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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_842_Библиотеки_им_академика_М_И_Перельмана.pdf
Sportsmen Hernia
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may be increased due to the forces produced by
the muscles, and just this last possibility could be
dened as SH.
On the other hand, this disruption of the muscle/tendon at their insertion site could be dened
as a PBSI (pubic bone stress injury) which aects
not only the pubic bone itself but also the muscles
and their tendons on both sides of the symphysis
pubis [5] (in the past, it was mistakenly referred to
as osteitis pubis). For that reasons, this term could
include dierent entities such as tendon enthesitis, pubic osteitis, or avulsion fractures.
In conclusion, this global entity could be considered an imbalance of the muscles (abductor
and abdominal) at the pubis, which leads to an
increase of the weakness of the posterior wall of
the groin and produces a tendon enthesitis, once
a true origin is not detected, since, for example, a
hernia is a hernia or a nerve entrapment is a nerve
entrapment, etc., which may lead to a degenerative arthropathy of the pubic symphyses in the
advances stages.
19.3 How Is This Entity Diagnosed?
Diagnosis of chronic groin pain is dicult, but
early diagnosis is very important since morbidity
will be reduced. ese groin injuries are some of
the most challenging injuries in the eld of sports
medicine, and the literature provides no consensus on denitions of or diagnostic criteria for
groin pain in athletes. e combination of complex anatomy, the variability of presentation, and
the nonspecic nature of the signs and symptoms
make the diagnostic process problematical [6].
erefore, management of groin injuries can
be challenging, and diagnosis can be dicult
because of the degree of overlap of symptoms
between the dierent problems. is clinical
setting demands the recruitment of a team with
experience of dierent aspects of groin pain, being
necessary to establish a multidisciplinary investigation in order to reveal the underlying cause [7].
ese examinations included general surgeons for
detection of inguinal hernia and neuralgia, orthopedic surgeons for detection of adductor tenoperiostitis and symphysitis, urologist for detection
of prostatitis, radiologist for performing dierent
imaging tests, and nuclear medicine for isotope
studies. For all these reasons, the so-called SH is
largely a clinical diagnosis of exclusion.
SH must be distinguished from the more common osteitis pubis and musculotendinous injuries
[8]. But the rst step is to determine the dierential diagnosis of hip and groin pain with respect
to the high frequency of referred pain from the
lumbar spine, lower abdomen, and pelvis [9],
which is very dicult in some cases. A systematic
approach to the hip and groin area is important to
identify the origin of pain. Both the history and
quality of symptoms and the physical exam are
the basics of the diagnostic algorithm, completed
in some cases the diagnostic work-up with roentgenograms and possibly an injection with a local
anesthetic to the suspected origin of pain oen
complete [9]. On the other hand, there are clinical
signs in the diagnosis of nerve pathologies, such
as obturator neuropathies; these patients usually
show clinical symptoms and signs of postexercise
groin, lower abdominal or medial tight pain, and
adductor muscle weakness and paresthesia in
cutaneous distribution of medial thigh. Except
clinical signs in the diagnosis of obturator neuropathy, diagnostic local anesthetic block and
electromyography could be used.
History of chronic groin pain that is nonresponsive to treatment should raise suspicion of
SH, but physical examination ndings are subtle,
and most diagnostic tests do not denitively conrm the diagnosis. Traditional physiotherapy
of isometric active weight-bearing exercise will
result in complete healing of almost all athletes
[10]. It is important to highlight that adductor strain is a possible part of this pathological
syndrome and so tenotomy, as procedure only
performed, should not be performed under any
circumstances.
Finally it must be said that, in selected cases,
correct diagnosis is only possible with diagnostic
laparoscopy [11].
19.3.1 Physical Examination
Physical examination is the rst step in the diagnosis of groin pain, although symptoms are oen
vague and diuse. When active, sportsmen start
to feel a dull pain in the groin region.
A deep palpation above the inguinal canal will
nd the area to be sensitive, the external inguinal
ring dilated [2]. In a digital examination of the
canal, a so bulge can be felt against the tip of the
nger and extreme sensitivity to pressure applied
228
S. Morales-Conde et al.
19
with the tip of the nger against the oor of the
canal where the genitofemoral nerve passes. With
this syndrome, the nerve is entrapped under the
IPT (ileo-pubic tract) in the internal inguinal ring
area. In addition, all the symptoms increase during coughing.
e clinical assessment of groin pain in athletes is dicult, with the lack of specic clinical
tests being in part responsible. e examinations
could include evaluation of adductor musclerelated pain and strength; iliopsoas musclerelated pain, strength, and exibility; abdominal
muscle- related pain; and strength and pain at the
symphysis joint, but the only test without acceptable interobserver reliability was the strength test
for iliopsoas muscle [12].
