İnguinodini'de Nonoperatif Hasta Yönetimi
Özet
Kasık fıtığı onarımı sonrası 3 aydan uzun süren patolojik ağrılar inguinodini (kronik kasık ağrısı) olarak adlandırılır. Genellikle nöropatik karakterde olan bu durumun etyolojisinde ilioinguinal, iliohipogastrik, genitofemoral ve lateral femoral kutanöz sinirler yer alır. Genç yaş, kadın cinsiyet, ameliyat öncesi ağrı varlığı, fıtığın tekrarlaması, deneyimsiz cerrahlar, açık fıtık onarımı ve yüksek yoğunluklu mesh kullanımı postoperatif nevralji için temel risk faktörleridir. Tanı; klinik öykü, fizik muayene, bıçak saplanır tarzda ağrı, duyusal algıda bozulma ve tanısal periferik sinir blokajı ile konur; görüntüleme yöntemleri ise nöropatik olmayan nedenleri dışlamak için kullanılır. Ağrıyı önlemek adına laparoskopik cerrahi seçimi, sinirlerin intraoperatif olarak tanımlanması ve korunması, hafif mesh kullanımı ve fibrin yapıştırıcılar ile atravmatik sabitleme önerilmektedir. Tedavi süreci multimodal ve multidisipliner bir yaklaşım gerektirir. Farmakolojik tedavide antikonvülzanlar (gabapentin, pregabalin), antidepresanlar, topikal ajanlar ve opioidler tercih edilmektedir. İlaçların kalıcı çözüm sunamadığı durumlarda, ultrasonografi eşliğinde uzun etkili lokal anestezik ve glukokortikoid enjeksiyonunu içeren sinir blokları uygulanır. Tekrarlayan bloklara yanıt vermeyen inatçı vakalarda ise kimyasal nöroliz, kriyoablasyon veya radyofrekans ablasyon gibi sinir ablasyonu yöntemleri ile inatçı ağrılarda nöromodülasyon cihazları devreye girmektedir.
Pathological pain lasting longer than 3 months after inguinal hernia repair is defined as inguinodynia (chronic groin pain). This condition is generally neuropathic, and the ilioinguinal, iliohypogastric, genitofemoral, and lateral femoral cutaneous nerves are involved in its etiology. Young age, female gender, preoperative pain, recurrent hernia, inexperienced surgeons, open repair, and heavyweight mesh usage are main risk factors for postoperative neuralgia. Diagnosis is established through clinical history, physical examination, stabbing pain, sensory impairment, and diagnostic nerve blocks, while imaging is used to exclude non-neuropathic causes. To prevent pain, laparoscopic surgery, intraoperative nerve identification, lightweight mesh, and atraumatic fixation with fibrin glue are recommended. Management requires a multimodal and multidisciplinary approach. Pharmacological treatments include anticonvulsants (gabapentin, pregabalin), antidepressants, topical agents, and opioids. When medications provide temporary relief, ultrasound-guided nerve blocks with local anesthetics and glucocorticoids are performed. For intractable cases resistant to repetitive blocks, nerve ablation methods such as chemical neurolysis, cryoablation, or radiofrequency ablation are utilized, while neuromodulation devices are considered for persistent pain.
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