Laparoscopic Inguinal Exploration and Mesh Placement for Chronic Pelvic Pain.

2013·0.42 MB·English

by  Yong, Paul J.

S P
CIENTIFIC APER
Laparoscopic Inguinal Exploration and Mesh
Placement for Chronic Pelvic Pain
Paul J. Yong, MD, PhD, Christina Williams, MD, Catherine Allaire, MD
ABSTRACT Conclusion: In select women with chronic pelvic pain,
empiric laparoscopic inguinal exploration and mesh
Background and Objective: Chronic pelvic pain affects
placement results in moderate improvement in outcome.
15% of women. Our objective was to evaluate empiric
ApositiveCarnett’stestintheipsilateralabdominallower
laparoscopicinguinalexplorationandmeshplacementin
quadrant is a predictor of better outcome.
this population.
Key Words: Chronic pelvic pain, Laparoscopy, Inguinal,
Methods: Retrospective cohort with follow-up question-
Mesh.
naireofwomenwithlateralizingchronicpelvicpain(right
orleft),ipsilateralinguinaltendernessonpelvicexamina-
tion, no clinical hernia on abdominal examination, and
ipsilateral empiric laparoscopic inguinal exploration with
INTRODUCTION
mesh placement (2003–2009). Primary outcome was pain
level at the last postoperative visit. Secondary outcomes
Chronic pelvic pain (at least 6 mo duration) affects up to
were pain level and SF-36 scores from the follow-up
15%women,canhaveadevastatingimpactonquality-of-
questionnaire.
life, and can be of musculoskeletal, neuropathic, gastro-
intestinal,urologic,orgynecologicorigin.1Onemusculo-
Results: Forty-eight cases met the study criteria. Surgery
skeletal cause of chronic pelvic pain is a hernia, which
wasdoneempiricallyforallpatients,withonly7patients
maybeinguinal,obturator,femoral,sciatic,ventral,Spige-
(15%) found to have an ipsilateral patent processus vagi-
lian,orincisional.2Ifaninguinal(indirect)herniaispres-
nalis(shallowperitonealdimpleoradeeperdefect(occult
ent, surgical repair of such hernias is effective for treat-
hernia)).Of43casesinformativefortheprimaryoutcome,
ment of chronic pelvic pain.3 One method of repair is
there was pain improvement in 15 patients (35%); pain
transabdominal preperitoneal (TAPP), involving laparo-
improvementthenreturnofthepainin18patients(42%);
scopicexplorationandplacementofmeshattheinguinal
and pain unchanged in 9 patients (21%) and worse in 1
canal.4
patient (2%). Improvement in pain was associated with a
positive Carnett’s test in the ipsilateral abdominal lower However, most women with chronic pelvic pain will not
quadrant(P(cid:1).024).Thirteenpatientsreturnedtheques- have a clinical hernia. Two abstracts have described em-
tionnaire (27%), and the pain was now described as im- piric laparoscopic inguinal exploration and mesh place-
provedin9patients(69%),unchangedin4patients(31%), ment in women with chronic pelvic pain but without a
and worse in none. Three SF-36 subscales showed im- clinicalhernia.5,6Itisimportanttodeterminewhetherthis
provement (physical functioning, social functioning, and empiric treatment is indeed evidence-based, in particular
pain). whether it is safe and effective in women with chronic
pelvic pain. In this retrospective study with follow-up
questionnaire, we review our experience with empiric
DepartmentofObstetricsandGynecology,UniversityofBritishColumbia,Van-
laparoscopic exploration and mesh placement in women
couver, BC, Canada (all authors).; Division of Reproductive Endocrinology and
Infertility,UniversityofBritishColumbia,Vancouver,BC,Canada(Drs.Williams, with lateralizing chronic pelvic pain (right or left), no
Allaire).;BCWomen’sCenterforReproductiveHealth,Vancouver,BC,Canada(all evidence of clinical hernia on abdominal examination,
authors).
andipsilateralinguinaltendernessonpelvicexamination.
In memory of Rachael Bagnall, medical student and research assistant on this
project,whopassedawaybeforethestudycouldbecompleted.
