the base of your penis, gets to your penis or your clitoris for example, and your rectum. Those are all peripheral nerves. The smaller the nerve, the less important it is usually your sciatic nerve. For example, you may have heard of sciatic nerve. That’s L 4-5. L 5 S 1. They come out towards out of your buttock area, out of your spine, again, brain down to the spine out of the buttock area, down the back of your thigh, and it wraps around the knee down towards the base of your foot.

Speaker 1 (11:06):

Those nerves start big and the further out they go, they keep giving branches, branches, branches, and they get thinner. The smaller the branch, the more end point of the branch, the less the consequence of cutting those nerves also the more likely for them to get injured. So when you cut the nerve, what you’re doing is you are disconnecting the area of the nerve which is injured from communicating with your brain and therefore saying, I hurt, I burn, I’m hyperactive, I’m hypersensitive. So the same way that the traffic goes from the brain down your spine to let’s say your groin area, wherever that skin is in the groin area, let’s say you scratch the groin, that scratching takes the scratching action on the skin and then takes it all the way, travels through that nerve up your spine to your brain and says, this area of my groin is being scratched.

Speaker 1 (12:07):

If I take a little needle and prick it, it’ll tell you my groin area is being pricked. If I cut anywhere between the brain and that skin area, if I cut that nerve, then that communication theoretically is gone and you can be numb in that area, which means I can take a pin prick or I can scratch the area and you would have no idea that I even touched that area. That’s what should happen with a neurectomy. If you have a nerve injury in that area, then without me even pin breaking it with a needle or scratching it, you’ll have pain because the nerve is active because it’s been injured and it’s hyperactive. That’s kind of layman’s way of explaining everything. I personally am not a fan of cutting nerves. It is necessary at times, but there was a time in our surgical history where the term triple neurectomy became very popular. What does triple neurectomy mean? There’s three major nerves for open surgery, the ileal, ileal hypogastric and the genital branch of the genital femoral nerve. Those three nerves are part of the nerves that we always check as part of a, you should always check of an open inguinal hernia repair with a laparoscopic approach or the robotic approach. Those nerves are often not visible and what are visible and at higher risk of being injured are the genital femoral nerve and the lateral femoral cutaneous nerve.

Speaker 1 (13:44):

These are all nerves that mostly have sensation, not too much motor function. The further up you go and all of these nerves, the more motor function they gain or the further distal you go away from the brain and further out you go the more sensory function they have and the less motor function they have. So at some point there was a lot of surgery being done and hernias and mesh placement and people were getting injuries, whether it was with tissue repair or with mesh repair. They were getting injuries to these nerves. The nerves are kind of in the way of the Hernia repair and the decision was made that as part of this pain cycle, let’s cut these nerves and by cutting these nerves we’ll get rid of the pain. That’s kind of what was going on in the discussion. So the triple neurectomy first did not start as a triple neurectomy.

Speaker 1 (14:47):

It first started as where people, surgeons were seeing nerves that were a problem and then they were cutting those nerves. However, Dr. Parviz Amid, who’s the godfather of meshoma and a lot of mesh and Hernia related disease processes and treatments figured out that if he cut all three of those nerves in these opening hernias, the patients were more likely to be cured of their pain symptoms than if he selectively cut those nerves, and that’s how the term triple neurectomy came to about. I love Dr. Amid. I think he is a genius and he’s added so much to our world. However, this idea of triple neurectomy has kind of taken a life of its own and there are a lot of surgeons that just use the word triple neurectomy like it’s a given package deal and overuse the need for neurectomy number one and then over-treat by cutting out nerves that are totally normal.

