***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Purpose A large r and omized , multicenter European study recently reported a reduction in early pain after open inguinal surgery when self-gripping mesh was used compared with sutured Lichtenstein repair . This secondary exploratory study is focused on the influence of nerve identification and h and ling on post-operative pain . Methods Post-operative VAS pain data and Surgical Pain Scores ( SPS ) from 507 patients included in this study were analyzed according to whether inguinal nerves were preserved or resected during surgery to investigate whether identification and peri-operative nerve h and ling impact post-operative pain . Results Preservation of the ilio-hypogastric nerve during Lichtenstein mesh repair with suture fixation was associated with significantly more post-operative pain compared with resection at each follow-up ( p ≤ 0.003 ) . This difference was not significant with self-gripping mesh repair . The decrease from baseline in post-operative VAS and SPS scores were significantly greater after self-gripping mesh repair compared to Lichtenstein repair at 1 year , but only when the ilio-hypogastric nerve was preserved ( VAS scores , p = 0.009 ; SPS scores , p = 0.015 ) . No such difference was observed with the ilio-inguinal nerve . When self-gripping mesh was used , preservation of the ilio-hypogastric nerve was associated with significantly greater decreases in post-operative pain ( change in VAS score from baseline ) compared with Lichtenstein repair at each follow-up ( p ≤ 0.018 ) . Conclusions The ilio-hypogastric nerve is in danger of being traumatized during Lichtenstein mesh repair with suture fixation . The use of self-gripping mesh was shown to reduce the level of post-operative pain when the ilio-hypogastric nerve was preserved . Resection of the ilio-hypogastric nerve during Lichtenstein repair eliminates this difference The European Hernia Society ( EHS ) is proud to present the EHS Guidelines for the Treatment of  Inguinal Hernia in Adult Patients . The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare . They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS . They are evidence -based and , when necessary , a consensus was reached among all members . The Guidelines have been review ed by a Steering Committee . Before finalisation , feedback from different national hernia societies was obtained . The  Appraisal of Guidelines for REsearch and Evaluation ( AGREE ) instrument was used by the Cochrane Association to vali date the Guidelines . The Guidelines can be used to adjust local protocol s , for training purpose s and quality control . They will be revised in 2012 in order to keep them up date d. In between revisions , it is the intention of the Working Group to provide every year , during the EHS annual congress , a short up date of new high-level evidence ( r and omised controlled trials [ RCTs ] and meta-analyses ) . Developing guidelines leads to questions that remain to be answered by specific research . Therefore , we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment . In addition , a short summary , specifically for the general practitioner , is given . In order to increase the practical use of the Guidelines by consultants and residents , more details on the most important surgical techniques , local infiltration anaesthesia and a patient information sheet is provided . The most important challenge now will be the implementation of the Guidelines in daily surgical practice . This remains an important task for the EHS . The establishment of an EHS school for teaching inguinal hernia repair surgical techniques , including tips and tricks from experts to overcome the learning curve ( especially in endoscopic repair ) , will be the next step . Working together on this project was a great learning experience , and it was worthwhile and fun . Cultural differences between members were easily overcome by educating each other , respecting different views and always coming back to the principles of evidence -based medicine . The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project BACKGROUND Ultrasound-guided ( USG ) ilioinguinal/iliohypogastric nerve ( II/IHN ) block is a widely vali date d anesthetic technique for inguinal herniorrhaphy . As the spermatic cord , scrotum , and adjacent thigh receive sensory innervation from the genital branch of genitofemoral nerve ( GFN ) , the addition of GFN block has been suggested to improve the quality of perioperative anesthesia and analgesia . The aim of this study