MATERIALS AND METHODS
Addresscorrespondenceto:Dr.PaulYong,BCWomen’sCenterforReproductive
Health,D600–4500OakStreet,Vancouver,BC,V6H3N1,Canada.Telephone:
The BC Women’s Center for Reproductive Health is an
[phone],Fax:[phone],E-mail:[email protected]
academictertiaryreferralcenteraffiliatedwiththeUniver-
DOI:10.4293/108680812X13517013317310
sityofBritishColumbia,whichspecializesinchronicpel-
©2013byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. vic pain and endometriosis and in reproductive endocri-
74 JSLS(2013)17:74–81
nology and infertility. Patients referred for chronic pelvic caudallyintotheinternalringandinguinalcanal.Ifingui-
painorendometriosis,orboth,aregivenaninitialpreop- nal tenderness on pelvic examination is demonstrated
erativequestionnairethatincludesthe36-ItemShortForm ipsilateral to the patient’s lateralizing chronic pelvic pain,
HealthSurvey(SF-36)forquality-of-life.7Inadditiontoan thenthepatientisofferedipsilaterallaparoscopicinguinal
abdominalexaminationandultrasound-guidedpelvicex- exploration and mesh placement in addition to other in-
amination,patientswhoexhibitlateralizingchronicpelvic dicated procedures (e.g., excision of endometriosis).
pain (right- or left-sided) are examined for inguinal ten-
derness. On pelvic examination, a single digit is placed Surgical technique (Figure 1): After laparoscopic entry,
above the cervix, ventrally towards the pubic bone, then useof3or4ports,andinspectionforinguinalabnormal-
laterally towards the inguinal canal and the internal ring. ities, an incision is made ventral to where the round
During laparoscopy under low pressures, the examining ligamententersthepelvicsidewall,withattentiontoavoid
digit can be seen approaching the insertion of the round the inferior epigastric. The extraperitoneal space is ex-
ligament into the pelvic sidewall where it then dives plored until the round ligament is seen diving into the
Figure1.Laparoscopicinguinalexplorationandmesh.(A)Exampleofapatentprocessusvaginalis[arrow]lateraltoinsertionofthe
roundligamentintothepelvicsidewall.(B)Openingofextraperitonealspaceneartheroundligamentinsertionintothepelvicsidewall
where it dives into the internal ring [arrow], with accompanying fat [asterisk], which is removed prior to mesh placement. (C) Mesh
placementovertheroundligamentandinternalring.(D)Extraperitonealizationofthemesh.
JSLS(2013)17:74–81 75
LaparoscopicInguinalExplorationandMeshPlacementforChronicPelvicPain,YongPJetal.
inguinalinternalringtotheinguinalcanal.Fatisremoved of endometriosis classified as incidental, defined as con-
fromaroundtheligamentatitsentryintotheinternalring, tralateralornontenderonphysicalexamination;andother
andthenanapproximately3-cmx4-cmpieceofpolypro- concurrent procedures. Endometriosis was confirmed on
pylene mesh is placed over the round ligament and the histology in all cases. In addition, we reviewed the intra-
internalring.Theperitoneumisthensuturedtoextraperi- operativeandpostoperativecomplications,andthenum-
tonealizethemesh,usuallyincorporatingapieceofmesh ber of patients requiring reoperation for pelvic pain.
in the suture to avoid mesh migration.
Secondary (long-term) outcomes were from the mailed fol-
We performed a retrospective review of empiric laparo-
low-up postoperative questionnaire containing the SF-36
scopicinguinalexplorationandmeshplacementdoneby2
and a question about the current level of pain. The ques-
surgeons (CW and CA) at the BC Women’s Center for Re-
tionnaire asked whether the pain was currently improved,
productive Health. Inclusion criteria were lateralizing
unchanged, or worse. The SF-36 from the follow-up ques-
chronicpelvicpain,ipsilateralinguinaltendernessonpelvic
tionnaire (postoperative) was compared to the SF-36 from
examination, and ipsilateral empiric laparoscopic inguinal
the initial questionnaire (preoperative). The SF-36 was
explorationandmeshplacement(2003–2009).Exclusioncri-
scoredaspertheRANDSF-361.0protocol,whichderives8
terion was the presence of a clinical hernia on abdominal
subscalesbasedon35questionswith1additionalquestion
examination. Medical records were reviewed (preoperative
about health change over the last year (http://www.rand.
to postoperative), including the preoperative SF-36 and the
org/health/surveys_tools/mos/mos_core_36item.html)
levelofpainatthelastpostoperativevisit.Forthefollow-up
(Table 1). Each subscale and the health change question
questionnairecomponentofthestudy,patientsweresenta
are scored from 0–100, with a higher score indicating
packagebymailthatincludedaconsentformforthestudy
better quality-of-life.7
and a postoperative questionnaire containing another copy
oftheSF-36andaquestionaboutthecurrentlevelofpain.
