To clarify the role of a surgical neurectomy on pain in refractory patients after conservatively treated anterior cutaneous nerve entrapment syndrome (ACNES). ACNES is hardly ever considered in the differential diagnosis of chronic abdominal pain. Treatment is usually conservative. However, symptoms are often recalcitrant. Patients older than 18 years with a diagnosis of ACNES were randomized to undergo a neurectomy or a sham procedure via an open surgical procedure in day care. Both the patient and the principal investigator were blinded to the nature of surgery. Pain was recorded using a visual analog scale (1-100 mm) and a verbal rating scale (score 0-5; 0 = no pain, 5 = severe pain) before surgery and 6 weeks postoperatively. A reduction of at least 50% in the visual analog scale score and/or 2 points on the verbal rating scale was considered a "successful response." Forty-four patients were randomized between August 2008 and December 2010 (39 women, median age = 42 years; both groups, n = 22). In the neurectomy group, 16 patients reported a successful pain response. In contrast, significant pain reduction was obtained in 4 patients in the sham group (P = 0.001). Complications associated with surgery were hematoma (n = 5, conservative treatment), infection (antibiotic and drainage, n = 1), and worsened pain (n = 1). Neurectomy of the intercostal nerve endings at the level of the abdominal wall is an effective surgical procedure for pain reduction in ACNES patients who failed to respond to a conservative regimen.