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177
15. Recurrent Inguinal Hernia: The Best Approach
fascia medially. Additional dissection and damage to underlying
structures will thus be avoided. Among the risk factors for recurrence,
some if not most are amenable to preoperative correction. These include
technical factors such as the use of short-term absorbable sutures for
rraphy or mesh fi xation [ 39 ] and insuf fi cient coverage when mesh is used
[ 9, 11 ] , and patient-related factors including smoking and to a certain
degree, obesity.
Schwab and Klinge [ 40 ] proposed the following algorithm for the
treatment of recurrent mesh repair according to whether or not the
previous operation was complicated or not and whether prosthetic
material should be removed or not. If the postoperative course of the
preceding operation was uneventful, these authors propose an endoscopic
or open posterior repair when the initial route was anterior and the
Lichtenstein anterior repair when the initial operation was a posterior
repair. If, however, the previous operation was followed by a complication,
the authors advise an anterior or posterior transinguinal revision. If the
endoscopic route is chosen, practically only the TAPP technique is
possible, the TEP is reputed to be too dif fi cult [ 41 ] . If the prior operation
was an anterior mesh (Lichtenstein) repair, then an open posterior repair
(Wantz or Stoppa) seems appropriate.
The use of local anesthesia for recurrent hernia is not well studied.
Obviously, endoscopic repairs are always performed under general
anesthesia. Theoretically, all other procedures can be done under local
anesthesia. However, the increased complexity and longer dissection
times are characteristics that might preclude the use of local anesthesia.
Table 15.2 summarizes the therapeutic potentials according the
recommendations of the authors who have tried to systematize repair.
Conclusion
In conclusion, we recommend the following: when faced with
recurrence after tissue repair , the surgeon can choose between an open
anterior (Lichtenstein plug, or plug and patch, or Prolene Hernia
System) repair, an open posterior (Read, Rives, Stoppa, Kugel, Nyhus,
Wantz) repair, and a laparoscopic (TAPP or TEP) repair, essentially
based on the size of the hernia defect and surgeon preference and/or
expertise [ 3 ] .
If dealing with a recurrence after a mesh repair , the technique of
repair will depend on surgeon experience and on which anatomic
178
A. Fingerhut and M. Khoursheed
approach was used for the previous operation (anterior or posterior). For
recurrence after mesh placed through an open anterior approach , then a
Read, Rives, Stoppa, Nyhus, Wantz, Kugel, or a laparoscopic (TEP OR
TAPP) approach may be used.
For recurrence after mesh placed through a posterior (laparoscopic
for example) approach , the recommendation is to perform a laparoscopic
TAPP (if experienced in laparoscopy) or an open Lichtenstein, Prolene
Hernia System, or plug and patch technique if experienced in open
techniques. Decisions may be based on the size of the hernia defect and
surgeon preference and/or expertise [ 3 ] .
If mesh removal is needed , it is most likely best removed through an
open anterior approach, while some isolated plugs can be removed safely
laparoscopically. If a second mesh repair is envisioned in the same
operation, we propose an endoscopic or open posterior repair when the
initial route was anterior and the Lichtenstein anterior repair when the
initial operation was a posterior repair.
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15. Recurrent Inguinal Hernia: The Best Approach
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for recurrent inguinal hernia. Br J Surg. 2002;89:90–3.
23. Kouhia ST, Huttunen R, Silvasti SO, Heiskanen JT, Ahtola H, Uotila-Nieminen M,
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181
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_16,
© Springer Science+Business Media New York 2013
16. Athletic Groin Pain and Sports
Hernia
Nathaniel Stoikes and L. Michael Brunt
Sports hernia has become a topic of increasing interest in both the
sports and surgical communities as a number of high-pro fi le athletes have
been treated for this condition. This condition is not a true hernia and, as
such, the term “sports hernia” is not anatomically correct; rather, the
condition is better designated as “athletic pubalgia” given the variations
clinical presentations and underlying pathophysiology. Nonetheless, as
sports hernia is fi rmly ingrained in the lexicon of the medical and lay
literature, it will be used interchangeably with athletic pubalgia in this
review. Although sports hernia has garnered the most attention, most
athletic groin injuries do not evolve into a sports hernia type pubalgia and
are successfully managed with conservative measures. These injuries can
be challenging both from a diagnostic and clinical management standpoint
for many reasons including the extensive differential diagnosis, anatomic
complexity of the groin region, unpredictability regarding time to return
to sport, risk of chronicity, and the variety of management options. This
chapter will discuss basic considerations in athletic groin injuries,
describe the clinical entity of sports hernia in detail, and review the
various surgical approaches to its management.