Statistical analyses were carried out using SPSS 19.0. For
Thestudywasapprovedbytheresearchethicsboardsofthe
descriptivestatistics,meansaredescribedas(cid:2)-1standard
University of British Columbia and BC Women’s and Chil-
deviation. For tests of association between the primary
dren’sHospitals(H09–00025).
outcome and the predictor variables, the nonparametric
Theprimary(short-term)outcomewasthelevelofpainat 2-tailed Mann-Whitney and Spearman rank correlation
thelastpostoperativevisit,whichwascodedasfollows:1) testswereutilizedbecauseofnonnormalityandnondirec-
Improvement (complete or partial resolution); 2) Im- tional hypotheses; for the change in SF-36 scores, the
provement then return of the pain; 3) No change; or 4) parametric 1-tailed paired-sample t test was utilized. Lin-
Worse.Theprimaryoutcomewastestedforanassociation ear regression modeling was performed using likelihood
withthefollowingpredictorvariables:age;BMI;nullipar- ratio model building. (cid:1)(cid:1)0.05.
ity; side of the pain (right or left); duration of pain; pain
characteristics (cyclical or noncyclical); previous laparos-
copy;otherchronicpelvicpaindiagnosis(endometriosis, RESULTS
interstitial cystitis, irritable bowel syndrome, vulvodynia,
or psychiatric comorbidity); ipsilateral abdominal lower Forty-eightpatientsmettheinclusioncriteria.Nopatients
quadrant tenderness; positive Carnett’s test in the ipsilat- wereexcluded(i.e.,nonehadaclinicalherniaonabdom-
eral abdominal lower quadrant indicative of abdominal inal examination). Characteristics of the 48 patients are
wall pain (positive Carnett test(cid:1)worsening or no change summarized in Table 1. Of note, 38 patients (79%) had
in tenderness with abdominal wall flexion/contraction); hadapreviouslaparoscopy,andofthese,almostall(n(cid:1)
laparoscopic diagnosis of a patent processus vaginalis at 35) had had a previous laparoscopy for the same pain.
the round ligament insertion into the sidewall, either a The procedures performed at the previous laparoscopy
shallow peritoneal dimple or a larger defect (occult her- are also summarized in Table 1.
nia) (Figure 1)8; laparoscopic findings after exploration
of the ipsilateral inguinal internal ring; laparoscopic ab- At the time of empiric laparoscopic inguinal exploration
normality of the contralateral inguinal region; concurrent and mesh placement, there was a laparoscopic diagnosis
excision of endometriosis classified as symptomatic, de- of an ipsilateral patent processus vaginalis in 7 patients
fined as ipsilateral to the pain and tender on physical (15%) (Table 1; Figure 1); in an additional 5 patients
examination(i.e.,tenderintheipsilateralcul-desac,utero- (10%), there were laparoscopic findings after exploration
sacralligament,sidewall,oradnexa);concurrentexcision of the ipsilateral inguinal internal ring (Table 1). Empiric
76 JSLS(2013)17:74–81
Table1. Table1.(Continued)
PredictorVariables PredictorVariables
PredictorVariable StudySample PredictorVariable StudySample
(n(cid:1)48)a (n(cid:1)48)a
History Surgical
Age 31.4(cid:2)9.2 BeforeExploration:IpsilateralPatent 7(15)
BMI 24.4(cid:2)3.9 ProcessusVaginalisattheInguinal
InternalRingf(%)
Nulliparity(%) 24(51)
AfterExploration:IpsilateralFindingsat 5(10)
SideofPain(%) R(cid:1)27(56) theInguinalInternalRingg(%)
L(cid:1)18(38) ContralateralInguinalAbnormalityh(%) 4(8)
Bilateral(cid:1)3(6) ConcurrentExcisionofSymptomatic 4(8)
DurationofPain(%) (cid:3)1year(cid:1)8(18) Endometriosisi(%)
1–5years(cid:1)16(36) ConcurrentExcisionofIncidental 13(27)
Endometriosisj(%)
(cid:4)5years(cid:1)21(47)
OtherConcurrentLaparoscopic 8(17)
PainCharacteristicsb(%) Cyclical(cid:1)24(57) Procedurek(%)
Non-cyclical(cid:1)18(43)
aDenominator depends on the number of informative cases for
PreviousLaparoscopyc(%) 38(79) eachpredictorvariable.
