Esteban Quevedo Orrego1, Javier Robla Costales2, Carlos Rodríguez Aceves3, Rubén Diana Martín1, Adán González Álvarez1, Mariano Socolovsky1,4. 1. Neurosurgical Department, Complejo Asistencial Universitario de León, León, Spain. 2. Neurosurgical Department, HM Hospitales Regla/San Francisco, Calle Cardenal Landázuri 2, 24003, León, Spain. javierrobla@hotmail.com. 3. Centro Neurológico, Centro Médico ABC Campus Santa Fé, Ciudad de México, México. 4. Peripheral Nerve & Plexus Program, Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina.
Abstract
OBJECTIVE: To describe the first pediatric case in the literature of neuropathic inguinal pain secondary to iatrogenic nerve injury that occurred during a laparoscopic appendectomy, detailing clinical and morphological findings before and after surgery. The literature on adult patients is reviewed and pathophysiological, therapeutic, and prognostic factors are discussed. CLINICAL PRESENTATION: A 14-year-old female patient presented with a history of a laparoscopic appendectomy 3 years previously. Three months post-operatively, she developed progressively worsening neuropathic inguinal pain refractory to neuromodulators and several nerve blocks. Given her deterioration, poor response to conservative therapy, and clearly meeting the criteria for chronic post-operative inguinal pain (CPIP), surgical management was undertaken. RESULTS: Open surgery was performed through the previous incision, during which injury to a branch of the iliohypogastric nerve (IH) was confirmed. Neurolysis of the affected branch was performed, after which the patient experienced significant pain relief, resolution of allodynia, and reversal of skin hyperpigmentation. After discharge, analgesic therapy was gradually withdrawn and, ultimately, discontinued altogether. CONCLUSIONS: Understanding the neuroanatomy of the inguinal region is an indispensable requirement for all surgeons operating in this region, to avoid complications including CPIP and optimize patient outcomes. Surgical management of CPIP can be effective for controlling severe pain in patients in whom conservative management has failed. Studies are needed in the pediatric population to identify specific characteristics of this entity in youth.
OBJECTIVE: To describe the first pediatric case in the literature of neuropathic inguinal pain secondary to iatrogenic nerve injury that occurred during a laparoscopic appendectomy, detailing clinical and morphological findings before and after surgery. The literature on adult patients is reviewed and pathophysiological, therapeutic, and prognostic factors are discussed. CLINICAL PRESENTATION: A 14-year-old female patient presented with a history of a laparoscopic appendectomy 3 years previously. Three months post-operatively, she developed progressively worsening neuropathic inguinal pain refractory to neuromodulators and several nerve blocks. Given her deterioration, poor response to conservative therapy, and clearly meeting the criteria for chronic post-operative inguinal pain (CPIP), surgical management was undertaken. RESULTS: Open surgery was performed through the previous incision, during which injury to a branch of the iliohypogastric nerve (IH) was confirmed. Neurolysis of the affected branch was performed, after which the patient experienced significant pain relief, resolution of allodynia, and reversal of skin hyperpigmentation. After discharge, analgesic therapy was gradually withdrawn and, ultimately, discontinued altogether. CONCLUSIONS: Understanding the neuroanatomy of the inguinal region is an indispensable requirement for all surgeons operating in this region, to avoid complications including CPIP and optimize patient outcomes. Surgical management of CPIP can be effective for controlling severe pain in patients in whom conservative management has failed. Studies are needed in the pediatric population to identify specific characteristics of this entity in youth.
Authors: A R Wijsmuller; J F M Lange; G J Kleinrensink; D van Geldere; M P Simons; F J P M Huygen; J Jeekel; J F Lange Journal: World J Surg Date: 2007-02 Impact factor: 3.352
Authors: J F M Lange; A R Wijsmuller; D van Geldere; M P Simons; R Swart; J Oomen; G J Kleinrensink; J Jeekel; J F Lange Journal: Br J Surg Date: 2009-10 Impact factor: 6.939
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