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Mesh complications

Treatment of postoperative pelvic nerve injuries: the neuropelveological way

Marc Possover,
Dezember 8, 2019

If an injury to a pelvic nerve is suspected as a result of an operation, one should take action as soon as possible:

  • before neurological deficits become irreversible. A nerve is similar to an electrical cable: a copper wire (called an axon) is enclosed in a sheath. If, for example, a nerve is constricted by a suture, it will die after only a matter of hours. If one reacts in time and frees the nerve, the axon can perhaps still be saved and the nerve can recover in a relatively short space of time. If the axon is still dead, it can grow back again, as long as the sheath is still more or less intact. The axon grows about 1mm per day, while the sheath shows the way to the target. However, if the sheath is destroyed, the axon can no longer grow properly and the function of the nerve is irreversibly lost. On the other hand, so-called neuromas can develop, causing "stump and phantom pain". Therefore, the possibility of a surgical nerve lesion must always be taken very seriously indeed!
  • before secondary scar tissue forms around the nerve. For example, if a net was used, the secondary scarring that the net causes as a foreign body reaction can constrict the nerve and lead to neuropathic pain, even if the net was not placed directly on the nerve.

Treatment of mesh complications

In the case of neuropathic pain after net implantation for the treatment of a herniated uterus, bladder, vagina or for the treatment of an inguinal hernia, it is generally accepted that the solution to the problem lies in the surgical removal of the net. If this procedure is performed a few days after mesh implantation, before scar tissue has formed, the operation is usually not so complex and the situation will actually improve. The problem is that the removal of the mesh leads to a hernia and a third intervention becomes necessary.

If the mesh is removed months or years after the insertion operation, the scar tissue already formed by the implant remains on the nerve and the pain situation remains unchanged. Since millimeter-sized nerves in such scar plates are really not easy to recognize, such operations can even lead to nerve injury and further scar tissue, resulting in even greater pain and further complications.

From a neuropelveological point of view, it is not the net that causes the pain, but the irritation to or the pinching of the nerve. Therefore, the treatment of the mesh complication by a neuropelveologist does not aim to remove the implant, but rather to free the affected nerve.

After prolapse operations, it is absolutely impossible to free the pelvic nerves vaginally - it simply does not work, no matter how skilled the surgeon is in vaginal surgery. Such attempts either remain unsuccessful or lead to a severing of the nerve.

Neuropelveology, on the other hand, accesses the scar plate surrounding the nerve from the pelvis. Laparoscopically, the nerve is identified in the pelvis above the scar tissue. There, the anatomical conditions are still intact as this area was not included in the previous intervention. From there, the surgeon works his way down the nerve, millimeter by millimeter, and frees it from the scar tissue. The mesh may be partially severed or removed, but not wholly removed, not least to avoid further prolapse. In the case of net implants for the treatment of rectal retraction, the attempt to remove the implant would even lead to considerable risks of intestinal injury with secondary peritonitis, or even the need for an artificial outlet. Such explorations/decompressions of the pelvic nerves must be carried out by laparoscopy, as interventions on the pelvic nerves usually have to be performed by microsurgery. Laparoscopy offers the necessary magnification effect to be able to recognize pelvic nerves far smaller than 1mm in diameter and to perform surgery on them.

Since the neuropelveologist's intervention is not aimed at removing the net, but rather at freeing the nerve, a renewed prolapse of the intestine, vagina or inguinal hernia is not to be expected - the patient is then spared another operation.

Video: Laparoscopic decompression of the right genitofemoral nerve

Video: Entrapment of the pudendal nerve - laparoscopic nerve decompression

Video: Laparoscopic exploration/decompression of different pelvic somatic nerves

The described procedure is in fact absolutely logical, but only became possible with the introduction of laparoscopic pelvic nerve surgery - or the discipline of neuropelveology.

Such interventions, especially to improve mesh-related complications, are among the most difficult laparoscopic procedures in the pelvis. The operation must be successful on the first attempt, because subsequent interventions would be even more complex and dangerous. Therefore, only specially trained experts can be considered for such complex surgical interventions. However, this approach is worthwhile for the patients concerned, because it can provide a solution to the pain and suffering experienced in everyday life.

The LION procedure for the treatment of irreversible nerve damage

In the case of irreversible damage to the nerves (with destruction of the axon and possibly the sheath), the sole release of the nerves alone will not help. The axon can no longer grow, or does not grow in the right direction. In this case, neuromodulation is the method of choice. A stimulation electrode is placed by laparoscopy in direct contact with the damaged nerve - the LION procedure is performed: Laparoscopic Implantation Of Neuroprothesis.

Stimulation of the nerve with low current energy leads to pain reduction. The cause of the pain is not treated, but the pain information is drowned out by the current, so that the brain does not recognize the signal as "pain". If the sheath of the nerve is still present, stimulation of the damaged nerve can in principle lead to growth of the axon and regeneration of the nerve. With a remote control, the patient can independently determine the intensity of the current output.

 

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Marc Possover