Speaker 1 (15:55):

Their theory is mesh, sorry, nerves talk to each other. So if I don’t cut one that’s normal. Then the ones that’s abnormal talk the normal one and then start this pain cycle, which I don’t believe in for multiple reasons. One is there are plenty of nerves, so you can’t cut every single nerve. So if there’s crosstalk of nerves doesn’t meet, the fact that we’re identifying these three nerves is somewhat artificial. There are other nerves as well that are not part of the hernia repair that potentially nerves can do this crosstalk and talk to each other, so you can’t cut every single nerve. Secondly, the way I interpret the data is why are people that get triple neurectomy doing better from a pain standpoint than those that do selective neurectomy? Because if you willy-nilly cut everyone’s nerves every time they have a revisional surgery, there will be plenty of people that need it and plenty of people that didn’t need it. You’re basically over-treating them. Whereas if you take the time to really hone in and figure out which specific nerve is injured and which specific nerve is the problem and only direct your treatment to that nerve issue, then it takes much more time, much more thought, much more investment in that patient.

Speaker 1 (17:30):

And you may be wrong sometimes, and that’s the problem that you don’t have with triple neurectomy is you over-treat, but you’re always right. Now, if you’ve been a fan of Hernia Talk Live or you’ve been on herniatalk.com, that cutting a nerve is not without consequence. So if I cut a nerve, how do I know that that patient’s going to do better? There’s a certain percentage of people, and I think it’s around a quarter of people that will not respond well to a nerve being cut. They get this reaction to the nerve. We try and reduce that reaction by numbing the nerve before we cut it and basically reducing the overall activity of the nerve as it’s reaction to being cut. We also tie the nerve so that the ends of the nerve, it’s like electrical cables. It’s like one big cable with a lot of electrical wire within it.

Speaker 1 (18:37):

You don’t want those electrical wire ends to be exposed to scar tissue and so on. And about four to 5% of those patients who have the nerves cut will end up having lead for more surgery due to another neuroma or due to a neuroma. So we looked at our data, it’s 4%. Other people have looked at their data, it’s 5% and a small fraction of all of these people will get a really bad outcome, which is called CRPS or complex regional pain syndrome CRPS. And we discussed this a couple of weeks ago with our pain management doctors. That is a horrible complication because what’s happening is you are cutting and therefore eliciting this hyperactivity of the nerve locally, and then what happens is the whole body decides to go berserk and now all the nerves in the body are turned on by this nerve surgery and typically these are nerves in the arms and legs where you get a horrible, severe burning chronic pain that takes years, years to resolve and that’s really a horrible complication associated with nerve surgery.

Speaker 1 (20:14):

So that’s kind of my risk, which is I don’t want to turn a totally normal person with some chronic pain into a debilitated disabled person with CRPS and the more nerve surgery you do, the more you muck around with a nerves, the more you cut it and mess around with it, the higher the risk of getting CRPS. Some people are concerned to be more prone to it. We don’t know who those people are, but whatever the situation I, whatever the situation, you don’t want to be that surgeon that is overtreating people and therefore increasing the risk of CRPS complex regional pain syndrome because years you can’t work, you can’t survive, you can’t. I’ve known people personally unrelated to hernia surgery that have had chronic nerve damage for years. They’re in physical therapy, occupational therapy, water therapy, taking tons of medications, can’t work disabled completely financially distraught because of this CRPS.

Speaker 1 (21:32):

It is not anything to be taken lightly. So these people that think nerve should be cut or you should do triple I’m completely against. The other thing I want to talk about is this concept of laparoscopic neurectomy. So interestingly, I was contemplating this idea of laparoscopic triple. This is many, many years ago. I’m going to say 2006, maybe 2008 maybe. So the idea was instead of cutting the nerves in the groin area where there’s mesh and scar tissue and prior surgery, why don’t I go in laparoscopically and cut those same nerves before they hit the groin? I actually met with Dr. Amid about it and he’s like, that’s not a great idea. You can call it a radical. And what we were doing was we were cutting the nerves all the way up to the spine area. There was not a single, not a single book, not a single anatomy book, not a single anatomy picture anywhere because I went through all of them that explained that the ileal hypogastric nerve, ileal nerve have any motor function at all.