Gradual physical therapy combined with pharmacotherapy should be eective in most cases and
should be part of the diagnosis process. is process includes nonsteroid anti- inammatory drugs
and muscle relaxants. A physical therapy program
usually involves stretching and strengthening of
the adductor muscles, abdominal wall muscles,
iliopsoas muscle, quadriceps, and hamstrings. In
case that physical therapy and pharmacotherapy
fail, dierent tests should be performed.
19.3.2 Ultrasound
Ultrasound is a useful adjunct in evaluating the
groin for hernia. e overall accuracy in nding
a hernia of any kind by ultrasound is 92%, and,
on the other hand, this imaging test identies the
pathology in a groin without a palpable bulge at
an accuracy of 75% [13].
On the other hand, ultrasound enables a
dynamic assessment that is particularly useful
in these patients [2, 11]. Dynamic ultrasound
examination should be the diagnostic tool of rst
choice, since it is able to detect inguinal canal
posterior wall deciency in young males with no
clinical signs of hernia with chronic groin pain.
As the patient actively strains during the investigation, a real-time convex anterior bulge and
ballooning of the inguinal canal can be observed
at the supercial inguinal ring. is examination
has been proposed [14] to be performed with
the patient in the supine and erect positions, in a
relaxed state, as well as during coughing and during Valsalva maneuver.
A correlation between bilateral deciency of
the posterior wall and groin pain has been shown
[15], although the temporal relationship between
the clinical and ultrasound ndings is not
established. Ultrasound is also a useful tool for
identifying hernias and, therefore, aids surgical
management, since 39% of the patients examined
presenting groin pain were positive for hernias in
some studies [16], nding a very low rate of false
positive, giving a positive predictive value of 94%
in operated patients.
Ultrasound could be also useful in detecting
other ndings that could be related to groin pain,
such as a preperitoneal lipoma herniating into
the inner inguinal ring and canal, an evidence of
genitofemoral nerve entrapment by identifying
an edema behind the IPT on the level of internal
inguinal ring, or even a tear and strain of the conjoint tendon in its insertion to the pubis.
19.3.3 MRI andCT Scan
Bone scan, plain radiography, and ultrasound
have been used for diagnosing these entities, but
MRI appears to be a useful tool. A clinical and
imaging diagnosis is crucial, since in PBSI, there
is no need for surgical intervention.
MRI provided an accurate depiction of pubic
bone alterations and of adjacent myotendinous
structures [17], being also very useful to determine the presence of inguinal hernias [17], since
allows the direct visualization of the hernial sac
within the inguinal canal. Athletes with groin
pain and tenderness of the pubic symphysis and/
or superior pubic ramus have clinical features
consistent with the diagnosis of osteitis pubis. e
increased signal intensity seen on MRI is due to
pubic bone marrow edema. A stress injury to the
pubic bone is the most likely explanation for these
MRI ndings.
MRI can permit an accurate and early diagnosis of the dierent sport-related pubic conditions, being also a valuable tool in monitoring
the alterations with reference to their response to
treatment, which may also help bring the athletes
back to their activities. But it should also be considered that abnormal magnetic resonance imaging ndings are also common in asymptomatic
athletes, which decrease the value of magnetic
resonance imaging in surgical decision-making
Sportsmen Hernia
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19
[18], and, on the other hand, those patients with
the presence of pubic bone marrow edema in
MRI who undergo endoscopic repair for athletic pubalgia are not aected by this entity in
the recovery period, so this nding could lead to
confusion [19].
On the other hand, CT scan has been also
described as a diagnostic technique with high accuracy in detecting posterior wall deciencies [20].
