Abstract
Introduction
Careful identification and management of inguinal nerves during inguinal hernia repair is important to avoid iatrogenic injury. Documentation of this practice may inform postoperative clinical management. We set out to investigate how often surgeons identify inguinal nerves and document findings and management in their operation notes.
Methods
We carried out a retrospective review of operation notes at a single district general hospital. We analysed operation notes for documentation of identification and intraoperative management (preservation or sacrifice) of the inguinal nerves (iliohypogastric, ilioinguinal, genital branch of genitofemoral nerve). We collected data on the baseline characteristics of the patients, hernia characteristics and primary operating surgeons for subgroup analysis.
Results
A total of 100 patients were included in the analysis. Identification of any inguinal nerves (generic ‘nerve’) was documented in 17% of operation notes. Documentation in the operation notes of named individual nerves was limited. No documentation of intraoperative management of inguinal nerves was found in 83% of operation notes. Preservation of the inguinal nerves (generic ‘nerve’) was recorded in 8% and sacrifice recorded in 9% of cases. Subgroup analysis revealed similar incidence of documentation of identification and management of inguinal nerves across grades of primary surgeon, with overall incidence low for all grades.
Conclusion
This study reveals a lack of appreciation of the importance of documenting identification and management of inguinal nerves in operation notes. Further consideration of the potential implications of poor documentation would be beneficial to improve standards.
Keywords: Inguinal nerve, Inguinal hernia, Documentation, Chronic pain, Operation notes
Introduction
Inguinal hernia repair is one of the most commonly performed operations in the world, with up to 100,000 undertaken annually in the United Kingdom alone.1 Although there is an increasing trend of using laparoscopic surgery, the vast majority of repairs are still performed via a traditional open approach.2 Generally, these are considered to be routine operations and are often seen as training opportunities for junior surgeons. Most are performed in elective settings as day case procedures.
Despite the relative simplicity of this operation, it is not without risk. One of the most common and potentially debilitating complications following inguinal hernia surgery is chronic groin pain. This is reported to occur in 10–12% of patients and can be severe enough to impact significantly on activities of daily living in 0.5–6% of patients.3 The aetiology of this chronic pain is thought to be multifactorial. It is believed that pain often arises from injury to one of the three nerves encountered during the operation (ilioinguinal, iliohypogastric, genital branch of genitofemoral nerve). Injury to these nerves can occur for a variety of reasons.
The theory on the cause of chronic pain has influenced its management: if medications to control the pain are not enough, the individual nerves are targeted chemically or surgically. Identification of the paths that these nerves take intraoperatively is therefore important to avoid inadvertent injury. Documentation of their presence or absence, and whether they were protected, is important, as this provides evidence that an attempt was made to look for them and avoid direct injury. Documentation of whether they were preserved or sacrificed is important, as this may influence future management if the patient develops chronic groin pain.
With negligence claims on the rise, and chronic pain one of the leading causes of litigation related to inguinal hernia surgery, surgeons must be more attentive with every aspect of care delivered in the patient pathway, from referral to discharge. Often, the only way to evidence this is through robust documentation.
We set out to investigate how often surgeons actively look for inguinal nerves during inguinal hernia surgery and document their findings and management of these nerves in their operation notes.
Methods
We conducted the study via retrospective review of operation notes at a single district general hospital. We included the first 100 consecutive cases in 2019 of open inguinal hernia repair using prosthetic mesh. We gained information through the local clinical coding team, which identified patients through a general surgery elective list database. We obtained patient notes via the health records team within the clinical audit department. Patients included in the study were operated on by all consultants within the general surgical department at the district general hospital. Exclusion criteria were age under 18 years, recurrent repairs, bilateral repairs and emergency procedures.
We created a proforma to streamline data collection. We analysed operation notes for documentation of identification of the three inguinal nerves (iliohypogastric, ilioinguinal, genital branch of the genitofemoral nerve). We sought information on intraoperative management of inguinal nerves, specifically whether each nerve was preserved or sacrificed during groin dissection. We recorded if there was no documentation of the inguinal nerves. We obtained further data from review of the operation notes, including baseline characteristics of the patients, hernia characteristics and primary operating surgeons.
We analysed the data using GraphPad Prism version 7.00 for Windows (GraphPad Software, La Jolia, CA, USA).
Primary outcomes of the study were documentation of identification of inguinal nerve(s) in operation notes and documentation of management of inguinal nerve(s) (preservation or sacrifice) in operation notes.
Results
A total of 100 patients were included in the analysis. Baseline demographics of patients included in the study revealed the majority to be male (88%). The most common age group was 61–80 years (49%) (Table 1). Hernial characteristics identified in the operation notes showed the majority to be inguinal (96%). There were similar numbers of left- (42%) and right-sided (58%) hernias, and similar numbers of direct (42%) and indirect (55%) hernias (Table 2). The documented grade of primary surgeon was similar between consultants (36%) and trainee registrars (34%) (Table 3).
