Inguinal hernia repair is one of the most frequently performed procedures in general surgery, with an estimated lifetime risk of 27% in men and 3% in women (1). The standard surgical approach for inguinal hernia is mesh-based hernioplasty, such as the Lichtenstein tension-free repair, which has significantly reduced recurrence rates (2). However, chronic postoperative groin pain (CPGP) remains a major concern, affecting up to 54% of patients, with 6–10% experiencing severe pain that interferes with daily activities (3). This has shifted the focus of hernia surgery from recurrence prevention to optimizing postoperative pain outcomes.

One of the primary contributors to CPGP is ilioinguinal nerve involvement, either through traction, entrapment, or direct injury during dissection or mesh placement (4). The ilioinguinal nerve, a branch of the lumbar plexus (T12-L1), provides sensory innervation to the upper medial thigh, scrotum/labia majora, and inguinal region. Surgical management of this nerve remains controversial. Some advocate for nerve preservation, arguing that it maintains normal sensory function and reduces the risk of neuroma formation (5). Others recommend prophylactic neurectomy, suggesting that nerve excision prevents later entrapment-related pain and minimizes the incidence of CPGP (6).

Several studies have investigated the impact of ilioinguinal nerve handling during inguinal hernioplasty. A meta-analysis reported that patients undergoing neurectomy had a lower incidence of moderate-to-severe chronic pain at six months postoperatively compared to those with nerve preservation (7). However, other studies indicate that nerve excision may lead to hypoesthesia or numbness in the inguinal region, raising concerns about long-term sensory deficits (8).

Given the ongoing debate, this study aims to compare ilioinguinal nerve preservation versus prophylactic neurectomy in Lichtenstein tension-free mesh hernioplasty. The primary objective is to evaluate differences in chronic postoperative pain, while secondary outcomes include sensory disturbances and overall patient satisfaction. Assessment of these parameters seeks to provide evidence-based recommendations to improve the surgical management of the ilioinguinal nerve in hernia repair.

This hospital-based prospective interventional study was conducted at the Department of General Surgery, Gadag Institute of Medical Sciences, Karnataka, India. The study aimed to compare the outcomes of ilioinguinal nerve preservation versus neurectomy in patients undergoing Lichtenstein tension-free mesh hernioplasty for inguinal hernia.

Study Duration

The study was conducted over a period of one and a half years, with a six-month follow-up for each patient. The study period extended from February 2021 to August 2022.

Study Population

Patients aged between 18 and 65 years diagnosed with an uncomplicated primary inguinal hernia were included in the study. Only those undergoing Lichtenstein mesh hernioplasty and providing written informed consent were enrolled. Patients with recurrent inguinal hernia, bilateral hernias, or complicated hernias such as strangulated or obstructed cases were excluded. Additionally, individuals with prior groin surgeries, known neuropathy, chronic pain syndromes, or previous pelvic irradiation were not considered for participation.

Sample Size and Grouping

A total of 100 patients who met the inclusion criteria were enrolled in the study. The patients were randomly allocated into two groups. Group A consisted of 50 patients who underwent Lichtenstein hernioplasty with ilioinguinal nerve preservation, while Group B included 50 patients who underwent the procedure with prophylactic ilioinguinal neurectomy.

Surgical Procedure

All patients underwent a standardized Lichtenstein tension-free mesh repair performed by senior surgeons under spinal anesthesia. The procedure involved an inguinal incision and dissection of the inguinal canal, followed by identification of the ilioinguinal nerve. In Group A, the nerve was carefully preserved and avoided during mesh placement. In Group B, the nerve was ligated and divided proximal to the deep inguinal ring. Mesh fixation was performed using non-absorbable sutures to secure it to the inguinal ligament and conjoint tendon. The external oblique aponeurosis, subcutaneous tissue, and skin were then closed in layers.

Postoperative Pain and Sensory Assessment

Pain was assessed using the Visual Analog Scale (VAS) ranging from 0 to 10 and the Verbal Rating Scale (VRS) categorizing pain as mild, moderate, or severe. These assessments were conducted on postoperative day one, as well as at one month, three months, and six months following surgery. Sensory disturbances, including hypoesthesia and numbness, were evaluated by light touch and pinprick testing in the medial thigh and groin region.