19.4 How Is This Entity Treated?
Chronic groin pain in athletes is a dicult problem requiring a multidisciplinary approach not
only to diagnosis but also to treatment planning
[21]. Based on previous denitions, in case this
imbalance of the groin causes a disruption of
the muscle/tendon at their insertion site on the
pubis, treatment should be based on rest, antiinammatory medication, and a proper training
program followed by a reevaluation. For that reason, conservative treatment is tried rst [22], but
there is no evidence-based consensus available
to guide decision-making [21]. But in case that a
weak area has been found at the groin due to the
forces produced by the muscles, patients should
undergo a surgical repair of the groin reinforcing
the posterior wall with or without a mesh, since if
a conjoined tendon is adequately supported by a
mesh or with a stabilization by a suture repair like
a minimal repair [3], adductor discomfort almost
uniformly resolves with postoperative rehabilitation, being rarely that the abductor requires an
operative release, a tenotomy, or a perforation on
the pubis.
19.4.1 Conservative Treatment
Traditional conservative treatment has low success rates [2], being demonstrated in one RCT
that an active physical training program aiming at
strengthening the muscles to stabilize the hip and
pelvis is of advantage for the patient when compared with rather passive measures [23].
Many groin pain due to problems related to
the musculoskeletal system are a self-limiting
disease that can take several months to resolve,
and corticosteroid injection can sometimes hasten this rehabilitation process. is treatment
can be expected to aord at least 1year of relief
of adductor- related groin pain in a competitive athlete with normal ndings on a magnetic
resonance imaging scan; however, it should be
employed only as a diagnostic test or short-term
treatment for a competitive athlete with evidence
of enthesopathy on magnetic resonance imaging.
But, on the other hand, recent studies have demonstrated that for conservative treatment, the use
of radio-frequency denervation of both ilioinguinal nerve and inguinal ligament in the treatment
of refractory SH is safe and ecacious at least in
the short term and is superior to anesthetic/steroid injection [24].
Finally we can state that most studies agree
that surgical therapy seems to be superior to
nonsurgical treatment [2, 11], even that a recent
systematic review states that aer conservative
treatment, athletes return faster to play [25],
although the studies included are of poor quality. In this sense, a recent prospective randomized
trial, conducted by Paajanen etal. [26], supports
our way of treating these patients, oering a surgical treatment to solve the groin pain. is study
mesh repair on 60 patients with a diagnosis of
chronic groin pain and suspected SH. Operative
repair was more eective than nonoperative
treatment to decrease chronic groin pain aer
1 month and up to 12months of follow-up. Of
the 30 athletes who underwent operation, 90%
returned to sports activities aer 3 months of
convalescence compared to 27% of the 30 athletes
in the nonoperative group. For this reason, surgical treatment should be considered a valid option
to solve this entity. On the other hand, a preventive training program could be successful to avoid
such injuries. An 8-year experience in Australian
rules football professionals with a preventive core
stability program shows a signicant decrease of
groin problems [27].
19.4.2 Surgery
Conservative treatment of this entity does not
oen result in resolution of symptoms [28]. In
some series the athletes have received dierent
conservative treatments without success, and the
surgical procedures performed in these cases have
oered a denitive resolution to this problem.
230
S. Morales-Conde et al.
19
Although, several surgical approaches are available for the repair of inguinal hernias, but without
knowing the true natural history of this disorder,
and the problem is that it is dicult to know when
it is appropriate to have a surgical intervention
[14]. e conclusion could be that it is recommended operating only if conservative therapy,
with prolonged rest, fails [29].
It is important to establish that precise diagnosis is always preferable, before to perform a
surgical approach in a patient with chronic groin
pain. Steele etal. [30] show no signicant dierence in outcome between subjects who had an
abnormal ultrasound scan on the symptomatic
side and those who had a normal scan. ere
was a signicant dierence in outcome between
patients who had a bone scan with increased
uptake at the symptomatic pubic tubercle and
those who did not (p<0.04). is study supports
other researches that show that good results can
be obtained with surgery when posterior inguinal
wall deciency is the sole diagnosis.
Surgical intervention of chronic groin pain by
performing a posterior repair results in pain-free
return of full activities in a majority of cases [28],
although there is no consensus view supporting any particular surgical procedure for SH [8].
Various types of operations, based on the variable theories regarding the pathophysiological
process, have been developed for the treatment of
this syndrome. Some surgeons focus on the external elements of the inguinal canal and repair the
external oblique fascia or enforce the groin with
the rectus abdominis. Some researchers believe
that the problem is in the lower abdominal muscles, or is caused by nerve entrapment, and treat
it accordingly, showing good results performing
an open technique, Bassini or Shouldice [31],
and neurotomy of the inguinal nerve, describing
benets for the patients, but the overall quality of
most of the studies is low [22].