AtLeastOneOtherChronicPelvicPain 35(73) bSixpatientshadaprevioushysterectomy.
Diagnosisd(%) cOf the 38 patients with previous laparoscopy, 35 had the pre-
Endometriosis 22(46) vious laparoscopy for the same pain involving the following
procedures:treatmentofendometriosis(n(cid:1)16),diagnosticpro-
Interstitialcystitis 3(6) cedure only (n(cid:1)11), ovarian cystectomy (n(cid:1)2), treatment of
Irritablebowelsyndrome 6(13) endometriosis and ovarian cystectomy (n(cid:1)1), empiric appen-
dectomy (n(cid:1)1), empiric appendectomy and paratubal cystec-
Vulvodynia 3(6) tomy(n(cid:1)1),salpingectomy(n(cid:1)1),lysisofadhesions(n(cid:1)1),and
hysterectomy(n(cid:1)1).
Psychiatriccomorbidity 10(21)
dSomepatientshadmorethanoneotherdiagnosis.
Othere 3(6)
eHistory of pelvic fractures, previous PID requiring hysterec-
InitialSF-36Score(fromthePre-
tomy,andinflammatoryboweldisease.
operativeQuestionnaire)
fBefore exploration, there was a patent processus vaginalis,
Physicalfunctioning 68.2(cid:2)27.0 which appeared as a shallow dimple or larger defect (occult
Rolefunctioning(physical) 33.1(cid:2)36.1 hernia)attheperitoneumneartheroundligamentinsertioninto
the pelvic sidewall (where it later enters the ipsilateral inguinal
Rolefunctioning(emotional) 59.5(cid:2)42.6 internalring)f(Figure1).
Energy/Fatigue 38.6(cid:2)23.1 gAfterexploration,therewasevidenceofan“inguinalhernia,”a
“smalldefect,”or“largeamountoffat”attheipsilateralinguinal
Emotionalwell-being 64.5(cid:2)18.6
ring.
Socialfunctioning 59.7(cid:2)25.0 hFindings at the contralateral (nonpainful, nontender side) in-
Pain 42.7(cid:2)22.5 guinalregion:3patientswithapatentprocessusvaginalish;and
1patientwithadirectinguinalhernia.
Generalhealth 58.2(cid:2)20.7
iExcision of endometriosis that was ipsilateral and tender on
Healthchange 35.8(cid:2)28.7 physicalexam(ie,tenderintheipsilateralcul-de-sac,uterosacral
ligament,sidewall,oradnexa).Endometriosiswasconfirmedon
Examination
histology.
IpsilateralAbdominalLowerQuadrant 38(79) jExicisionofendometriosisthatwaseithercontralateralornon-
Tenderness(%) tender on physical examination. Endometriosis confirmed on
PositiveCarnett’sTestintheIpsilateral 13(27) histology.
AbdominalLowerQuadrant(%) kIncluded an ipsilateral ovarian suspension, ipsilateral salpingo-
oophorectomy, ipsilateral lysis of adhesions, and empiric appen-
dectomy,aswellasproceduresthatweredoneforotherindications
(contralateralovariancystectomy,contralateralsalpingo-oophorec-
tomy,contralateralsalpingectomyofaccessoryfallopiantube,and
tuballigation).
JSLS(2013)17:74–81 77
LaparoscopicInguinalExplorationandMeshPlacementforChronicPelvicPain,YongPJetal.
ipsilateral inguinal exploration and mesh placement was regression model was constructed with a positive Carnett’s
doneforallpatients,regardlessofwhetherthesefindings testandtimetolastpostoperativevisitaspredictorvariables
were present or not. In addition, 4 patients (8%) had a fortheprimaryoutcome,thetimetolastpostoperativevisit
laparoscopic abnormality of the contralateral inguinal re- fell out of the model (P (cid:1) .14) with only the positive Car-
gion(thesidewithnopainortenderness;Table1),which nett’stestremainingsignificant(P(cid:1).024).