Table 1 .
Patient demographics
| Characteristic | % |
|---|---|
| Age (years) | |
| 18–25 | 1 |
| 26–40 | 5 |
| 41–60 | 26 |
| 61–80 | 49 |
| >80 | 19 |
| Gender | % |
| Female | 12 |
| Male | 88 |
Table 2 .
Hernia characteristics
| Characteristic | % |
|---|---|
| Laterality | |
| Left | 42 |
| Right | 58 |
| Type | |
| Inguinal | 96 |
| Inguinoscrotal | 4 |
| Position | |
| Direct | 42 |
| Indirect | 55 |
| Both | 2 |
| Other (lipoma) | 1 |
Table 3 .
Grade of primary surgeon
| Grade | % |
|---|---|
| Consultant | 36 |
| Senior clinical fellow (SCF) | 27 |
| Trainee registrar (SpR) | 34 |
| Senior house officer (SHO) | 3 |
Table 4 summarises the documentation of nerve identification and management. Identification of any of the inguinal nerves (generic ‘nerve’) was documented in 17% of operation notes. Documentation of individual nerves was limited, with the ilioinguinal nerve documented in 9%, iliohypogastric nerve in 1%, and genital branch of the genitofemoral nerve in 2% of cases.
Table 4 .
Comparison between grade of surgeon and nerve identification and decision on nerve management
| Grade of surgeon | Nerves identified | ||||
|---|---|---|---|---|---|
| Ilioinguinal (9) | Iliohypogastric (1) | Genital branch of genitofemoral (2) | Generic (17) | Total (29) | |
| Consultant | 3 | 1 | 2 | 7 | 13 |
| SCF | 0 | 0 | 0 | 9 | 9 |
| SpR | 6 | 0 | 0 | 1 | 7 |
| SHO | 0 | 0 | 0 | 0 | 0 |
| Nerve management: preserved (p) | |||||
| Grade of surgeon | Ilioinguinal (2) | Iliohypogastric (0) | Genital branch of genitofemoral (0) | Generic (8) | Total nerve preserved (10) |
| Consultant | 1 | 0 | 0 | 6 | 7 |
| SCF | 0 | 0 | 0 | 2 | 2 |
| SpR | 1 | 0 | 0 | 0 | 1 |
| SHO | 0 | 0 | 0 | 0 | 0 |
| Nerve management: sacrificed (s) | |||||
| Grade of surgeon | Ilioinguinal (7) | Iliohypogastric (1) | Genital branch of genitofemoral (2) | Generic (9) | Total nerve sacrificed (19) |
| Consultant | 2 | 1 | 2 | 1 | 6 |
| SCF | 0 | 0 | 0 | 7 | 7 |
| SpR | 5 | 0 | 0 | 1 | 6 |
| SHO | 0 | 0 | 0 | 0 | 0 |
There was no documentation of management of inguinal nerves in 83% of operation notes. Preservation of any of the inguinal nerves (generic ‘nerve’) was recorded in 8% and sacrifice in 9% of cases. Management of individual named nerves largely showed poor documentation (Table 4).
Subgroup analysis revealed similar incidence of documentation of identification and management of inguinal nerves by separate grades of primary surgeon, with the overall percentages being low for all grades. Inguinal nerve identification was documented equally by consultants (36%) and trainee registrars (24%). Specific documentation of nerve preservation was higher in the consultant group (19%) compared with the trainee registrar group (3%) but was similar for documentation of nerve sacrifice (17% and 21%, respectively).
Discussion
This study demonstrates documentation of identification and management of inguinal nerves for inguinal hernia repair is poor. Results suggest inguinal nerves have not been considered a priority in this cohort of patients undergoing surgery. We believe documentation of the nerves in operation notes for inguinal hernia repair surgery is necessary and important.
With regard to chronic pain, careful nerve identification and management are essential to avoid harmful long-term outcomes. Without clear documentation, we are unable to determine whether this has taken place or to plan future therapeutic intervention if patients return with chronic pain. A review on persistent postsurgical pain concluded that nerve injury is the most important factor causing chronic pain.4 Nerve damage is caused by either direct injury intraoperatively or indirect injury secondary to mesh placement. Fibrosis reaction secondary to mesh (‘meshoma’) has been linked to neuropathic pain due to incorporation of the inguinal nerves within the mesh.5 Poor documentation in this study may be the result of a lack of appreciation of the implications of nerve injury.
Lack of documentation may be due to poor understanding of the anatomy of the inguinal nerves. For the fully trained surgeon, the anatomy may be very straightforward – but for junior surgeons who are often performing these operations, as demonstrated in this study, this may not be the case. Anatomical studies identify three inguinal nerves (iliohypogastric, ilioinguinal, genital branch of the genitofemoral nerve).
