Nerve injury associated with pelvic surgery
- Jermaine E Gray, MD
Jermaine E Gray, MD
- Assistant Professor of Obstetrics and Gynecology
- University of Mississippi Medical Center
- Section Editors
- William J Mann, Jr, MD
William J Mann, Jr, MD
- Section Editor — Gynecologic Surgery
- Clinical Professor
- Department of Obstetrics and Gynecology
- Virginia Commonwealth University School of Medicine
- Hilary Sanfey, MD
Hilary Sanfey, MD
- Section Editor — General Surgical Principles; Quality and Safety
- Professor of Surgery
- SIU School of Medicine
Neural injury can be an unexpected and distressing complication of an otherwise successful operation. Pain, paresthesias, loss of sensation, and weakness are the most common symptoms.
The most common causes of nerve injury during pelvic surgery are:
- Transection from incision, trocar insertion, or thermal injury from electrosurgical devices
- Entrapment from ligation for control of bleeding, tissue reapproximation (eg, closure of retroperitoneum), or reconstructive pelvic surgery (eg, vaginal or bladder suspension procedures)
- Compression or stretching of the nerve from patient positioning, retractors, clamps, or hematoma
The degree of neural injury determines whether symptoms will be reversible or permanent. The typical manifestations are motor weakness and sensory deficit in the area of the involved nerve. However, transection or ligation injuries can result in pain.
This topic will focus upon injury to abdominal and pelvic nerves. The clinical presentation and diagnosis of peripheral nerve injuries are discussed in detail separately. (See "Overview of lower extremity peripheral nerve syndromes" and "Overview of upper extremity peripheral nerve syndromes".)
- Cardosi RJ, Cox CS, Hoffman MS. Postoperative neuropathies after major pelvic surgery. Obstet Gynecol 2002; 100:240.
- Bohrer JC, Walters MD, Park A, et al. Pelvic nerve injury following gynecologic surgery: a prospective cohort study. Am J Obstet Gynecol 2009; 201:531.e1.
- Whiteside JL, Barber MD, Walters MD, Falcone T. Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions. Am J Obstet Gynecol 2003; 189:1574.
- Sippo WC, Burghardt A, Gomez AC. Nerve entrapment after Pfannenstiel incision. Am J Obstet Gynecol 1987; 157:420.
- Loos MJ, Scheltinga MR, Mulders LG, Roumen RM. The Pfannenstiel incision as a source of chronic pain. Obstet Gynecol 2008; 111:839.
- Ducic I, Moxley M, Al-Attar A. Algorithm for treatment of postoperative incisional groin pain after cesarean delivery or hysterectomy. Obstet Gynecol 2006; 108:27.
- Ducic I, Dellon AL. Testicular pain after inguinal hernia repair: an approach to resection of the genital branch of genitofemoral nerve. J Am Coll Surg 2004; 198:181.
- Grosz CR. Iliohypogastric nerve injury. Am J Surg 1981; 142:628.
- Kim DH, Murovic JA, Tiel RL, Kline DG. Surgical management of 33 ilioinguinal and iliohypogastric neuralgias at Louisiana State University Health Sciences Center. Neurosurgery 2005; 56:1013.
- Irvin W, Andersen W, Taylor P, Rice L. Minimizing the risk of neurologic injury in gynecologic surgery. Obstet Gynecol 2004; 103:374.
- Chan JK, Manetta A. Prevention of femoral nerve injuries in gynecologic surgery. Am J Obstet Gynecol 2002; 186:1.
- Noldus J, Graefen M, Huland H. Major postoperative complications secondary to use of the Bookwalter self-retaining retractor. Urology 2002; 60:964.
- Goldman JA, Feldberg D, Dicker D, et al. Femoral neuropathy subsequent to abdominal hysterectomy. A comparative study. Eur J Obstet Gynecol Reprod Biol 1985; 20:385.
- Sajid, M, Shakir, A, Khatri, K, Baig, M. Lithotomy-related neurovascular complications in the lower limbs after colorectal surgery. Colorectal Dis. 2010 May 6. [Epub ahead of print].
- Kim DH, Murovic JA, Tiel RL, Kline DG. Intrapelvic and thigh-level femoral nerve lesions: management and outcomes in 119 surgically treated cases. J Neurosurg 2004; 100:989.
