Chronic post-surgical abdominal pain (CPSAP) is a debilitating condition that affects a significant number of patients following abdominal surgeries. While surgical interventions are often necessary to address underlying medical issues, the development of persistent pain can significantly impact patients’ quality of life. Understanding the pathogenesis of CPSAP, particularly the involvement of the ilioinguinal nerve, iliohypogastric nerve, and genitofemoral nerve, is crucial for effective management and improved patient outcomes.
It is usually seen in patients undergoing lower abdominal surgeries such as hernia repair, appendicectomy, abdominal hysterectomy, laparoscopic and robotic surgeries. Following abdominal surgeries, nerve injury or entrapment can occur due to various factors, including surgical trauma, laparoscopic or robotic port insertion, tissue inflammation, or scar formation.
Pathogenesis and Causes
The ilioinguinal and iliohypogastric nerves, originating from the lumbar plexus, innervate the lower abdomen and groin region. The genitofemoral nerve, also originating from the lumbar plexus, supplies sensation to the genital and inner thigh areas. Damage or irritation to these nerves during surgery can lead to neuropathic pain syndromes characterized by persistent, burning, or shooting pain.
The ilioinguinal nerve plays a significant role in CPSAP, particularly in procedures involving the lower abdomen and inguinal region. It can become entrapped or injured during surgeries such as hernia repairs or abdominal wall reconstructions. Similarly, the iliohypogastric nerve, running parallel to the ilioinguinal nerve, can be affected during procedures involving the lower abdomen and pelvic region.
The genitofemoral nerve, although less commonly implicated, can contribute to CPSAP, especially following surgeries involving the lower abdomen or pelvis. Entrapment or irritation of this nerve can result in pain radiating to the genitalia or inner thigh.
The pathogenesis of CPSAP involves a complex interplay of peripheral and central sensitization mechanisms. Nerve injury or irritation leads to the release of inflammatory mediators, sensitizing peripheral nociceptors and amplifying pain signals. Over time, central sensitization can occur, resulting in hyperexcitability of neurons within the spinal cord and brain, leading to persistent pain perception even in the absence of ongoing tissue damage.
Managing Chronic Post Surgical Abdominal Pain
Management of CPSAP requires a multidisciplinary approach tailored to the individual patient. Conservative treatments such as physical therapy, nerve blocks, or pharmacotherapy may provide relief for some patients. Interventional procedures targeting the affected nerves, such as ilioinguinal, iliohypogastric, or genitofemoral nerve blocks, and later radiofrequency ablation procedures on some of the nerves, can be particularly beneficial in refractory cases, providing targeted pain relief while minimizing systemic side effects. These interventions are performed on day care basis, using ultrasonography guidance to localize the nerves for targeted delivery of the medication around the nerves which help in early an lasting relief for the patients.
In conclusion, chronic post-surgical abdominal pain is a challenging condition with significant implications for patients’ well-being. Understanding the involvement of the ilioinguinal, iliohypogastric, and genitofemoral nerves in its pathogenesis is essential for effective management. By addressing the underlying neuropathic mechanisms and utilizing targeted interventions, we can alleviate pain and improve the quality of life for patients suffering from CPSAP.