Speaker 1 (22:59):

Not a single nerve, not a single paper, not a single book. There was a surgeon in, I think in Germany maybe that described a laparoscopic neurectomy or retro perineal neurectomy. And then we went ahead and we did three patients and presented that to sages and then we did a full anatomy evaluation of these nerves because what I learned was what you learn in the books is very different than what you see in the abdominal see in the abdomen. So we then did hundreds of cadaver dissections to try and better understand what we call the lumbar plexus, which are these nerves that are coming out of the back. I told you T 12, L 1, L 2, we started doing more laparoscopic triple neurectomies, talked about it to a couple of my friends, Dr. Parviz Amid specifically and Dr. David Chen we’re at the dinner with me and we thought it was a great idea.

Speaker 1 (24:10):

Then I had my first patient complication, which was the abdominal wall on the side of the triple neurectomy started to bulge out and the patient’s like, what’s going on here? The pain’s better. But now I’m having this discomfort because I feel like one part of my body has no support. It’s giving back pain. It actually gives me this stretching painful bulge, and if you look at them, the one belly is protruded on one side and not the other side that didn’t have it. If you do it bilaterally, I mean left and right side the laparoscopic. So the whole belly becomes very distended and we learned very quickly that this must be what’s called a denervation of the abdominal wall because between the spine and the groin, that length of nerve is not purely sensory. There are little branches that you can’t see that have never been reported that actually give out little branches to the muscles. So if you cut that whole segment of nerve out, you’re going to get a denervation of the abdominal wall. Horrible complication.

Speaker 1 (25:31):

I started talking about it and telling people not to do laparoscopic triple neurectomy, not to do laparoscopic neurectomies because you’re putting the patient, not everyone, the patient at risk for abdominal denervation, which is a completely not reversible disabling problem. There’s nothing you can do about it. However, then another paper came out with, I forget the number, let’s say a hundred patients consecutively doing these and they’re like, this is a great procedure. I talked to that author and I said, because he presented it at I think Pacific Coast Surgical Association, I’m not sure, and I went up to him, I said, you just presented a paper saying that laparoscopic triple neurectomy is a great idea. They address people’s pain, but in the complications you didn’t mention the denervation that they get and did you not see any denervation? Oh yeah, I saw tons of denervation, but you didn’t report it in the paper.

Speaker 1 (26:40):

He’s like, oh, they just get better. Just give ’em time. They get better over which they do not. They do not get better. No amount of physical therapy will regain that function. The nerve is cut, it’s gone. And if you go into hernia talk.com, there is a member participant that actually mentioned that they had this laparoscopic triple and now they have and they were told, you may get a bulging, it’s reversible, which of course it’s not. And then what they did was they told the patient, oh, maybe you can have a tar TAR, which stands for, what’s the acronym TAR, trans versus abdominal release to help the bulging. Completely the wrong answer. Number one, this is not a hernia, it’s a denervation. So no amount of muscle release will help and it may actually worsen the situation. If anything, you would benefit from a plication like a tummy tuck, but even that’s not a good procedure.

Speaker 1 (27:50):

So here we have someone who’s making comments. I have a lopsided abdomen to prove it. I wish my provider had known in 2014 when I had mine. That’s true, and it causes a different kind of pain. There’s no cure. That’s also true. It’s a horrible situation. So in general, I not only prefer not to do it, I highly encourage other surgeons not to do it and I’m contemplating writing maybe a letter or something that says, do not do it and do understand this is not some great laparoscopic option to open neurectomy. It is not. People think laparoscopic or robotic is just better than open for neurectomy. It is not a good operation. If you do ever need a neurectomy, then the only way to do it as safe as possible is to cut the nerve as distal and far away from the spine as possible to reduce the risk of having the muscle.