was not explored or repaired. Four patients (8%) had a
Therewerenointraoperativecomplications,andthepost-
concurrent excision of endometriosis classified as symp-
operativecomplicationsweremildanduncommon(10%):
tomatic, while 13 patients (27%) had concurrent excision
hospitalization for postoperative pain (n (cid:1) 2), bladder
of endometriosis classified as incidental (Table 1).
infection (n (cid:1) 1), endometritis (n (cid:1) 1), and “slow recov-
Five patients did not return for a postoperative visit, and ery” (n (cid:1) 1). Eight patients required reoperation for pain
therefore 43 patients were informative for the primary (17%), which included repeat laparoscopy for mesh re-
outcome (pain level at the last postoperative visit). The moval (n (cid:1) 3), open groin exploration by a general
averagetimetothelastpostoperativevisitwas12.6(cid:2)14.2 surgeon(n(cid:1)2),hysterectomy(n(cid:1)1),hysterectomyand
mo (range (cid:2) 1 to 58) from the date of surgery. For the ipsilateralsalpingo-oophorectomy(n(cid:1)1),andunknown
primary (short-term) outcome, there was pain improve- (n (cid:1) 1). One patient requested mesh removal after a
ment in 15 patients (35%) (complete resolution in 3 and motor vehicle accident resulted in return of the pain, and
partial resolution in 12 patients), pain improvement then noinguinalabnormalitywasnotedduringrepeatlaparos-
return of the pain in 18 patients (42%), and pain un- copy. A second patient requested mesh removal after
changed in 9 patients (21%) and worse in 1 patient (2%). return of the pain secondary to trauma, and again no
The average time to return of the pain was 8.7(cid:2)-9.8 mo inguinalabnormalitywasnoted.Athirdpatientrequested
(range (cid:2) 1 to 34) from the date of surgery, and triggers mesh removal after the pain returned (unknown cause),
were trauma (n (cid:1) 3), sports (n (cid:1) 2), pregnancy (n (cid:1) 2), andtheinguinalcanallookedslightlyinflamedandthick-
bikini wax (n (cid:1) 1), and unknown (n (cid:1) 10). ened with pathology showing mild chronic and foreign
body inflammation. None of these patients had significant
The predictor variables are listed in Table 1. Neither a improvements in their pain after mesh removal (and one
concurrent surgical procedure (such as excision of en- patient requested repeat inguinal exploration and mesh
dometriosis, whether classified as symptomatic or inci- placement),althoughfollow-upwaslimited.Anadditional2
dental), nor the presence of an ipsilateral patent pro- patientswerereferredtoageneralsurgeonandunderwent
cessus vaginalis, was associated with the primary open groin exploration. One of these patients had experi-
outcome (Table 1). The only predictor variable signif- encednoimprovementafterlaparoscopicinguinalexplora-
icantly associated with the primary outcome was a tionandmeshplacement,whiletheotherpatienthadexpe-
positiveCarnett’stestintheipsilateralabdominallower rienced improvement then return of the pain. After open
quadrant, with a positive Carnett’s test associated with groinexploration,bothpatientshadaninitialimprovement,
improvement of the pain at the last postoperative visit thenreturnofthesamepainwithin3mo.
(Spearman’srho(cid:1)0.34,P(cid:1).024).Ofthe11patientswitha
For the secondary (long-term) outcomes, 13 patients
positive Carnett’s test informative for the primary outcome,
(27%) returned the questionnaire. The time between the
improvement occurred in 8 patients (73%) (complete reso-
surgeryandthedateofthequestionnairewas73.2(cid:2)30.6
lutionin2andpartialresolutionin6patients),improvement
mo(range(cid:1)23to102).Therewasnoevidenceofselec-
thenreturnofthepainin2patients,nochangein1patient,
tionbias,asthese13patientshadasimilardistributionfor
and worsening in no patients. Of the 32 patients with a
the primary outcome (improvement in 4, improvement
negative Carnett’s test, improvement occurred in 7 patients
thenreturnofthepainin5,nochangein3,andworsein
(22%) (complete resolution in 1 and partial resolution in 6
0) compared to the rest of the sample (P (cid:1) .54), and
patients),improvementthenreturnofthepainin16patients,
similar initial (preoperative) SF-36 subscale scores com-
nochangein8patients,andworseningin1patient.Noneof
paredtotherestofthesample(P(cid:1).39to0.98).Inthese
the other predictor variables in Table 1 had an association
13 patients who returned the follow-up questionnaire,
withtheprimaryoutcome.
