PMC5612803_01
Dermatomal mapping indicated ilioinguinal and iliohypogastric nerve problems. Circles indicate normal sensation. Crosses are points where the patient felt pain and tenderness. The area surrounded by the square is the point of maximum tenderness.
gr1.jpg
PMC5612803_01_gr1.jpg
fig0005
Pain assessment by dermatomal mapping, as described by Alvarez et al., revealed tenderness at the level of the iliac crest and along the upper side of the surgical wound, indicating the presence of ilioinguinal nerve (IIN) and iliohypogastric nerve (IHGN) problems (Fig. 1).
Operative position of the patient (A). A three-port method was used (B). Blue-encircled arrowheads indicate the ilioinguinal and iliohypogastric nerves, which formed a common trunk. The asterisk indicates the quadratus lumborum muscle (C). Green-encircled arrowheads indicate the genital branch of the genitofemoral nerve coursing in front of the psoas. Arrows indicate the ureter (D). Yellow-encircled and orange-encircled arrowheads indicate the distal and proximal stumps of the common trunk of the ilioinguinal and iliohypogastric nerves, respectively (E). Gray-encircled arrowheads indicate the residual nerve emerging from L2/3 and running toward the inguinal region (F).
gr2.jpg
PMC5612803_01_gr2.jpg
fig0010
Under general anesthesia, the patient was placed in the lateral decubitus position, which is similar to the position used for nephrectomy (Fig. 2A). Another 12-mm port and a 5-mm port were inserted, as shown in Fig. 2B. These nerves formed a common trunk (Fig. 2C) and passed through the retroperitoneal cavity until they perforated the transversus abdominis near the anterior part of the iliac crest. Then, the genital branch of the genitofemoral nerve (GFN) was identified in front of the psoas (Fig. 2D). The ureter was also identified as medial to the psoas. After identification of all three nerves, each nerve was resected after placing a clip proximally and distally to close the neurilemmal sheath to prevent neuroma formation (Fig. 2E). Although a nerve emerged from L2/3 toward the inguinal region (Fig. 2F), the nerve remained in situ.
Dermatomal mapping on postoperative day 1. Circles indicate normal sensation. Minuses indicate numbness. (A). Dermatomal mapping 3 months after surgery. Circles indicate normal sensation. Crosses are points where the patient felt pain and tenderness (B).
gr3.jpg
PMC5612803_01_gr3.jpg
fig0015
Dermatomal mapping on postoperative day 1 revealed numbness and complete elimination of pain (Fig. 3A). The pain relief lasted for a few months; however, another type of pain appeared at the lateral side of the pubis 3 months after surgery (Fig. 3B).