Statistical Analysis

Continuous variables such as pain scores were compared using the independent t-test, while categorical variables, including the presence of hypoesthesia, were analyzed using the chi-square test. A p-value of less than 0.05 was considered statistically significant.

Ethical Considerations

Ethical approval for the study was obtained from the Institutional Ethics Committee of Gadag Institute of Medical Sciences. Written informed consent was obtained from all participants before enrollment. The study was conducted in accordance with the Declaration of Helsinki guidelines for human research.

The study included a total of 100 patients who underwent Lichtenstein tension-free mesh hernioplasty for primary inguinal hernia. Among them, 50 patients were assigned to Group A, where the ilioinguinal nerve was preserved, while the remaining 50 patients in Group B underwent prophylactic ilioinguinal neurectomy. The results were analyzed based on demographic characteristics, postoperative pain assessment, sensory disturbances, and overall patient satisfaction.

Demographic Characteristics

The mean age of patients in Group A was 44.3 ± 9.2 years, while in Group B, it was 45.1 ± 8.8 years. The majority of patients in both groups were male, with a male-to-female ratio of 9:1. The mean duration of hernia symptoms before surgery was 8.5 ± 3.2 months in Group A and 9.1 ± 2.9 months in Group B. There was no significant difference between the groups in terms of age distribution, gender, or symptom duration (p > 0.05).

Table 1: Baseline Characteristics of the Study Population

Postoperative Pain Assessment

Pain scores were evaluated using the Visual Analog Scale (VAS) at postoperative day one, one month, three months, and six months. On postoperative day one, the mean VAS score was higher in Group B (6.4 ± 1.1) compared to Group A (5.9 ± 1.3), but the difference was not statistically significant (p = 0.08). However, at subsequent follow-up intervals, the incidence of chronic postoperative pain was significantly lower in Group B. At six months, 19.2% of patients in Group A reported chronic groin pain compared to 8.3% in Group B (p = 0.04), indicating a significant reduction in chronic pain with prophylactic neurectomy.

Table 2: Postoperative Pain Assessment (VAS Scores)

*Statistically significant (p < 0.05)

Incidence of Hypoesthesia and Numbness

Sensory disturbances were assessed using light touch and pinprick testing. The incidence of postoperative hypoesthesia was higher in Group B compared to Group A at all follow-up intervals. At one month, 62% of patients in Group B reported hypoesthesia, compared to 57.6% in Group A. However, by six months, the difference in hypoesthesia between the two groups was minimal (16.6% in Group B vs. 11.5% in Group A, p = 0.41), suggesting that neurosensory disturbances tend to resolve over time in both groups.

Table 3: Incidence of Hypoesthesia at Different Follow-Up Intervals

Comparison of Chronic Groin Pain at Six Months

At six months postoperatively, a significantly lower percentage of patients in Group B reported moderate-to-severe chronic pain compared to Group A. The difference was statistically significant; supporting the hypothesis that prophylactic neurectomy reduces long-term pain.

Table 4: Incidence of Chronic Groin Pain at Six Months

*Statistically significant (p < 0.05)

Overall Patient Satisfaction

Patient satisfaction was assessed at six months using a Likert scale (Excellent, Good, Fair, Poor). Patients in Group B reported a higher level of satisfaction with their postoperative outcomes compared to Group A. A greater number of patients in the neurectomy group reported their experience as "Excellent" or "Good," correlating with lower pain scores and fewer residual symptoms.

Table 5: Patient Satisfaction at Six Months

*Statistically significant (p < 0.05)

The findings of this study suggest that prophylactic neurectomy in inguinal hernioplasty significantly reduces the incidence of chronic groin pain at six months while leading to a slightly higher but transient incidence of hypoesthesia. Despite this, overall patient satisfaction was higher in the neurectomy group, indicating that the benefits of reduced chronic pain outweigh the minor sensory disturbances observed.

Chronic postoperative groin pain (CPGP) is a significant concern following inguinal hernia repair, often surpassing recurrence as the primary complication affecting patient outcomes. The present study compared ilioinguinal nerve preservation versus prophylactic neurectomy in patients undergoing Lichtenstein tension-free mesh hernioplasty, focusing on postoperative pain, sensory disturbances, and overall patient satisfaction. The findings provide valuable insights into optimizing nerve management during hernia repair.