pain was now described as being improved in 9 patients
Inaddition,therewaspossibleevidenceofselectionbias, (69%), unchanged in 4 patients (31%), and worse in 0
aspatientswhohadalongertimetothelastpostoperative patients. Three SF-36 subscales improved from the initial
visithadatrendtowardsmorepainfortheprimaryoutcome questionnaire(preoperative)tothefollow-upquestionnaire
(Spearman’s rho(cid:1)-.31, P (cid:1) .045). However, when a linear (postoperative):physicalfunctioning(P(cid:1).032),socialfunc-
78 JSLS(2013)17:74–81
tioning(P(cid:1).036),andpain(P(cid:1).035)(Table2).TheSF-36 is to decompress the ilioinguinal nerve by removing the
question about health change also improved (P (cid:1) .003) fat and placing a mesh at the internal ring. There have
(Table2). only been 2 reports of empiric laparoscopic inguinal ex-
ploration and mesh placement in women with chronic
DISCUSSION pelvic pain, some of whom with inguinal tenderness on
pelvicexamination.Areviewcitedanabstractstatingthat
In this retrospective study with follow-up questionnaire,
80% to 85% of women with chronic pelvic pain obtain
we found that empiric laparoscopic inguinal exploration
“significant”: or complete resolution of their pain with
and mesh placement in women with lateralizing chronic
laparoscopic inguinal exploration and mesh placement,
pelvic pain (right or left), no clinical herniaonabdominal
although sample size was not provided.5 In another ab-
examination, and ipsilateral inguinal tenderness on pelvic
stract, Janicki et al.6 reported on 21 women with chronic
examination,resultedinimprovementin35%andimprove-
pelvic pain who underwent laparoscopic inguinal explo-
ment with return of the pain in 42% at the time of the last
ration and mesh placement, and found that 74% to 78%
postoperative visit. Of the 27% of patients who returned a
had “great” improvement or complete resolution of their
questionnaire for long-term follow-up, 69% reported their
painat6moto12mo.Hussainetal.9alsoreportedahigh
pain was improved, and several SF-36 subscales showed
curerate(70%)forthesamesurgeryforchronicgroinpain
improvement(physicalfunctioning,socialfunctioning,pain)
(n (cid:1) 43), although their study sample was 93% male and
inadditiontoanimprovementinhealthchangeoverthelast
the majority had a dilated external ring on examination.
year. Complications were uncommon and mild. Three pa-
Our study had a more modest improvement rate, which
tients with return of pain requested mesh removal, without
may be because three-fourths of our study sample had a
significantimprovementinsymptoms.
comorbidchronicpelvicpaindiagnosisandhalfhadpain
Theprimaryoutcomewasnotfoundtobeassociatedwith
lastingmorethan5y(Table1),suggestingmanywomen
thepresenceorabsenceofanipsilateralpatentprocessus
with chronic pain syndrome, central sensitization, and
vaginalis. It should be emphasized that the surgery was
hyperalgesia. In addition, we found 42% of patients had
doneempiricallyinallpatients,regardlessofwhetherthe
an initial improvement then the pain returned after an
ipsilateralinguinalregionlookednormalorwhetherthere
average of 8.7 mo. These patients may have experienced
was an ipsilateral patent processus vaginalis. The inci-
a true recurrence due to failure of the procedure, or else
dence of patent processus vaginalis in this study (15%) is
have had a temporary placebo effect of the laparoscopy.
consistent with previous reports.8
In a randomized trial for laparoscopic excision of endo-
In this study population, it is thought that the chronic metriosis, Abbott et al.10 found that about one-third of
pelvicpainandinguinaltendernessmayarisefromincar- patients will have pain improvement at 6 mo from a
cerated fat in the inguinal canal.5 The goal of the surgery placebo diagnostic laparoscopy.
Table2.