Speaker 1 (28:57):

Let’s see. I’m in awe that a skilled hernia surgeon can also present a comprehensive and brilliant neuroanatomy and neurophysiology lecture. Thank you. I’m learning so much, even though I consider myself well educated. That’s very kind of you. Thank you. As I’m coughing away, I’m sorry about the coughing today. So if you guys think it would be good for me to write a letter to some journal, the problem is it’s so difficult to write these letters without a lot of data. I stopped doing it after I had two patients. I’m like, this is it. Never doing this laparoscopic neurectomy again. Unfortunately, I see a lot of doctors offering it. They think they’re being and very advanced. It’s actually the wrong procedure to do so I’m a big advocate against doing that. The genital femoral nerve even there is a branch of that also that gives muscle function and specifically in men, it gives function to the cremasteric muscle.

Speaker 1 (30:10):

So if you cut that nerve or if it’s injured as part of a meshoma removal or surgery, you can get weakness of the cremasteric muscle. Then the testicle falls really low and often it falls low so that the two testicles are very disparately abnormal. The side where the nerve is cut with a genital femoral nerve is much, much lower. Sometimes it can be so bad that the testicle actually touches the toilet water if you’re sitting on a toilet bowl, that would be an extreme situation. But these are complications that we see. Here’s another question. I feel a lot better, but still have some issues. Still excited to feel better than I have in almost a decade. Thank you for saving me Dr. Towfigh. You were the best. Oh, thank you so much. Glad you’re doing better. That’s a me problem.

Speaker 1 (31:09):

Here’s another question. Aren’t there still top Hernia surgeons at top academic? Okay, lemme, aren’t there still top Hernia surgeons at top academic institutions doing these? Why would they? Yes, there absolutely are. It’s a horrible problem. They’re doing it because they’re probably unaware that there is a significant portion of people that get this denervation and many of them are unaware of the anatomy, which is why I think I should write a paper that pleads against it because no one, including the person who wrote the article, no one has officially made a paper ref refuting the research paper that has been published, which says what a great thing laparoscopic triple neurectomy is. So if you’re in Turkey or Spain or Canada or Nebraska and you’re reading papers on different neurectomy options, chronic pain options, and you have a highly respected hernia surgeon write a paper on laparoscopic triple neurectomy and its amazing outcomes and they fail to mention anything about this complication of abdominal wall denervation, which I find a bit odd and disingenuous and never been to a meeting and no one’s ever talked about it, there’s no paper published to refute those results, then it’s kind of you think you’re doing a great thing.

Speaker 1 (32:52):

Oh yeah, laparoscopic triple neurectomy, that’s so much better than open. You can include a picture of my abdomen and I can include a list of problems that’s causing, actually, I will take you up on that. Absolutely. Does this mean that neuromodulation by spinal cord or dorsal root ganglion stimulation is a better option for totally refractory post hernia surgery?

Speaker 1 (33:18):

No, it doesn’t mean that. So what it means is that neurectomy, when done distally peripherally as far away from the spine as possible can be the right choice. I personally feel that selective neurectomy is the right choice, not automatic triple neurectomy because there are consequences to cutting nerves. In our study, we found that pragmatic neuropathy, which means a normal nerve is cut to prevent pain or prevent pain, had a 0% neuroma rate and cutting a disease nerve had a 4% neuroma rate. So that’s kind of where we are. However, if you need more surgery beyond the groin area and you’re at risk of having nerves that need to be addressed more proximally, then at that point you’re kind of at a stage four, an end stage nerve problem and perhaps some type of nerve stimulator would be indicated to reduce your risk of having denervation.

