C Simpkins, AM Cota and N Johnson
Department of Surgery, Torbay Hospital, Lawes Bridge,
Torquay, TQ2 7AA
Correspondence to
SMJ 2007 52(4): 54
A
40-year-old gentleman underwent a routine TEPP (trans-extraperitoneal) procedure
without the use of staples to fix the mesh. He presented with symptoms of
lateral cutaneous nerve of the thigh injury. We present this rare complication
and its management.
Laparoscopic
hernia repairs are being carried out in increasing numbers as there are known
reported benefits. In our centre having performed over 200 cases, we present a
rare complication of the procedure.
A
40-year-old builder underwent laparoscopic repair of his bilateral inguinal
hernia. A TEPP procedure was carried out and bilateral polypropylene mesh (Bard
3D Max mesh 10.8cm X 16 cm) was placed without the use of staples.
Postoperatively he complained of numbness in his right thigh. He was
prescribed analgesia and discharged. He contacted the hospital for an outpatient
appointment as the numbness in his thigh failed to resolve. In outpatients he
was found to have loss of touch sensation in the distribution of the lateral
cutaneous nerve of the thigh. He was prescribed amytrptilline and tegretol and
is due to see the Consultant Neurologist.
There
are several open and laparoscopic approaches to inguinal hernia repair. Open
repair with mesh is associated with a recurrence rate of 5-20% with one in three
patients developing postoperative pain. Laparoscopic approaches are currently
under development and the perceived benefit
are quicker recovery and lower complication rate due to clear
visualisation of landmarks and hernial defects.1
There
are two main laparoscopic approaches. TAPP (transabdominal) and TEPP (trans-extraperitoneal)
repair with recurrence rates of 2% and 0.3%.1, 2 The reported
incidence of other complications like thigh parasthesias, inferior epigastric
artery injury, bladder injury and retention is higher in patients having TAPP
when compared to TEPP.2
Neuropathies
following laparoscopic hernia repairs have been attributed to staples used to
anchor the mesh.3 Nerves
at risk during TEPP include the iliohypogastric, ilio-inguinal and the lateral
femoral cutaneous nerve of the thigh (LFCN). This nerve is known to have a
variable course in 13% of cadavers.3 As it passes from the pelvis
into the thigh it runs through an aponeurotico-fascial tunnel beginning at the
iliopubic tract and ending at the inguinal ligament.4, 5 It’s position varies in relation to the anterior
superior iliac spine and the iliopubic tract and exclusive use of the ASIS as a
guide for staple placement may still result in nerve entrapment.6, 7
Our case, where no staples
were used, suggests that the nerve was most likely to have been severed during
dissection.
Our
experience suggests the only way to reduce the risk of nerve injury is to be
aware of the variable nature of this nerve and look for it’s presence during
surgery.
1.Ramshaw BJ, Tucker JG, Conner T, et al. A
comparison of the approaches to laparoscopic hernioraphy. Surg Endosc. 1996 Jan;
10(1):29-32.
2. Rosenberger R J, Loeweneck H, Meyer G. The
cutaneous nerves encountered during laparoscopic repair of inguinal hernia: new
anatomical findings for the surgeon. Surg Endosc. 2000 Aug; 14(8):731-5.
3. Grothaus MC, Holt M, Mekhail AO, et al.
Lateral femoral cutaneous nerve: an anatomic study. Clin Orthop relat Res. 2005
Aug;(37):164-8.
4. Marks SC, Gilroy AM, Page DW. The clinical
anatomy of laparoscopic inguinal hernia repair. Singapore Med J. 1996 Oct;
37(5):519-21.
5.Dibenedetto LM, Lei Q, Gilroy AM, et al.
Variations in the inferior pelvic pathway of the lateral femoral cutaneous
nerve: implications for laparoscopic hernia repair. Clin Anat. 1996; 9(4):232-6.
6. Aszmann OC, Dellon ES, Dellon AL. Anatomic
course of the lateral femoral cutaneous nerve and it’s susceptibility to
compression and injury. Plast Reconstr Surg. 1997 Sep ;( 100(3):600-4.
7. Dias Filho LC, Franca SM et al. lateral femoral cutaneous neuralgia: an anatomical insight. Clin Anat. 2003 Jul; 16(4):309-16.