ComparisonofSF-36SubscaleScores
SF-36 InitialQuestionnaire Follow-upQuestionnaire PairedSample P-Value
(Preoperative) (Postoperative) ttest
Physicalfunctioning 66.0(cid:2)33.0 84.2(cid:2)16.6 2.06 .032
Rolefunctioning(physical) 31.3(cid:2)37.1 56.3(cid:2)44.1 1.59 .07
Rolefunctioning(emotional) 69.4(cid:2)43.7 58.3(cid:2)42.9 0.60 .28
Energy/Fatigue 39.7(cid:2)28.1 47.1(cid:2)23.2 0.92 .19
Emotionalwell-being 67.3(cid:2)17.5 72.8(cid:2)16.4 0.76 .23
Socialfunctioning 58.3(cid:2)29.4 76.0(cid:2)17.2 1.99 .036
Pain 43.5(cid:2)22.4 59.6(cid:2)19.9 2.02 .035
Generalhealth 59.2(cid:2)24.4 70.0(cid:2)20.0 1.50 .08
Healthchange 29.2(cid:2)20.9 58.3(cid:2)19.5 3.39 .003
JSLS(2013)17:74–81 79
LaparoscopicInguinalExplorationandMeshPlacementforChronicPelvicPain,YongPJetal.
Weaknesses of our study include a low response rate for ilioinguinal nerve in the inguinal canal, and therefore
the follow-up questionnaire (27%) and the lack of a sep- mayimprovethisilioinguinalpain.Noneofourpatients
arate control group. However, the patients who returned had a diagnostic ilioinguinal nerve block, which has
the follow-up questionnaire had a similar distribution for been used for diagnosis of entrapment prior to ilioin-
the primary outcome and the initial (preoperative) SF-36 guinalneurolysisornerveresectionthroughanabdom-
subscale scores compared to the patients who did not inal incision.12,14 In the future, a diagnostic ilioinguinal
returnthequestionnaire(seeResults),suggestingalackof block may also be useful to identify which women may
selection bias. In addition, it is not possible to formally respond to empiric laparoscopic inguinal exploration
ruleoutaplaceboeffectofthesurgerywithoutaseparate and mesh.
placebo control group, which would be difficult for this
study(i.e.,itwouldrequireagroupassignedtodiagnostic
laparoscopy only). Finally, a proportion of patients had CONCLUSION
concurrent surgical procedures including excision of en-
Our study found moderate improvement in pain and
dometriosis (Table 1): 8% had a concurrent excision of
quality-of-life after empiric laparoscopic inguinal ex-
endometriosis classified as symptomatic and 27% had
ploration and mesh placement in women with lateral-
concurrent excision of endometriosis classified as inci-
izing chronic pelvic pain, no clinical hernia on abdom-
dental. Although we believe there to be a rational basis
inalexamination,andipsilateralinguinaltendernesson
for this subdivision of endometriosis (as defined in the
pelvic examination. Patients with a positive Carnett’s
Methods), we acknowledge that we cannot be certain
testintheipsilateralabdominallowerquadranthadthe
that incidental endometriosis was truly incidental and
best response. Future research should include a pro-
unrelated to the patient’s pain. In addition, although
spective study, ideally with randomization. For exam-
concurrent excision of endometriosis, whether symp-
ple, patients could be randomized to laparoscopic in-
tomatic or incidental, was not associated with the pri-
guinal exploration and mesh placement, or to medical
mary outcome (see Results), we acknowledge that con-
management with neuromodulator medications and/or
current excision of endometriosis should still be
hormonal suppression. We consider such a prospective
considered a confounder in this study.
randomized study to be an important step before em-
Strengths of the study include a larger sample size than piriclaparoscopicexplorationandmeshplacementcan
previous studies, long follow-up for the group who re- be widely accepted as a treatment modality for women
turned the questionnaire (73 mo) compared to previous with chronic pelvic pain. In the meantime, empiric
studies,andtheincorporationofaquality-of-lifemeasure laparoscopic inguinal exploration and mesh placement
(SF-36).Inparticular,theimprovementinSF-36scoresfor appears to be, at a minimum, a safe treatment option
physical functioning, social functioning, pain, and the that may result in moderate improvement in select
health change question were not only statistically signifi- women with lateralizing chronic pelvic pain, most no-
cantbutalsoclinicallysignificant,beingmuchlargerthan tably those with ipsilateral inguinal tenderness on pel-
the minimally clinically important difference of 3 to 5 vic examination and a positive Carnett’s test in the
points.7 ipsilateral abdominal lower quadrant.
The only predictor variable associated with improve-
ment of the pain at the last postoperative visit (i.e., the
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