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Invited Critique
July 1, 2004

Randomized Controlled Trial of Preservation or Elective Division of Ilioinguinal Nerve on Open Inguinal Hernia Repair With Polypropylene Mesh—Invited Critique

Arch Surg. 2004;139(7):759. doi:10.1001/archsurg.139.7.759

What this excellent study by Picchio and colleagues demonstrates is that one of the most debilitating problems after an open hernia repair is chronic groin pain. Preserving or dividing the ilioinguinal nerves makes little difference to the eventual outcome.

Unfortunately, quality-of-life issues are rarely considered when patients are counseled for hernia surgery. The emphasis is rather on recurrence rates, an easily measurable end point compared with the subjective opinions of patients. Chronic groin pain and sensory changes can be debilitating; Gillion and Fagniez1 reported that in 5% of their patients this discomfort was more troublesome than the preexisting hernia. They also noted that "posterior approaches, in particular laparoscopic, were associated with statistically fewer sensory changes than inguinal approaches." Why should this be the case? Preperitoneal placement of the mesh, as reported by Stoppa,2 covers the myopectineal orifices through which all groin hernias protrude and the truncal segments of the ilioinguinal and iliohypogastric nerves rather than the thin branches in the groin.