The iliohypogastric nerve emerges through the external oblique muscle and continues cranially to the spermatic cord to innervate the hypogastric region. The ilioinguinal nerve runs a similar course but caudal to the iliac crest and continues anteriorly, parallel to the spermatic cord.6 The genitofemoral branch is normally found caudal to the cord structures at the level of the deep inguinal ring.7,8
Intraoperatively, inguinal nerves are identified upon division of the external oblique when developing planes to identify cord structures in males (Figure 1) or the round ligament in females (Figure 2). Inguinal nerves are positioned on the floor of this newly developed space. The ilioinguinal nerve and genital branch of the genitofemoral nerve lie adjacent to cord structures anteriorly and inferiorly, respectively. It is important to be aware of nerves when separating the hernial sac from cord structures and when securing the mesh after herniorrhaphy, specifically when delivering stitches to approximate mesh close to the pubic tubercle and when securing the inferior border of the mesh to the inferior border of the inguinal ligament. The iliohypogastric nerve lies superior to the cord structures and ligament in groin dissection, and this structure should be identified when securing the mesh superiorly.
Figure 1 .
Groin dissection in male
Figure 2 .
Groin dissection in female (dotted line indicates location of genital branch of genitofemoral nerve upon further dissection)
Variations in patterns of nerve distribution are well recognised, and surgeons must be aware of this to avoid iatrogenic injury. Pooled statistics reveal the presence of iliohypogastric nerve (98%, 60–100%), ilioinguinal nerve (84%, 56–100%), and genital branch of the genitofemoral nerve (99%) in anatomical dissections.7–9 Variations in anatomy exist at multiple levels across the path of inguinal nerves. Surgeons must appreciate this to inform identification and management of inguinal nerves intraoperatively.
This study identifies two primary modalities of the management of inguinal nerves intraoperatively – preservation and sacrifice. The literature is divided regarding the optimal approach to nerve dissection in inguinal hernia repair.10–12 No definitive evidence exists for either preservation or sacrifice of inguinal nerves. The most recent international guidelines for groin hernia management advocate a ‘nerve recognition approach’ for optimal patient outcomes and to prevent chronic pain.3 This study has observed no consensus on the intraoperative management of inguinal nerves. The lack of clear evidence may be a further contributing factor to poor documentation standards revealed in this study.
Documentation of management of inguinal nerves remains important for planning therapeutic interventions for chronic pain. Treatment modalities involve targeting inguinal nerves medically or surgically. A seminal study by Lichtenstein et al suggested the optimal approach is the use of nerve block followed by repeated procedures if successful, advising neurectomy if pain is not controlled.13 A large systematic review concluded neurectomy is a successful therapeutic option for chronic pain following inguinal hernia repair.14 More recent reviews have emphasised the need for an individualised multidisciplinary approach.15 The availability of detailed information regarding the initial operation is vital to ongoing management.
Poor documentation may take place in the presence of competent and excellent care. Unfortunately, this issue is endemic to the NHS, despite clear guidance from various medical governing bodies.16 The Royal College of Surgeons of England states surgeons must document all clinically relevant intraoperative findings ‘clearly, accurately and legibly’, with enough detail to ensure continuity of care.17 This advice is echoed in General Medical Council guidance on recordkeeping, which emphasises the importance of thorough documentation to support patient care.18 Surgical professionals must maintain high standards of documentation in everyday working to provide best practice and ensure patient safety.
We have discussed possible reasons for poor documentation of inguinal nerves in operation notes. Importantly, poor documentation can be easily interpreted as negligence. Chronic pain following inguinal hernia repair has been linked to multiple medicolegal litigation cases.19 Operation notes are medicolegal documents that can be used as evidence in court proceedings involving litigation. A recent review of data from the NHS Litigation Authority concluded that between 1995 and 2016, the volume of claims for inguinal hernia repair increased, with 35% of claims secondary to chronic pain.20 This is a huge financial burden on surgeons and the NHS, but it is potentially avoidable with clear and accurate documentation.
Literature review revealed no other studies examining this research question. This study offers a novel insight into documentation practice for identification and management of inguinal nerves in operation notes for inguinal hernia repair. This study has limitations as it is a single-centre, retrospective, observational review of documentation practice. Despite best efforts in uniformity of data collection, it may be subject to bias. Nonetheless, the study maintains external validity in that data are taken from a high-volume general surgical department broadly comparable to most centres across the UK. This paper raises significant questions as to whether this topic requires further consideration and publicity. The weight of evidence suggests documentation of identification and management of inguinal nerves in operation notes following inguinal hernia repair is necessary and important for patients and surgeons.
Conclusion
Inguinal hernia repair is a routine operation performed commonly worldwide, but it can be associated with significant morbidity. This study has revealed a lack of appreciation of the importance of documentation of identification and management of inguinal nerves in operation notes. This cohort revealed poor levels of documentation across all grades of surgeons partaking in inguinal hernia repair. Further consideration of the significant implications for postoperative chronic pain, alongside best practice and medicolegal litigation, would be beneficial to improve documentation standards.
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