But the most popular surgical procedure
associated to the posterior repair of the groin,
with mesh or sutures, is tenotomy [32–35], being
also performed as an isolated technique by some
groups [36, 37]. ere are some groups who
believe on the need of performing this systematic
tenotomy of the abductor longus muscles during
the laparoscopic or open repair of the posterior
deciency of the abdominal wall. But, basically
the main recommendation of most of the authors
is that, in cases where PWD or tear of the posterior inguinal wall are clearly diagnosed, routine
inguinal hernia repair should be done as the main
procedure [11, 28], being the need of a tenotomy a
current discussion in the literature nowadays that
we usually do not perform.
In this last sense, a number of reports have
been published describing dierent repairs of the
posterior inguinal wall deciency as the main
approach for the SH with excellent results. is
procedure can be performed either with sutures
or synthetic mesh, being performed by an open
approach or laparoscopically, both with good
results [2, 38], being the endoscopic preperitoneal approach the technique more used in the
last year [18, 39–41] and the one recommended
by our groups and recent guidelines [42–46].
e laparoscopic approach may provide better
posterior inguinal wall exposure, enabling easier
bilateral reinforcement [47], and possibly allow
a quicker recovery time than open surgery [2,
21, 32, 37, 48]. In this sense, CJ Ingoldby [38]
has published a comparative nonrandomized
study comparing the open and the laparoscopic
approach, showing that the endoscopic repair
permits an early return to activity. In fact, overall
postsurgical recovery time (based on return to
sports activity) was found to be in some studies
of 17.7weeks aer open and 6.1weeks aer laparoscopic repair [2].
Regarding the two types of laparoscopic
approaches, TEP and TAPP, both have been successfully applied to treat this entity. ere are no
studies showing the true ecacy of these dierent techniques, and a recent systematic review
comparing the dierent laparoscopic approaches
shows no dierence between the two techniques
in terms of return to sporting activity, although
more reported cases to date in the literature used
the TAPP technique compared with TEP repair
[49]; thus a recommendation for one or the other
method cannot be given and depends on the skill
and personal preference of the surgeon involved,
being the TEP approach the preferable technique
by our groups.
Finally, beside the placement of the mesh in
the preperitoneal space, during the operation, the
inguinal canal should be thoroughly explored in
order to nd the dierent entities that could be
detected during the surgery such as a true inguinal hernia, a wide internal ring and peritoneal
Sportsmen Hernia
231
19
. Fig.19.1 a and b
Endoscopic view (TEP) of
the inguinal area that could
be involved in the
development of a
“sportsmen hernia”
a
Area of developmen of the
weakness of the posterior
abdominal walll
Symphysis pubis
b
Linea
alba
Rectus muscle
Cooper´s ligament
Rectus muscle
Epigastric
vessels
Area of developmen of the
weakness of the posterior
abdominal walll
Symphysis pubis
Cooper´s ligament
dimple, a hernia femoralis, a preperitoneal
lipoma, hernia obturatoria, a pre-vascular hernia, an obvious musculotendinous tear, a muscle
asymmetry, and a signicant bulge in the posterior wall, but even if no clear pathology is identied, reinforcement of the wall using a mesh oers
good clinical results for athletes with idiopathic
groin pain. Basically, the most common nding
in athletes with chronic groin pain was a deciency of the posterior wall of the inguinal canal
Figs. . 19.1a, b and . 19.2).
(
Inguinal
cord
e endoscopic repair of this entity requires
the placement of a mesh in the inguinal region.
Recent meta-analysis has shown that the only
advantage of the so-called lightweight meshes is
that they improve the discomfort at short term and
could oer an additional advantage to this group of
patients who are willing to return to sports activities
as soon as possible [50]. Atraumatic xation with
glue in in these cases should also be considered in
order to decrease acute and chronic pain, being the
alternative used by our group in these patients.
