The data presented in this chapter represent the best available high-quality studies to date on this topic. The counterargument to the proposition of prophylactic neurectomy is that the incidence of significant chronic pain may be reduced to less than 1 % with three-nerve identification and meticulous operative technique (Alfieri S et al. International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia. 2011;15(3):239–49). This is lower than the rates of pain reported in both the control and prophylactic neurectomy groups in each of these cited studies. If pain rates can be reduced with good technique, intentionally causing the sensory disturbances or risk of deafferentation pain with neurectomy in all patients may be considered unnecessary. “Pragmatic neurectomy” was coined in response to the concept of prophylactic neurectomy and simply refers to the logical practice of performing a neurectomy at the time of hernia repair whenever a nerve is recognizably injured or is at risk for injury due to its neuroanatomic location, course, or operative factors. Neurectomy in these cases is absolutely recommended. The author’s conclusion that no patient in each of these studies developed severe pain is significant, and “prophylactic neurectomy” in at-risk individuals is likely prudent. Mild sensory disturbances and numbness are vastly preferable to chronic pain in high-risk patients. Using preoperative risk calculators such as the Carolinas Equation for Quality of Life (CeQOL; www.​carolinashealthc​are.​org/​ceqol ) and understanding high-risk populations for the development of chronic pain will help surgeons to decide who will benefit from prophylactic neurectomy. Tailoring the right operation for each patient in conjunction with a good informed consent makes for good practice.

Routine neurectomy is a concept that is not unique to inguinal surgery and is commonly practiced in other general surgical procedures. In 1998, Abdullah et al. performed a randomized, controlled trial studying routine division versus preservation of the intercostobrachial nerve in patients undergoing axillary dissection for breast cancer [4]. This study was performed in an intention-to-treat fashion and as such was essentially a comparison between routine and pragmatic neurectomies. The study demonstrated that there is increased incidence of sensory loss at hospital discharge in the routine neurectomy group (78 vs. 60 %, p < 0.05), as well as pain (30 vs. 16 %, p < 0.05). However, differences in pain, diminished sensation, sensory loss, and paresthesia were lost by 3-month follow-up [4]. While the authors suggest that nerve preservation may be favored given the early symptomatic differences, the longer-term follow-up results suggest nerve division does not portend significant functional or sensory deficits. In addition, nerve pain during inguinal hernia repair is typically due to nerve entrapment within suture or mesh, which are not used during axillary dissection.

Ravichandran et al. were among the first to perform a randomized trial on the topic of ilioinguinal neurectomy [5]. This study was, and still is, unique in this body of literature in that it is self-controlled. The authors enlisted patients who were planned for bilateral inguinal hernia repair and randomized the patients’ right or left side to undergo routine neurectomy, while the other side had nerve preservation. In comparing the neurectomy side to that of nerve preservation, there was no difference in pain rated on a 10-point scale noted on postoperative day 1 (2.9 vs. 2.5, p = 0.98). At 6 months, just two patients complained of minor wound discomfort, one on the divided side and one on the preserved side. Physical examination on patients 6 months postoperatively revealed an increased incidence of diminished touch sensation on the divided side (9 patients vs. 1 patient; no p-value given) as well as increased incidence of diminished pain sensation (8 vs. 5; no p-value given). However, it is important to note that just two of the 20 patients reported any symptoms of numbness at their 6-month follow-up, including one complaining of lateral thigh numbness, an area not supplied by the ilioinguinal nerve [5]. As such, it is reasonable to conclude from this study that patients undergoing routine neurectomy do not have increased incidence of immediate postoperative nor chronic pain, nor do they have increased incidence of symptomatic sensory loss. The study is underpowered to provide statistically significant differences in these groups and does not provide statistical analysis of all its data; however, it is a landmark and otherwise well-designed study of the debate.