Speaker 1 (34:34):

And if you want to know more about how nerve stimulators and dorsal root ganglion stimulators work and why they work, listen to our podcast and a YouTube video from Hernia Talk Live two weeks ago because we had a really, really good discussion with our pain management specialists on that. So highly recommend that. Alright, we had some questions. I’m going to go through those that were submitted earlier. Here’s one, it says, why is not recognizing a nerve and injuring it during a dissection more problematic than a so-called pragmatic neurectomy done intentionally by the surgeon when he or she encounters either whether a named or unnamed nerve during the dissection to get to the angle floor? That’s a great question. So I mentioned that if you cut a small nerve because you’re trying to prevent injury, let’s say I’m removing Mesh, it’s a totally normal nerve, but with me removing the mesh off the nerve, I’m actually going to injure the nerve, so I’m going to cut that otherwise healthy nerve, we found an R study of 0% neuroma rate, whereas if the patient had Neuralgia, which means nerve pain in a specific distribution of a specific nerve, let’s say the ileal nerve, and our goal is to go in there to specifically address that ileal nerve cutting that diseased, abnormal, painful ileal nerve and appropriately tying it off, giving it numbing medication, dunking it into the muscle and doing all the tips and tricks that we’re taught to help reduce complications and neuromas, you still have a 4% neuroma rate.

Speaker 1 (36:27):

Why is that a, we don’t know. We were actually quite surprised to see that cutting a healthy nerve gave zero risk of neuroma, at least in our study. It could be that we just don’t understand enough about how the nervous system works. So if a nerve is already diseased and hyperactive, then possibly cutting it to stop that hyperactivity and disease and cutting out the disease portion is a successful 96% of the time. But in some patients they are just neuroma makers or nerve the same way. Some people scar more than others and some people feel pain more than others. Maybe people that have already demonstrated a propensity towards non-healing of nerves, that cutting at the nerve again will also put them in that direction. I don’t know. That’s kind of a theory that I have. Distal neurectomy requires reentering a previously operated inguinal canal or groin through scar tissue, not virginal access site. That’s not true.

Speaker 1 (37:39):

Distal neurectomy does not imply you have to also cut out the Mesh or go into an area that’s been pre operated on. You can go just outside that area and cut the nerve proximal to where it was injured. So you don’t have to take out nerve, you don’t have to go through the disease scar if your only purpose is to address nerve pain. Okay, here’s the next question. What is the difference between neurectomy and neuroplasty? So neurectomy is cutting the nerve. Ectomy always means to excise. Neurolysis means to carefully dissect the nerve off of scar tissue or its natural pathway. For example, let’s say Shouldice technique. We do have to kind of dissect out the nerve and move it out of a place to do your suture repair so that you don’t risk capturing the nerve in your suture repair for example. So and the neuroplasty implies repairing a nerve and that can be done with sutures or by bringing in another nerve and there are all these different techniques, mostly people that do neuroplasty or neurosurgeons or plastic surgeons which have very highly specialized specialty in peripheral nerves and grafting grafting of nerves. I was told I need a triple should I agree to it. So I think if someone tells you to do a triple neurectomy, you should get a second opinion and if that second opinion agrees, then likely is that you do need a triple neurectomy. My personal bent is I only do triple neurectomy if every single one of those nerves is injured or at risk of being injured, but if it’s a totally normal nerve, I leave those alone and that’s what we call selective neurectomy. Let’s see, the next question.

Speaker 1 (39:57):

What do you think about laparoscopic neurectomy? Okay, we discussed that. I don’t like it. Are the ileal, inguinal ileal hypogastric and genital femoral nerves always identified during a hernia related procedure? That’s a good question. So they should be identified for open hernias. You must identify the ileal inguinal, ileal hypogastric and genital branch of the genital femoral nerve before doing much dissection that may injure it. Why? Because you may be doing dissection that may injured it and in either placing the mesh and the sutures or in doing your suture repair, you may accidentally injure those nerves. So if you’ve identified it first, you know where these nerves are and the trick is not to disturb those nerves as much as possible, let them be where they are, but identify it so you know where these things are before doing your surgery. It’s like driving in traffic.