232
S. Morales-Conde et al.
. Fig.19.2 Lipoma at
the cord as a cause of pain
in the inguinal region
Inguinal cord
Lipoma removed from the cord
19
19.5 Rehabilitation After Surgical
Treatment
With respect to postsurgical rehabilitation programs, up to now, there is no general agreement
about the best postoperative physical training
program to enable the athletes to return to full
sports activity in shortest time [28]. Valuable
studies having a high level of evidence are urgently
needed.
e eect of the presence of pubic bone marrow edema in magnetic resonance imaging on
recovery from endoscopic surgery for athletic
pubalgia has been published recently [19], and
it has been found that the presence of this entity
does not aect the recovery period aer the endoscopic surgical treatment of these patients, so the
presence of this edema should not change the
rehabilitation program.
e following program works well in our
experience:
5 First postoperative day: ergometer training
up to 50W.
5 Second to sixth postoperative day: ergometer
training up to 200W.
5 Seventh postoperative day: starting with
slight running.
5 Week 2: increasing load of training up to full
training in the third or fourth postoperative
week.
5 Associated manual lymphatic drainage and
physiotherapy should start already at day 1.
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19
235
Comparison toOpen
Techniques
BaukjeVanDenHeuvel, Robert J.Fitzgibbons, Jr.,
andReinhardBittner
20.1 Part 1 How Ido It–236
20.1.1 Introduction–236
20.1.2 Choice ofTechnique–238
20.1.3 Open Versus Laparoscopic Mesh Repair–238
20.1.4 Clinical Practice–239
20.2 Part 2 Statements andRecommendations–240
References–240
20
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_20
236
B. Van Den Heuvel et al.
20.1 Part 1 How Ido It
20.1.1 Introduction
e basic principles of modern inguinal hernia
surgery were born in 1884 when the Italian surgeon Edoardo Bassini (1844–1924) introduced a
new surgical technique [3, 37, 44]. Bassini discovered that the inguinal oor played an important
role in the etiology of inguinal hernias. He
approached the hernia from the anterior side. He
realized the importance of dierentiating direct
from indirect hernias, isolating the spermatic
cord, resecting indirect hernia sacs at the deep
inguinal ring ush with the peritoneum, complete
division of the external oblique aponeurosis and
the transversalis fascia and oblique reconstruction of the posterior wall of the inguinal canal by
a triple layer method with an anterior and posterior wall with an internal and external opening
(rings). e three layers consisted of the transversalis fascia, the aponeurosis of the internal oblique
muscle, and the aponeurosis of the transversus
abdominis muscle, which he sutured to the inguinal ligament [39]. Bassini published his results
showing a recurrence rate of 2.8% aer 5years of
follow-up. Modications were common and in
fact at least 70 named tissue repairs have been
described in the literature [2]. e technique (or
one of its modications) became accepted and
was the gold standard for inguinal hernia repair
for most of the twentieth century.
Perhaps the most widely accepted Bassini
modication was born in 1945 when the Canadian
surgeon Earle Shouldice (1890–1965) opened a
small hospital treating only inguinal hernias [4].
His surgical technique resembled Bassini, except
that instead of interrupted sutures to reconstruct
the inguinal oor he used four rows of continuous
stainless steel wire and excluded the periosteum
from the rst suture. Shouldice recognized the
importance of perioperative care of inguinal hernia patients as well, including preoperative preparation, local anesthesia, early mobilization, short
hospital stay and resuming normal activities as
soon as the patient felt comfortable [39]. Aer an
initial learning curve, a consistent recurrence rate
of approximately 1% was reported by Shouldice as
is depicted in
. Fig.20.1. In general practice long-
term results are less satisfying and show a recurrence rate of 1.7–15% [40]. Nevertheless, the
Shouldice technique is considered by most
authorities to be the best pure tissue repair for a
primary inguinal hernia.
Results from single centers usually with a spe-
cic interest in hernia repair using the Bassini
operation or one of its modications were similar
with recurrence rates less than 5%. However,
population based studies in the latter half of the
twentieth century revealed a recurrence rate as
high as 30% in general practice causing investigators to consider alternatives [3]. A popular theory
was that the tension produced by suturing structures together that were not normally in apposition resulted in undo tension and the poor results.
In 1958 the American surgeon Francis Usher
(1908–1980) introduced the revolutionary
tension- free mesh repair [36]. He had developed a
20
. Fig.20.1 Recurrence
rates of the Shouldice
technique after its
introduction in 1945
20
18
16
14
12
10
8
6
Recurrence rate (%)
4
2
0
1945 1950 1955 1960 1965 1970 1975 1980 1985 1990
Year
(1945–1991)