Postoperative Pain and the Role of Ilioinguinal Neurectomy

The results demonstrated that prophylactic ilioinguinal neurectomy significantly reduced the incidence of chronic groin pain at six months compared to nerve preservation. While the immediate postoperative pain (POD-1) was slightly higher in the neurectomy group, the pain scores at one, three, and six months were consistently lower than those in the nerve preservation group. At six months, only 8.3% of patients in the neurectomy group experienced chronic pain compared to 19.2% in the preservation group (p = 0.04). This aligns with previous studies reporting a reduction in long-term pain following ilioinguinal neurectomy (3, 6).

The mechanism behind this reduction in pain is likely due to the prevention of nerve entrapment and neuroma formation, which are common causes of persistent post-herniorrhaphy pain. Studies suggest that neuropathic pain after hernia repair arises from inflammation, fibrosis, or compression of the ilioinguinal nerve within the surgical field (9-12). Removal of the nerve during surgery, the risk of these complications significantly minimized.

Sensory Disturbances and Hypoesthesia

A notable concern regarding prophylactic neurectomy is postoperative sensory disturbances, particularly hypoesthesia and numbness in the inguinal and upper medial thigh region. In this study, sensory disturbances were slightly more common in the neurectomy group at early follow-ups. However, by six months, the difference between the groups was not statistically significant (p = 0.41), indicating that neurosensory changes tend to resolve or become well-tolerated over time.

This finding is consistent with previous studies reporting initial hypoesthesia rates between 30% and 60% following ilioinguinal neurectomy, with most patients adapting well over time (10, 11,14). Furthermore, hypoesthesia is often asymptomatic and does not significantly affect daily activities, unlike chronic pain, which has a more profound impact on quality of life(13).

Comparison with Previous Literature

Several clinical trials and meta-analyses have explored the role of ilioinguinal neurectomy in inguinal hernioplasty. A meta-analysis by Alfieri et al. (2011) found that neurectomy reduced the incidence of moderate-to-severe chronic pain while leading to minor, well-tolerated sensory loss (14). Similarly, Wijsmuller et al. (2007) reported that patients undergoing nerve preservation had a higher incidence of persistent neuropathic pain compared to those undergoing neurectomy (15). The present study supports these findings, reinforcing the benefit of prophylactic neurectomy in reducing chronic pain without significant long-term sensory deficits.

Patient Satisfaction and Clinical Implications

The overall patient satisfaction scores were higher in the neurectomy group, with 76% rating their postoperative experience as "Excellent" compared to 60% in the nerve preservation group. This suggests that reduced chronic pain is a stronger determinant of patient satisfaction than minor sensory changes.

Given the significant impact of chronic pain on daily activities, work productivity, and psychological well-being, surgeons must carefully consider nerve management strategies in hernia repair. The present findings suggest that routine ilioinguinal neurectomy should be considered in patients undergoing Lichtenstein mesh hernioplasty, particularly in individuals at higher risk for chronic pain. However, patient preferences should also be taken into account, and preoperative counseling about potential sensory changes is essential(16-19).

Limitations and Future Directions

While this study provides strong evidence supporting prophylactic neurectomy, there are a few limitations. First, the study did not assess long-term outcomes beyond six months, and it remains unclear whether some patients might experience late-onset neuropathic pain or persistent sensory disturbances. Future studies should include longer follow-up periods (12 months or more) to evaluate the durability of pain relief and sensory adaptation(20).

Second, this was a single-center study, which may limit the generalizability of the findings. A multicenter randomized controlled trial would provide more robust evidence. Additionally, quality-of-life assessments using validated questionnaires could provide a more comprehensive understanding of the functional impact of neurectomy versus nerve preservation.

The findings of this study demonstrate that prophylactic ilioinguinal neurectomy in Lichtenstein hernioplasty significantly reduces chronic groin pain at six months, with only minor and well-tolerated sensory disturbances. Patients undergoing neurectomy reported higher satisfaction rates, highlighting the importance of pain prevention in postoperative outcomes. Given the significant burden of chronic postoperative pain, routine ilioinguinal neurectomy appears to be a reasonable and effective approach in open inguinal hernia repair. However, patient counseling remains essential to ensure informed decision-making regarding the risks and benefits of this technique.

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