QuizMe 25

Nerve Injury (III)

A 28 yr old lady undergoes laparotomy with left saplingectomy for unstable ectopic pregnancy. Surgery was performed using a pfannenstiel incision and a self-retaining retractor, and lasted 60 minutes. On post op day 2, the patient describes severe burning pain in the left inguinal region and along the upper left thigh.

  • Low transverse abdominal incision
  • Retractor
  • Pain in inguinal region
  • Incision location and extension
  • Surgical dissection
  • Retractor placement
  • Patient positioning

Incision location and extension

The patient’s pain appears to be the result of an ilio-inguinal nerve injury. Insults to this nerve often present as sensory abnormality, in the form of hypo- or hyper-esthesia of the skin overlying the inguinal region, pubic tubercle, groin and upper thigh.

Although the ilio-inguuinal nerve typically follows a route outside of the gynecologic field of operation, it may be jeopardized when a low transverse abdominal incision is extended beyond the lateral border of the rectus abdominus muscle, and into the internal oblique muscle.

Ilio-inguinal nerve injuries are often due to direct transection of the nerve upon placement of the incision or during its extension. Suture entrapment during fascial closure, or constriction upon scar formation are also recognized possibilities.

Risk factors include low transverse abdominal incisions, especially if extended to allow for more exposure. Excessive lateral placement of a trocar during laparoscopic surgery may also pose risk to the nerve given its lateral anatomical course. 

  • W I, W A, P T, L R. Minimizing the riskof neurologic injury in gynecologic surgery. Obstet Gynecol, 2004 https://pubmed.ncbi.nlm.nih.gov/14754710/
  • OS A, MA B, T F. Nerve Injuries in Gynecologic Laparoscopy. J Minim Invasive Gynecol [Internet]. 2017
    https://pubmed.ncbi.nlm.nih.gov/27639546/
  • Bohrer JC, Walters MD, Park A,Polston D, Barber MD. Pelvic nerve injury following gynecologic surgery: a prospective cohort study. 2009www.AJG.org
  • P S, KM P. Peripheral nerve injuries resulting from common surgical
    procedures in the lower portion of the abdomen. Arch Surg [1982]. Availablefrom:https://pubmed.ncbi.nlm.nih.gov/7065874/
  • AD B, AP A. Postoperative neuropathy in gynecologic surgery.Obstet Gynecol Clin North Am [2010].Availablefrom:https://pubmed.ncbi.nlm.nih.gov/20674786/
Author

Dr Mustafa Qasem & Dr Aya Al-Shati

Reviewer

Mr Moiad Alazzam