Background
Groin injuries are common in sports with repetitive, high speed cutting,
turning, twisting, and kicking motions, such as soccer, football, and ice
hockey. The reported incidence of groin injuries in elite level athletes has
ranged from 5 to 28% in soccer players [ 1 ] to 6–15% in hockey players [ 2,
3 ] but is not exclusive to these sports. In contrast to most sports injuries,
these typically are soft tissue injuries (i.e., not skeletal) that do not
182
N. Stoikes and L.M. Brunt
necessarily arise from direct physical contact. Various risk factors for the
development of groin injuries have been described: [
4 ] these include a
prior history of groin injury, older player status, and lack of off-season
sports-speci fi c conditioning activity (e.g., ice skating for hockey players).
In one prospective study of NHL players, reduced adductor muscle
strength was signi fi cantly associated with an increased risk of adductor
strain injury [
5 ] . More importantly, implementation of an adductor
strengthening program reduced the injury incidence by almost 80%.
Presentation
Establishing a diagnosis of a sports hernia can be challenging as the
fi ndings are often subtle, and patients can have a varied presentation. It
should be considered in part a diagnosis of exclusion, but the differential
diagnosis can be vast as there are many components to the dynamic
abdominal and pelvic region that must be ruled out.
A typical scenario is that of an athlete who presents with complaints
of moderately intense pain and discomfort in the region of the superior
pubis and in the lower abdominal/inguinal region associated with
exertion. In some cases, the pain may be more vague and radiate to the
upper thigh or across the lower abdomen. These symptoms are most
pronounced with explosive movements and usually abate with rest. Pain
may also be noted with sneezing and coughing. Pain along the upper
adductor muscle group, principally the adductor longus and its attachment
to the inferior pubis, is not unusual.
A detailed history including location of pain, quality and intensity of
pain, onset, duration, and inciting factors should be noted. Other important
details include how the athlete has managed these symptoms since the
injury, including rest and treatments that he or she has undergone. It is key
to note how long the patient has truly rested or decreased activity as most
athletic groin injuries eventually resolve with conservative management
On physical exam, symptoms can be reproduced through a series of
maneuvers involving an evaluation of the abdominal core. Thorough
examination should include assessment for inguinal hernia, palpation of
the inguinal fl oor, pubis, rectus abdominis, adductor muscles, and hips.
Pain may be elicited in these regions during a resisted sit-up, trunk
rotation, and resisted hip and thigh movements including hip fl exion and
adduction. True inguinal hernia pathology is rarely found, but the inguinal
fl oor may feel weak or have a slight bulging effect on Valsalva coupled
183
16. Athletic Groin Pain and Sports Hernia
with tenderness in the inguinal fl oor. In our series at Washington
University, we identi fi ed the following in patients who subsequently
underwent surgery for a sports hernia: 90.7% weak inguinal fl oor; 80.2%
tenderness in medial inguinal fl oor; 63.8% pain with resisted sit-up,
fl oor; 63.8% pain with resisted sit-up; 73.3% pain with trunk rotation;
and 56.7% pain with resisted adduction [ 6 ] .
Differential Diagnosis
The differential diagnosis and clinical presentation of various athletic
groin injuries (Table 16.1 ) has been extensively reviewed elsewhere [ 7– 9 ] .
The most common causes of groin pain in athletes are muscle strains of
the musculature of the lower abdominal wall, hip fl exors, and adductor
muscles of the upper thigh. Other causes include:
1. Osteitis pubis
2. Pubic stress fracture
3. Inguinal hernia
4. Sports hernia/athletic pubalgia
5. Hip joint injury (labral tears, femoral-acetabular impingement,
other hip pathology)
Table 16.1. Differential diagnosis of athletic groin injuries.
• Pelvis
– Traumatic fracture or contusions
– Stress-related fractures
– Osteitis pubis
• Muscular strains
– Abdominal: rectus abdominis, obliques
– Hip fl exors/iliopsoas
– Adductor group (longus, brevis, magnus, pectineus, obturator externus)
• Hip Injuries
– Labral tears
– Femoral-acetabular impingement
– Osteoarthritis
– Stress fractures
• Sports hernia/athletic pubalgia
• Inguinal hernia
• Nonathletic causes (endometriosis, ovarian pathology, in fl ammatory bowel
disease, etc.)