Speaker 1 (40:58):

You need to identify where the light is and where the people where the crosswalks are so you don’t hit pedestrians, doesn’t mean you have to move things around, just identify it to protect it. For laparoscopic surgery, that’s a different story. With laparoscopic or robotic hernia repairs, you really should not be identifying any nerves because by identifying it you have to dissect through certain tissue levels to get to them. So the genital femoral nerve is deep to a fascia away from the spermatic cord and the round ligament and the lateral femoral cutaneous nerve is also deep to a fascia. So in someone that’s obese or normal weight, you should not be seeing those nerves and thin people where there’s no fat and therefore those tissues are quite thinned out or transparent, no fat. You may see those nerves, but you shouldn’t be digging to look for those nerves because by doing that you may expose them either to the mesh or scar tissue whereas they’re in their normal state. So for laparoscopic or robotic angle hernia pairs, we usually do not identify the nerves. However, if I’m removing a mesh and or there’s a nerve question robotically, then yes, I would want to identify those nerves and make sure that they’re healthy before finishing the surgery. How common are inadvertent neurectomies in what kind of hernia related procedure do they most frequently occur and what are the consequences for the patient?

Speaker 1 (42:40):

Well, we prefer to have as minimal an amount of inadvertent neurectomies as possible. The more complicated the hernia, the larger the hernia or if there’s been prior surgery, the higher the risk of inadvertent neurectomy or injury to the nerve. They tend not to be in abdominal wall hernias. They’re mostly in inguinal hernias. We don’t know the exact number, but as you know, there’s just 12% number that’s been thrown around as a chronic pain rate after inguinal hernia, mostly from open surgery. Much of these are because of inadvertent neurectomies and if it’s a small injury to the nerve, some patients will just heal that on their own. If it’s involved in scar tissue and or mesh that’s higher and more difficult to heal from, you can calm down the nerve with a lot of different procedures That includes steroid injections and massaging and some do PRP. It’s not very common.

Speaker 1 (43:50):

Hydrocele dissection, we discussed that a couple weeks ago, and you can also do ablations of those nerves to kind of calm them down, but neurectomy is not the answer to all nerve type pain. Let’s see. Here’s a question. Can you injure an unnamed nerve while doing laparoscopic Mesh for repair or not usually or can scarring around the Mesh associated with healing and trap unnamed nerves and does not make lap repair more dangerous? Does that make lap repair more dangerous and open repair because of injury to a more proximal No. So it’s not common to have nerve injuries with laparoscopic repairs as compared to open and no, the unnamed nerves are usually not consequential.

Speaker 1 (44:45):

Next question, are there cases in which preventative preventative triple or selective neurectomy is recommended? So there is a thought that pragmatic neurectomy or preventive neurectomy is indicated. Usually that’s for let’s say ileal inguinal nerve. Usually we don’t and there are some surgeons that always cut those nerves as a way of preventing that nerve from getting injured. It’s the craziest idea to me it’s basically saying it’s so crazy. There are surgeons that believe that if you cut the ileal nerve during surgery that you’ll prevent ileal Neuralgia. Although most ileal Neuralgia is because you’re a heavy handed surgeon or you are a sloppy surgeon that is causing either too much damage to the nerve, too much scar tissue or the mesh is not put in flat enough and therefore can damage the ileal nerve.

Speaker 1 (46:04):

Cutting that nerve should not be the next best option. You should just be a cleaner surgeon and identify the nerve instead of just cutting it. So there is some thought also that part of the pain with hernias is because the nerve is being squished and that squishiness actually damages the nerve. So in the groin you’re having squishing of the ileal nerve because of the fat and then what happens there is the nerve is damaged and then you’re leaving a damaged nerve behind and doing this hernia repair and therefore you should cut all these nerves. Also kind of a creepy idea, there are papers that have shown pathology which shows the nerve is not healthy or has some type of, they call it ischemic injury and it’s hard to believe because there’s plenty of us that don’t ever do the ileal inguinal neurectomy that’s pragmatic or preventive and our patients do just fine.

