Gastrointestinal Surgery| Volume 286, P96-103, June 2023

Download started.


Are Nerves Left In Situ Associated With Less Chronic Pain Than Manipulation During Inguinal Hernia Repair?

Published:February 15, 2023DOI:



      Nerve damage has been implicated in chronic groin pain, particularly iliohypogastric, ilioinguinal, and genital branches of genitofemoral nerves. We investigated whether three nerve identification (3N) and preservation is associated with decreased pain 6 mo after hernia repair compared to two common strategies of nerve management: ilioinguinal nerve identification (1N) and two nerve identification (2N).


      We identified adult inguinal hernia patients within the Abdominal Core Health Quality Collaborative national database. Six-month postoperative pain was defined using the EuraHS Quality of Life tool. A proportional odds model was used to estimate odds ratios (ORs) and expected mean differences in 6-month pain for nerve management while adjusting for confounders identified a priori.


      Four thousand four hundred fifty one participants were analyzed; 358 (3N), 1731 (1N), and 2362 (2N) consisting mostly of White males (84%) over the age of 60 y old. Academic centers identified all three nerves more often than ilioinguinal or two nerve identification methods. Median 6-month postoperative pain scores were 0 [interquartile range 0-2] for all nerve management groups (P = 0.51 3N versus 1N and 3N versus 2N). There was no evidence of a difference in the odds of higher 6-month pain score in nerve management methods after adjustment (3N versus 1N OR: 0.95; 95% confidence interval 0.36-1.95, 3N versus 2N OR: 1.00; 95% confidence interval 0.50-1.85).


      Although guidelines emphasize three nerve preservation, the management strategies evaluated were not associated with statistically significant differences in pain 6 mo after operation. These findings suggest that nerve manipulation may not contribute as a significant role in chronic groin pain after open inguinal hernia repair.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Surgical Research
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Treede R.D.
        • Rief W.
        • Barke A.
        • et al.
        A classification of chronic pain for ICD-11.
        Pain. 2015; 156: 1003
        • Nikkolo Ceith
        • Lepner Urmas
        Chronic pain after open inguinal hernia repair.
        Postgrad Med. 2016; 128: 69-75
        • O'Dwyer P.J.
        • Kingsnorth A.N.
        • Molloy R.G.
        • Small P.K.
        • Lammers B.
        • Horeyseck G.
        Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair.
        J Br Surg. 2005; 92: 166-170
        • Reinpold W.
        Risk factors of chronic pain after inguinal hernia repair: a systematic review.
        Innov Surg Sci. 2017; 2: 61-68
        • Cavazzola L.T.
        • Rosen M.J.
        Laparoscopic versus open inguinal hernia repair.
        Surg Clin. 2013; 93: 1269-1279
        • Alfieri S.
        • Rotondi F.
        • Di Giorgio A.
        • Fumagalli U.
        • Salzano A.
        • Di Miceli D.
        • Groin Pain Trial Group
        Influence of preservation versus division of ilioinguinal, iliohypogastric, and genital nerves during open mesh herniorrhaphy: prospective multicentric study of chronic pain.
        Ann Surg. 2006; 243: 553
        • Alfieri S.
        • Amid P.K.
        • Campanelli G.
        • et al.
        International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery.
        Hernia. 2011; 15: 239-249
        • Wijsmuller A.R.
        • Lange J.F.M.
        • Van Geldere D.
        • et al.
        Surgical techniques preventing chronic pain after Lichtenstein hernia repair: state-of-the-art vs daily practice in The Netherlands.
        Hernia. 2007; 11: 147-151
        • Izard G.
        • Gailleton R.
        • Randrianasolo S.
        • Houry R.
        Treatment of inguinal hernias by Mc Vay's technique. Apropos of 1332 cases.
        Ann Chir. 1996; 50: 755-766
        • HerniaSurge Group
        International guidelines for groin hernia management.
        Hernia. 2018; 22: 1-165
        • Wijsmuller A.R.
        • Lange J.F.M.
        • Kleinrensink G.J.
        • et al.
        Nerve-identifying inguinal hernia repair: a surgical anatomical study.
        World J Surg. 2007; 31: 414-420
        • Poulose B.K.
        • Roll S.
        • Murphy J.W.
        • et al.
        Design and implementation of the Americas Hernia Society Quality Collaborative (AHSQC): improving value in hernia care.
        Hernia. 2016; 20: 177-189
        • Muysoms F.E.
        • Vanlander A.
        • Ceulemans R.
        • et al.
        A prospective, multicenter, observational study on quality of life after laparoscopic inguinal hernia repair with ProGrip laparoscopic, self-fixating mesh according to the European Registry for Abdominal Wall Hernias Quality of Life Instrument.
        Surgery. 2016; 160: 1344-1357
        • Harrell Jr., Frank E.
        • with contributions from Charles Dupont and many others
        Hmisc: Harrell miscellaneous. R package version 4.4-2.
        (Available at:)
        Date: 2020
        Date accessed: April 22, 2022
        • Hill J.
        Reducing Bias in Treatment Effect Estimation in Observational Studies Suffering From Missing Data. Working Paper 04-01.
        Columbia University Institute for Social and Economic Research and Policy (ISERP), New York, NY2004
        • Granger E.
        • Sergeant J.C.
        • Lunt M.
        Avoiding pitfalls when combining multiple imputation and propensity scores.
        Stat Med. 2019; 38: 5120-5132
        • Alfieri S.
        A meta-analytic approach to ilioinguinal nerve excision or preservation during open inguinal hernia repair.
        Ann Surg. 2008; 247: 1078-1080
        • Ravichandran D.
        • Kalambe B.G.
        • Pain J.A.
        Pilot randomized controlled study of preservation or division of ilioinguinal nerve in open mesh repair of inguinal hernia.
        J Br Surg. 2000; 87: 1166-1167
        • Schmedt C.G.
        • Sauerland S.
        • Bittner R.
        Comparison of endoscopic procedures vs Lichtenstein and other open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials.
        Surg Endosc. 2005; 19: 188-199