Prophylactic neurectomy in open inguinal repair: less chronic pain, more sensory change

Design

Systematic review and meta-analysis of 17 RCTs

Population

3,406 adults undergoing elective open anterior inguinal hernia repair

Primary outcome

Chronic postoperative inguinal pain

Effect

9.3% vs 18.1%; RR 0.37 (0.25–0.55); I² 69%

This meta-analysis pooled 17 randomised trials comparing planned division of one or more inguinal nerves with preservation during elective open anterior inguinal hernia repair.

At longest follow-up, chronic postoperative inguinal pain affected 9.3% after neurectomy against 18.1% after preservation (RR 0.37, 95% CI 0.25–0.55), and the benefit was seen at 3, 6 and 12 months. Acute pain and rescue analgesia were also lower. But sensory loss or change increased, the effect on moderate-to-severe chronic pain was uncertain, and quality of life, recurrence and complications did not differ. Heterogeneity was substantial (I² 69%), and many trials did not report whether nerves were identified in the preservation arm.

The authors conclude, reasonably, that this does not support routine neurectomy. What it does support is deliberate nerve identification, and a lower threshold to divide a nerve that is in the way of the mesh or already damaged, after discussing the sensory trade-off with the patient beforehand.

• Do not divide inguinal nerves routinely; the evidence does not show better quality of life.
• Consider elective division of a nerve that is injured, entrapped or lying across the mesh.
• Discuss the trade-off before surgery: less chronic pain against more sensory change.
• Identify nerves deliberately — 'preservation' in many trials may have meant not looking.
• The finding applies to open anterior repair, not laparoscopic or robotic approaches.

Why it matters

It frames neurectomy as a selective, consented decision rather than either a routine step or a taboo.

Don't overread it

Less chronic pain overall did not translate into better quality of life or clearly fewer severe-pain cases.

The statistics, in plain English

A risk ratio of 0.37 means chronic pain was about 63% less likely after neurectomy. I² of 69% means trial results varied a lot, so the true effect in a given unit is uncertain. 'Statistically uncertain' for moderate-to-severe pain means the interval included no effect.

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