Speaker 1 (47:15):

So I don’t want to be that surgeon does extra surgery that then causes either neuroma or CRPS complex regional pain syndrome, which is disabling. There hasn’t been anyone that’s actually studied the risk of doing that with pragmatic neurectomy and the surgeons that do it swear by it, they think that they’re preventing pain. So most of us that are hernia special don’t believe in doing that, but there’s enough surgeons out there doing it that it is considered part of a standard approach for especially inguinal hernias. I think it’s crazy, especially in women to cut the ileal nerve means that probably their inner thigh and maybe even their moms may be numb if they cut their genital nerve branch. Certainly that’s very horrible. I had never heard of a pragmatic triple neurectomy on an elective case until I saw one patient recently who had an elective hernia repair. It’s a female elective hernia repair and a triple neurectomy at the time of the elective hernia pair. And when she asked the surgeon, he said, oh, this is considered standard completely not standard number one. She now has complications from her surgery. Number two, it’s not cool for a female to be completely numb in her groin and mind from a sexual satisfaction standpoint. Number three, it shows the poor understanding of the surgeon and gender-based differences in hernia repairs. Number four. So does it happen Apparently yes. Should it happen? Not in my book.

Speaker 1 (48:59):

Do plenty of well-respected surgeons that are considered hernia specialists do this? Yes. Should they? Not in my book, but that’s something to be debated amongst ours, amongst ourselves and they debate and it’s just a stupid debate. Honestly, I don’t agree with it. Is meh the cause of the existence of neurectomies in hernia repairs? That’s also a great question. No, and yes, so mesh is not the only reason why neurectomies are necessary. There are plenty of people that have neuromas or nerve damage as part of a tissue repair. As you know, we’ve talked about this before. The chronic pain rate after tissue repair is considered similar to the chronic pain rate after open inguinal hernia repair with mesh because of this risk of tearing and even nerve injury as part of a tissue repair. So no, the risk of the need for neurectomies is not purely a mesh issue.

Speaker 1 (50:08):

But yes, the majority of neurectomies that are necessary are done in patients with mesh repairs. I hope that, I don’t know that’s clear or not. Let’s see. Next one. Is it always impossible to reinnovate the involved muscles after a neurectomy? So it’s always impossible. Like I mentioned earlier, there are plastic surgeons and maybe neurosurgeons that do this nerve grafting. They basically take a nerve from one area of the body and re-implant it onto a disease nerve and encourage those muscles to gain function by recruiting food and energy from a more normal nerve because the other nerve was cut. They usually do that with larger nerves, so they usually do it from the flank back and not for the flank forward because those nerve tend to be really small and just dissecting it alone can cause injury. So usually it’s done for necessary muscles like muscles of the hand or muscles of the face and not done for unnecessary muscles like groin muscle. That’s not considered necessary for life and function. So if you have a ovate abdominal wall and there’s one specific nerve that has been injured, you can consider having that one specific nerve grafted to gain function. They often fail as grafts can fail, but most of these patients, it’s not just one nerve, it’s multiple nerves and so it doesn’t work.

Speaker 1 (51:56):

Let’s see. I’ll bring a specialist about that by the way to talk about it. Does surgical neuroma treatment essentially involve a second neurectomy more proximal to the spine and can neuroma recur? Yes. So yes. So the risk is 4% neuroma when you re-excise a neuroma and in doing so you’re getting closer and closer to the spine and again, the risk of that neuroma having another neuroma is again 4%. So we haven’t found that that risk is higher if you recut it, but yeah, it is that. Okay, next question. I love that you guys sent in questions ahead of time. Do motor and sensory functions of the ileal hypogastric, ileal inguinal, and general femoral nerves change pathways as they move away from the spine? Yes. So to my knowledge, I have never been able to visually see branches. They’re probably microscopic and really small, but there aren’t these obvious branches coming out of the nerves when they exit the spine towards the groin.