is to compare GFN block plus II/IHN block with II/IHN block alone for intraoperative anesthesia and post-operative pain management . METHODS We enrolled 80 , ASA I-III , male adults scheduled for elective open herniorrhaphy . Patients were r and omized to receive either USG II/IHN plus GFN block ( Case Group ) or USG II/IHN block alone ( Control Group ) . The outcome measures were the assessment of postoperative VAS scores on coughing and the adequacy of anesthesia , measured with intraoperative requirement for extra local anesthetic ( LA ) infiltration and number of patients needing systemic sedation . RESULTS The requirement of intraoperative additional doses of LA was significantly lower in the Case Group ( median LA volume administered by the surgeon : 13.8±5.6 mL vs. 20.7±9.1 mL , P<0.05 ) . Two patients in the Control Group needed systemic sedation . VAS scores at 15 minutes , 30 minutes , 1 hour , 2 hours , pre-discharge , and 24 hours were significantly lower in the Case Group ( P<0.005 ) . Four cases of femoral nerve block were reported , three in the Control Group , one in the Case Group ( 2.2 % vs. 7.7 % , P>0.05 ) . CONCLUSIONS The combination of GFN block and II/IHN block is associated with lower postoperative VAS scores and lower doses of intraoperative additional LA OBJECTIVE To identify the nerves in the groin during  inguinal hernia repair by inguinotomy . METHODS We conducted a prospect i ve , sequenced , non-r and omized study comprising 38 patients undergoing inguinal hernia repair with placement of polypropylene mesh .  RESULTS The male patients were 36 ( 94.7 % ) , with a mean age and st and ard deviation of 43.1 ± 14.5 , body mass index of 24.4 ± 2.8 . Comorbidities were hypertension in two ( 5.2 % ) , smoking in 12 ( 31.5 % ) and obesity in two ( 5.2 % ) . The hernia was located only on the right in 21 ( 55.2 % ) patients , only on the left in 11 ( 28.9 % ) , and was bilateral in six ( 15.7 % ) patients . Prior hernia repair was present in seven ( 18.4 % ) patients . The identification of the three nerves during operation was made in 20 ( 52.6 % ) patients , the ilioinguinal nerve and the iliohypogastric nerve were identified in 33 ( 86.8 % ) , and the genital nerve branch of the genitofemoral nerve , in 20 ( 52.6 % ) . Resection of at least one of the nerves was performed in seven ( 18.4 % ) cases , two iliohypogastric nerves and five ilioinguinal nerves . The average operating time was 70.8 ± 18.2 minutes . The hospital stay was 1.42 ± 1.18 days . Ten patients ( 26.3 % ) returned to physical activity around the first postoperative visit , and 37 ( 97.3 % ) in the last . The follow-up time was 95.6 ± 23.5 days . The inability to identify the ilioinguinal nerve was associated with previous repair ( p = 0.035 ) . CONCLUSION The identification of the three nerves during inguinal hernia surgery has been described in more than half of the cases and prior repair interfered with the identification of ilioinguinal nerve BACKGROUND The neuropathic groin pain after  inguinal hernia repair  is usually due to a neuroma of the ilioinguinal , iliohypogastric , or genitofemoral nerve . When the postherniorrhaphy pain symptoms include mostly testicular pain , then the genital branch of the genitofemoral nerve comes first in the differential diagnosis . Nerve blocks are helpful in determining which of the three nerves is implicated in the pain syndrome . Although the surgical approach to the ilioinguinal nerve is now well established , it has been difficult to identify the genitofemoral reliably enough to permit resection of this nerve . STUDY DESIGN Anatomic cadaver dissections of nerves exiting the lumbosacral plexus were performed . Their course was followed to their final terminations . Based on these findings , an operative approach was design ed to address the involved nerve at a specific site . The results and outcomes were prospect ively followed . RESULTS The present anatomic study identifies the site within the inguinal canal where the genital branch of the genitofemoral nerve may be identified . The design ed operative approach points to the proximal site of the canal to be opened for an exposure . It also dictates that the nerve should be dissected and resected proximal to the surgical repair or mesh reconstruction , which allows its retroperitoneal placement . All four patients were relieved of their preoperative symptoms using this approach . CONCLUSIONS Severe and chronic testicular pain after inguinal hernia repair can be treated by a design ed approach that identifies the genital branch