184
N. Stoikes and L.M. Brunt
Imaging
Since the diagnosis of sports hernia pubalgia can be elusive, various
imaging modalities can be used to provide more objective evidence for
diagnosis and to assist in excluding other potential causes. Plain x-rays
of the hip and pelvis are low yield but should be done in selected athletes
to identify any gross structural abnormalities or stress fractures. Pelvic
MRI provides more detailed structural information of the pelvis and soft
tissues (muscles and tendons) and is the preferred imaging modality for
evaluation of chronic athletic groin pain in our center. The pelvic MRI
should include both axial, coronal, and sagittal oblique sequences.
Common MRI fi ndings can be divided into two main subtypes: bony and
soft tissue. Bony pathology includes edema and stress reaction in the
parasymphyseal pubis and a secondary cleft sign in the pubis which is an
abnormal extension of the central symphyseal cleft at the anterior and
inferior margin of the pubis (Fig. 16.1 ). Soft tissue fi ndings include
muscle tears or edema of the adductor muscle groups, lower rectus
abdominis muscle, or at the common insertion site of rectus-adductor
complex on the pubis (Fig. 16.2 ).
Though not commonly used in North America, ultrasound of the
groin has been utilized preferentially by some groups [ 10 ] . The advantage
of this modality is the ability to view the dynamic movements of the
inguinal fl oor during a Valsalva maneuver, but it is operator dependent.
Fig. 16.1. Coronal STIR
(short T1 inversion recovery)
MRI sequence that shows a
symphyseal cleft and
parasymphyseal edema seen
commonly in athletic
pubalgia. Arrow indicates
the “cleft” ( white signal)
between the pubis and the
aponeurosis ( black
structure). Note also the
marrow edema in the pubis
which is more pronounced
on the right (symptomatic)
side.
185
16. Athletic Groin Pain and Sports Hernia
Pathophysiology
As evidenced by the pathology found on imaging modalities and at
surgical exploration, the groin is a dynamic area with a fi xation point located
at the pubis. The theory of a “pubic joint” originates from Meyers [ 11, 12 ]
wherein the pubis is the fulcrum between the abdominal muscles and upper
thigh muscles. As with any point of fi xation carrying stress loads, unequal
distribution of or imbalance of forces can lead to excessive stress on the
focal point (the pubis) and the opposing muscle units (rectus abdominis, hip
fl exors, or adductors), leading to further weakness of the region. The end
result of this process is pubalgia type pain and weakening or disruption of
the rectus-adductor complex where it attaches at the pubis.
Other mechanisms include weakening in the inguinal fl oor and canal
that is caused again by excessive force transmitted across the pubis from
the powerful thigh musculature. The bowing of the inguinal fl oor and
resultant widening of the inguinal canal causes the rectus to retract medically
and superiorly which creates increased tension, and, thereby, pain across
the pubis [ 10 ] . These observations are consistent with our experience in
which common fi ndings at operation (Figs. 16.3 and 16.4 ) have been an
attenuated external oblique aponeurosis (96.7%), weak inguinal fl oor
(100%), torn internal oblique (63.9%), and rectus abnormalities (80.3%).
Fig. 16.2 Sagittal T2-weighted MRI images with fat suppression just off the
midline sequences that show a tear or disruption in the rectus-adductor complex
at the pubis. The large arrow points to the tendon origin of the adductor longus
(dark structure) as it goes down the thigh. ( a ) Abnormal side which shows a
partial separation of the common aponeurosis formed at the junction of the rectus
muscle and adductor origin from the periosteum of the anteroinferior pubic bone.
R rectus, P pubis. ( b ) Normal side.
186
N. Stoikes and L.M. Brunt
Regardless, the common mechanism is likely a combination of overuse and
imbalance of forces acting across the pelvis [ 13 ] .
Muschawek has also postulated that bulging of the posterior inguinal
fl oor may compress the genital nerve which can produce pain during
Valsalva [ 10 ] . As a result, selective resection of the genital nerve is
performed in some of her athletes [ 14 ] . Finally, some groups have
suggested that defects within the external oblique, which may be coupled
with entrapment and compression of the ilioinguinal and iliohypogastric
nerves, are the primary mechanisms of injury and pain [ 15 ] .
Fig. 16.3. Disrupted
posterior inguinal fl oor in an
athlete undergoing repair of
sports hernia pubalgia. Ext
external oblique, Int internal
oblique. Arrows point to the
weakened posterior fl oor.
Fig. 16.4. Attenuated
external oblique ( large
arrows ) found at operation
for sports hernia pubalgia.
Note the ilioinguinal nerve
exiting a slit in the external
oblique at a sharp angle
( small arrows ) .