Background and Aim. Previous studies have reported 63% of primary inguinal hernia patients present with apparent enlargement of the ilioinguinal nerve beyond the inguinal ring. This may be due to hernia-related pressure on the canal portion of the ilioinguinal nerve, a form of compression neuropathy. The ilioinguinal nerve of 30 patients was resected near the external inguinal ring during herniorrhaphy and histologically characterized to investigate the underlying cause of the size discrepancy. Methods. 30 male patients with primary inguinal hernias undergoing primary inguinal herniorrhaphy were prospectively recruited for ilioinguinal nerve resection and evaluation. Three samples of the resected ilioinguinal nerve (proximal, canal, and distal) were evaluated using Masson’s trichrome stain to measure fascicle and total nerve cross-sectional area and detect changes in collagen. Results. The fascicle cross-sectional area in the canal segment was significantly decreased compared to the proximal control with a large effect size observed (p=0.016,η2 =0.16). There was no significant difference in the nerve cross-sectional area between locations, but there was a moderate to large effect size observed between locations (p=0.165,η2 =0.105). There was no significant difference in collagen content nor effect size observed between locations (p=0.99,η2 =1.503×10−4). Interpretation. The decrease in the fascicle cross-sectional area within the inguinal canal further suggests that there is chronic pressure applied by hernia tissue consistent with axon degeneration. Collagen content is uniformly distributed along the length of the nerve. Further studies with larger samples are needed to confirm the observed effect of nerve location on the total nerve cross-sectional area and axon loss.

Background: Surgical response of patients with symptomatic biliary colic but atypical findings of gallbladder polyps, hyper-dynamic gallbladder and otherwise negative biliary workup are underrepresented in the literature from community practice. Methods: A clinical outcome study with a retrospective design compared the short term and long term symptomatic improvement reported by patients with pre-operatively diagnosed biliary dyskinesia to all other biliary colic patients with atypical pre-operative diagnoses. All patients underwent surgery at Meridian Surgery Center from the years 2010-2017.600 patients were reviewed for biliary dyskinesia, gallbladder polyps, hyper-dynamic gallbladder and negative workup. Results: Short term and long term results were compiled from a total 182 patients. Short term response rates were assessed from 74 biliary dyskinesia, 40 hyper-dynamic, 23 gallbladder polyps, and 45 negative workup patients. Long term responses were received from 19 biliary dyskinesia patients, 11 hyperdynamic patients, 9 polyp patients, and 7 negative workup patients. Long term improvement among biliary dyskinesia patients was 84%, and 83% among patients with atypical findings, representing a long term drop in symptoms. There is no significant difference between symptom recovery of patients with biliary dyskinesia and those with another atypical diagnosis: hyperdynamic (82%), polyps (89%), negative workup (57%). Conclusion: These results allow us to conclude that there is a comparable biliary colic improvement between biliary dyskinesia, gallbladder polyps, hyper-dynamic gallbladder and negative workup patients after cholecystectomy in both short term and long term follow up. (C) 2019 Elsevier Inc. All rights reserved.

Introduction: Enlargement of the ilioinguinal nerve distal to the inguinal ring is common in primary open inguinal herniorrhaphy and is histologically consistent with compression neuropathy. However, the origin of this neuropathy has not been thoroughly studied in primary inguinal hernia. Methods: In this prospective study, 143 primary inguinal herniorrhaphies were performed. Prior to surgery, all patients completed a preoperative pain questionnaire from the Carolina Comfort Scale and Visual Analog Scale-evaluating pain with various activities. Pain scores were statistically compared with several different anatomical surgical observations. Results: When each variable is individually compared with pain scores, a significant positive correlation exists between nerve enlargement and increased pain compared to those without enlargement for preoperative "most of the time pain" (P < 0.0017). There is also a statistically significant positive correlation between nerve enlargement and external ring fibrosis (P < 0.001). 81% of patients with enlargement have histological abnormalities. Conclusion: Preoperative pain in primary inguinal hernia is correlated with ilioinguinal nerve enlargement, which is also correlated with fibrosis of the external oblique fascia at the external ring. (C) 2019 Elsevier Inc. All rights reserved.

Background The multimodality addition of preoperative gabapentin, acetaminophen, and celecoxib (GAC) and postoperative TENS has been recommended to diminish narcotics. We predict that GAC-TENS implementation will reduce recovery room time, improve pain control, reduce narcotic refills, and demonstrate usefulness of TENS treatment. Methods A prospective study compared a control group of patients not utilizing the GAC-TENS protocol during 2015 to patients using the GAC-TENS protocol during 2016. Results There was less recovery room time in the control group compared to the protocol group. Postoperative day one pain control was similar between the groups. Less refills were noted. TENS unit satisfaction level was rated "very helpful" by 63% of patients. Conclusion The results call into question the efficacy of the American Pain Society recommendations as they increase time in recovery room but do not decrease the quantity of narcotics used in the recovery room, nor do they improve pain satisfaction responses.

PURPOSE:The purpose of this study is to describe the known soft tissue neuro-histology factors associated with compression neuropathy in relation to the incidence of preoperative pain in primary inguinal hernia. Enlargement of the ilioinguinal nerve occurs in 63% of patients with primary inguinal hernia; compression neuropathy has similar gross features. METHODS:Patients completed pain questionnaires pertaining to preoperative pain and the quality of pain experienced. During routine inguinal hernia repair, nerve segments were sampled for histologic evaluation. RESULTS:Twenty-two thickened nerve segments (63% of total) with proximal and distal specimens were resected for examination and comparison. We quantified various histologic indicators including nerve diameter, fascicle count, myxoid content within the epineurium, perineurium and endoneurium. Increased preoperative patient pain scores correlate with increased nerve diameter, increased fascicle count and increased myxoid material both within the perineurium and endoneurium. CONCLUSION:These findings support the concept that preoperative hernia pain is associated with compression neuropathy.