of the genitofemoral nerve in the proximal inguinal canal , its resection point proximal to the previous operative field , and placement behind the peritoneum Aims Chronic pain following inguinal hernia repair may be related to the h and ling of cutaneous nerves . This study aims to investigate the frequency of cutaneous nerve division in routine practice and the effect that nerve division has on long-term pain outcomes . Methods The outcomes of 172 patients who underwent open inguinal hernia repair over a two-year period during the course of a clinical trial were recorded prospect ively for 1 year . Pain scores for patients in whom one of the nerves was divided were compared with those of patients in whom all three were preserved . Result All nerves were preserved in 95 cases ( 55.2 % ) . The ilioinguinal , genital and iliohypogastric nerves were divided in 33 ( 19.2 % ) , 12 ( 7.0 % ) and 14 ( 8.1 % ) cases , respectively . There was no significant difference in pain scores between any of the nerve division groups compared to the group in which all three were preserved . There were three ( 1.7 % ) cases of significant chronic pain , two in which no nerves were divided . Conclusion The division of cutaneous nerves during inguinal hernia repair has no significant effect on postoperative pain . However , there are very few adverse outcomes , and so , a pragmatic approach of dividing nerves when they would otherwise be damaged may be appropriate OBJECTIVE The aim of this study was to evaluate the effectiveness of bilateral ilioinguinal-iliohypogastric nerve blocks for pain relief following ambulatory bilateral varicocelectomy . STUDY DESIGN Prospect i ve and r and omised . PATIENTS AND METHODS Sixty adult men scheduled for bilateral varicocelectomy were included in this prospect i ve study . All patients had a st and ardised general anesthesia . After surgical procedures , patients were r and omized into two groups : patients in group I received a bilateral ilioinguinal nerve block with 15 ml x 2 of 0.25 % bupivacaine ; patients in group II received subcutaneously 1 mg kg-1 of tramadol .  Visual analogue pain scores at rest and during mobilisation were recorded at 5 min and 1 , 3 , 5 postoperative hours . The side effects of analgesia and amounts of rescue analgesics were recorded . RESULTS Pain scores at rest and during mobilisation , the incidence of postoperative nausea and vomiting and additional analgesics requirement were significantly reduced in group I. There was no complication . CONCLUSION Ilioinguinal nerve block is effective in controlling pain after bilateral varicocelectomy in ambulatory surgery Background Surgical strategy regarding nerve identification and resection in relation to  chronic postoperative pain  remains controversial . A central question is whether nerves in the operation field , when identified , should be preserved or resected . In the present study , the hypotheses that the identification and consequent resection of nerves ‘ at risk ’ have no influence on postoperative pain has been tested . Methods A single-centre study was conducted in 525 patients undergoing Lichtenstein hernioplasty . One surgeon ( 364 operations , Group A ) consequently resected nerves ‘ at risk ’ for being injured and nine surgeons ( 161 operations , Group B ) adhered to the general routine of nerve preservation .  All cases were ambulatory surgery on anaesthetised patients and the groups were similar with regard to age , body mass index ( BMI ) and preoperative pain . Self-reported pain at 3 months was recorded on a 10-box visual analogue scale ( VAS ) . The identification and resection of nerves were continuously registered . Statistical calculations were performed with Fisher ’s exact test and ordinal logistic regression . Results There was no significant difference in the number of identified nerves in the two groups of patients ( iliohypogastricus , P = 0.555 ; ilioinguinalis , P = 0.831 ; genital branch , P = 0.21 
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For those outcomes , a visual analysis of funnel and Doi plots indicated irregularity and provided evidence that larger studies tended to have lower identification rates .
Conclusions The identification rates of the inguinal nerves in our study were lower than reported in literature .
The lowest was found for GNF , suggesting that this nerve was the most difficult to identify .
Knowledge regarding the anatomy of the inguinal nerves can facilitate their proper identification and reduce the risk of iatrogenic injury and postoperative pain