İnguinodoni ve Cerrahi Tedavi Yöntemleri
Özet
İnguinal herni cerrahisi sonrası üç aydan uzun süren kronik kasık ağrısı "inguinodini" olarak tanımlanmakta olup dünyadaki insidansı %10-12 arasındadır. Lumbar pleksustan çıkan ilioinguinal, iliohipogastrik ve genitofemoral sinirlerin zedelenmesi etyolojide önemli rol oynar. Genç yaş, kadın cinsiyeti, nüks operasyonlar, anterior yaklaşım ve preoperatif ağrı öyküsü başlıca risk faktörleridir. Sekiz haftadan uzun süren ağrılar nöropatik karakterde kabul edilir ve cerrahi esnasındaki kesilme, manipülasyon veya dikiş reaksiyonları (primer) ile meshe bağlı inflamasyon ve fibrozis (sekonder) sonucu gelişebilir. Profilakside hafif, makro gözenekli meshlerin ve sütür yerine fibrin yapıştırıcıların tercih edilmesi ağrı riskini azaltır. Klinik olarak nöropatik ağrı; yanma, batma, tetik noktalarının varlığı ve uyluk veya skrotuma yayılımla karakterizedir. Tanı klinik olarak konur; MRI gibi radyolojik yöntemler nöropatik olmayan nedenleri ekarte etmek için kullanılır. Tedavide ilk adım medikal analjezikler, sinir blokları ve ablasyon uygulamalarıdır. Ameliyatsız yöntemlere yanıt vermeyen hastalarda, ilk cerrahiden 6-12 ay sonra cerrahi tedavi düşünülür. En etkili cerrahi yöntem mesh eksizyonu ile kombine edilen triple (üçlü) nörektomi olup hastaların %90'ından fazlasında kalıcı iyileşme sağlar. Ayrıca laparoskopik nöroprotez implantasyonu (LION) da alternatif bir tekniktir.
Chronic groin pain lasting more than three months after inguinal hernia surgery is defined as inguinodynia, with a global incidence of 10% to 12%. Injuries to the ilioinguinal, iliohypogastric, and genitofemoral nerves arising from the lumbar plexus play a major role in its etiology. Key risk factors include young age, female gender, recurrent operations, anterior approach, and a history of preoperative pain. Pain lasting longer than eight weeks is considered neuropathic and can develop from primary injuries like transection, manipulation, or suture entrapment, or secondary injuries such as mesh-induced inflammation and fibrosis. In prophylaxis, choosing lightweight, macroporous meshes and using fibrin sealants instead of sutures reduce the risk of pain. Clinically, neuropathic pain is characterized by burning, stabbing, distinct trigger points, and radiation to the thigh or scrotum. Diagnosis is clinical, and MRI is utilized to rule out non-neuropathic causes. Initial management involves medical analgesics, nerve blocks, and ablation. For patients non-responsive to non-operative methods, surgical treatment is considered 6 to 12 months after the primary repair. The most effective surgical approach is triple neurectomy combined with mesh excision, providing permanent relief in over 90% of cases, while laparoscopic neuroprosthesis implantation (LION) serves as an alternative technique.
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