Speaker 1 (53:06):

I have dissected those nerves. I’ve seen those nerve injured, let’s say during, what do you call it, spine surgery lateral approach. So it’s called exlif. So when they go transversely, they can injure those nerves and I’ve seen neuromas and I’ve had to treat those neuromas. The larger the nerve, the more difficult it is to treat the neuroma. That said, in doing so, you may have to redo the neuroma because it originally got cut and not all neuromas cause muscle denervation. It’s kind of crazy like that. What are the nerves that innervate the abdominal wall? What kind of surgery apart from spine surgery can damage these nerves and how can you tell if a bulging that appears after surgery is due to abdominal wall denervation? Okay, good question. So these occur due to any incision done on the abdominal wall, usually in the flank. So outside the rectus area, usually the rectus muscles, by the time the nerves get there, they’ve already branched enough that cutting any nerves in the middle of the body does not cause denervation. It’s the ones that are cut from the, what we call mid axillary line, sorry, mid clavicular line. So this is your midline and then your shoulder area is the axillary line, and then in between would be the clavicular line, mid clavicular line. So anything outside of that is where there’s larger nerves and cutting it can cause a risk of denervation. So kidney open kidney surgery, open aortic surgery, which people don’t really do that much anymore.

Speaker 1 (54:57):

Any spinal approach from the flank side, open gallbladder surgery, those are all incisions that are done on the sides. Any weird trauma incision, those can all potentially cause damage to those nerves. Now how can you tell the difference between a hernia and a denervation? Excellent, excellent question. So the hernia will be a bulging right over the hernia or the incision. A denervation would be a bulging anteriorly. It’s not a bulging out, it’s a bulging forward. So the incisions are always on the side. So if you have a Hernia on the side, the bulging will be outward. So it looks like an alien’s coming out of your belly from the side. But if there’s no hernia there and they have a denervation, the bulging goes forward. Now, if you’ve had damage to the nerve but not actually cut the nerve, let’s say you had a spine surgery and they pulled on the abdominal muscles so it stretched out but didn’t actually cause injury, then in those patients usually allow a year for them to regain muscle function and you don’t need to operate on those people.

Speaker 1 (56:11):

But if the denervation is complete and they’re not better after a year, that’s usually my rule of then considering basically it’s like a tummy tuck of the abdominal wall in that area. Let’s see. Interesting session. Thank you so much. Oh, you’re welcome. Yeah, I love it. I thought this was a good session because we talked about somewhat specialized topic, which is neurectomy and I’m not even neurosurgeon, but because of my work, which is often involves revisional, hernias and nerve pain, I’ve learned a lot over the time. We’ve had great guests before, which are pain management specialists that have talked about nerve ablation and spinal stimulators and hydrocele dissections and so on. We haven’t had a neurologist. I’m working on that to get you a really highly respected neurologist that understands peripheral nerves. Most of them are like stroke specialists or sleep specialists or movement disorders, Parkinson’s disease, but we don’t really have peripheral nerve specialists that many of them.

Speaker 1 (57:23):

But I have a couple connections I’m working on to get you. Then lastly, there is a handful of plastic surgeons that actually do this nerve grafting, and I’m trying to get them to speak on hernia talk. So on that note, that’s the end of Hernia Talk Live. Thanks everyone for joining me on Hernia Talk Tuesday. We have a guest next week. I’m super excited to speak with him and he’s a really smart guy. I follow him on Twitter and whenever there’s discussion, I don’t want to say something, he’ll say something and I’m like, that’s exactly what I want to say. So we think alike. So I really appreciate that and it kind of implies that they’re thinkers and as you know, I really like thinkers. So that’ll be next week, really looking forward to that discussion. Until then, don’t forget to subscribe to my YouTube channel and please post a review on my podcast, Hernia Talk Live. I’ll see you all next week. Bye everyone.