- Schneiderman BI, Bomze E. Paresthesias of the lateral femoral cutaneous nerve after pelvic surgery. Am Surg 1967; 33:84.
- Murovic JA, Kim DH, Tiel RL, Kline DG. Surgical management of 10 genitofemoral neuralgias at the Louisiana State University Health Sciences Center. Neurosurgery 2005; 56:298.
- Corona R, De Cicco C, Schonman R, et al. Tension-free Vaginal Tapes and Pelvic Nerve Neuropathy. J Minim Invasive Gynecol 2008; 15:262.
- Kim DH, Murovic JA, Tiel RL, Kline DG. Management and outcomes in 318 operative common peroneal nerve lesions at the Louisiana State University Health Sciences Center. Neurosurgery 2004; 54:1421.
- Bohrer JC, Chen CC, Walters MD. Pudendal neuropathy involving the perforating cutaneous nerve after cystocele repair with graft. Obstet Gynecol 2008; 112:496.
- Benson JT, Griffis K. Pudendal neuralgia, a severe pain syndrome. Am J Obstet Gynecol 2005; 192:1663.
- Lefaucheur JP, Labat JJ, Amarenco G, et al. What is the place of electroneuromyographic studies in the diagnosis and management of pudendal neuralgia related to entrapment syndrome? Neurophysiol Clin 2007; 37:223.
- Labat JJ, Riant T, Robert R, et al. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn 2008; 27:306.
- Alevizon SJ, Finan MA. Sacrospinous colpopexy: management of postoperative pudendal nerve entrapment. Obstet Gynecol 1996; 88:713.
- Robert R, Labat JJ, Bensignor M, et al. Decompression and transposition of the pudendal nerve in pudendal neuralgia: a randomized controlled trial and long-term evaluation. Eur Urol 2005; 47:403.
- Flynn MK, Weidner AC, Amundsen CL. Sensory nerve injury after uterosacral ligament suspension. Am J Obstet Gynecol 2006; 195:1869.
- Siddique SA, Gutman RE, Schön Ybarra MA, et al. Relationship of the uterosacral ligament to the sacral plexus and to the pudendal nerve. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17:642.
- Wang R. Penile rehabilitation after radical prostatectomy: where do we stand and where are we going? J Sex Med 2007; 4:1085.
- Philosophe R. Avoiding complications of laparoscopic surgery. Fertil Steril 2003; 80 Suppl 4:30.
- Warner MA, Warner DO, Harper CM, et al. Lower extremity neuropathies associated with lithotomy positions. Anesthesiology 2000; 93:938.
- Chow CE, Friedell ML, Freeland MB, Dejesus S. A pitfall of protracted surgery in the lithotomy Position: lower extremity compartment syndrome. Am Surg 2007; 73:19.
- Winfree CJ, Kline DG. Intraoperative positioning nerve injuries. Surg Neurol 2005; 63:5.
- Phong SV, Koh LK. Anaesthesia for robotic-assisted radical prostatectomy: considerations for laparoscopy in the Trendelenburg position. Anaesth Intensive Care 2007; 35:281.
- American Associate of Neuromuscular and Electrodiagnostic Medicine. Referral Guidelines for Electrodiagnostic Medicine Consultations. Available online at: www.aanem.org/practiceissues/positionstatements/referral_guidelines_for_EDX.cfm (Accessed on May 3, 2010).
- TRANSECTION INJURIES FROM INCISIONS
- Longitudinal incisions
- Transverse incisions
- ENTRAPMENT INJURIES
- COMPRESSION INJURIES
- SELECTED NEUROPATHIES
- Iliohypogastric and ilioinguinal nerves
- Femoral nerve
- Genitofemoral and lateral femoral cutaneous nerves
- Obturator nerve
- Peroneal nerve
- Pudendal nerve
- Isolated nerve roots S1-S4
- Nervi erigentes
- Brachial plexus
- PREVENTION OF NERVE INJURY
- Avoid patient malposition
- Avoid prolonged lithotomy position
- Avoid extreme Trendelenburg position
- Attention to the surgical incision
- Attention to retractors
- SUMMARY AND RECOMMENDATIONS