Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1498_Библиотеки_им_академика_М_И_Перельмана.pdf
187
16. Athletic Groin Pain and Sports Hernia
Likely, there is no one mechanism that leads to sports hernia pubalgia,
and a combination of these mechanisms, which all focus on different
aspects of the physiology and anatomy of the groin, is grounded in the
fundamental principle that high-performance athletes stress their bodies
to maximum levels, which results in the accentuation of dynamic processes
in the lower body, thereby, stressing inherently weak regions such as the
groin. Factors which could impact the development of this condition but
which are as yet unproven might include the following: increased weight/
strength training, year-round training with no time off, single-sport focus
at a young age, and lack of strength and balance in the abdominal core.
Management Options
In the early phase of the clinical presentation, rest and other standard
conservative management measures as described below are indicated. In
selected cases, a combination of steroid and local anesthetic injection
can provide some symptomatic relief and may facilitate a return to play
or assist in differentiating the source of the pain. It is also important to
note the scope of the problem for the patient, which may also impact the
management approach. For example, the aggressiveness of the approach
and progression to surgical intervention may be different for a recreational
athlete versus a scholarship college athlete or professional athlete. In a
sense, the latter’s livelihood depends upon a quick return to top
performance, which thereby makes the risk to bene fi t ratio for surgery
more acceptable. Also, the recreational athlete does not have access to
professional trainers and other resources, which can lead to a delay in the
diagnosis and a prolonged time period in which the patient is neither
resting nor able to resume full athletic activity.
In all cases, fi rst-line management of an athletic groin injury should
be conservative with rest. Activities that produce symptoms, especially
explosive or torquing maneuvers, are to be avoided. Nonsteroidal anti-
in fl ammatory medications, ice, and physiotherapy should be incorporated
into the regimen as well. Light lower body activities such as jogging or
stationary biking can begin as symptoms improve, and sports-speci fi c
activities can be added in an incremental fashion. Explosive maneuvers
and intense gamelike conditions should be delayed until full lower
abdominal and lower body exercises can be performed. If conservative
measures have failed after 8–10 weeks, and the clinical presentation
suggests a more chronic sports hernia type pubalgia, then surgical
intervention should be considered.
188
N. Stoikes and L.M. Brunt
Surgical Technique
There is no consensus on the preferred surgical technique for the
treatment of sports hernia. The techniques reported can be broadly
grouped: open primary tissue repair, open tension-free mesh reinforcement,
and laparoscopic mesh repair. Adjuncts to these procedures include
neurectomy and adductor tendon release.
1 . Open primary repairs
(a) Meyer’s technique : Goals of this technique include
realigning the infero-lateral rectus to the pubis and inguinal
ligament using a primary sutured repair.
(b) Muschawek technique : This approach is also known as the
“minimal repair” technique [
13, 14 ] . It involves repair of
the posterior inguinal fl oor using two sequential imbricating
running sutures. The genital nerve is resected in select
cases, and the internal ring is buttressed with a cuff of
internal oblique muscle.
2 . Open tension-free mesh repair : This is the preferred approach
by the authors and utilizes the principles of the Lichtenstein
tension-free hernioplasty. The primary goal is to reinforce the
posterior inguinal fl oor rather than to reconstruct the internal
inguinal ring as one would do for an indirect hernia. Technical
points include resection of the ilioinguinal nerve if it is entrapped
by within a slit in the external oblique aponeurosis or if it will
be tethered by the mesh. Damaged internal oblique/tranversus
abdominis muscle fi bers are debrided as needed. Lightweight
polypropylene mesh is secured with nonabsorbable sutures to
the inguinal ligament laterally and to the transversus abdominis/
conjoined tendon medially (Fig.
16.5 ). The mesh is split, and
the tails are secured around the cord structures in a standard
fashion. Importantly, additional interrupted sutures are placed
medially to anchor the mesh to the distal rectus to further
stabilize the rectus and pubis. The external oblique aponeurosis
is reapproximated with absorbable suture such that the
attenuated portion is excluded. The Montreal group [ 16 ] also
uses a tension-free mesh approach but places the mesh just
beneath the external oblique aponeurosis rather than on the
posterior fl oor, and in most cases, ilioinguinal and/or
iliohypogastric neurectomy is also performed.
189
16. Athletic Groin Pain and Sports Hernia
3 . Laparoscopic mesh repair : Laparoscopic mesh repair is favored
by some groups [ 17– 19 ] . This approach also provides support
for the weakened posterior inguinal fl oor (Fig. 16.6 ) but
anecdotally has been associated with a somewhat higher rate of
incomplete relief of symptoms, although good results have been
reported in several case series. The advantage is that it may
allow faster return to play compared to some other approaches.
It is typically done via the totally extraperitoneal approach.
Adjunct procedures : An adductor release as described by Meyers [ 20 ]
entails releasing the epimysial fi bers of the adductor longus approxi-
mately 2–3 cm from its attachment to the pubis. The actual tendon is
not transected but instead “decompressed” with relaxing incisions to
soften the adductor compartment and to relieve it of pressure, tension,
and edema.
Fig. 16.5. Sutures anchoring
the medial side of the repair
of the right inguinal fl oor.
The sutures are placed in a
mattress fashion through
lightweight tension-free
polypropylene mesh.
Fig. 16.6. Posterior
laparoscopic view of
weakened posterior inguinal
fl oor ( arrows ) .
190
N. Stoikes and L.M. Brunt
Surgical Outcomes
Outcomes of surgical management are listed in Table 16.2 . Overall
results in terms of return to full athletic activity range from 60% to 90%,
with most series reporting greater than 90% of patients returning to their
sport. Follow-up is variable and not reported in some instances. Also, the
interval return to play is variable or not reported, which may be multifactorial
secondary to both the procedure and varied time pressures for rehabilitation
(in season vs. off-season). In the Washington University Medical Center
experience, we have done repairs is over 150 elite and recreational athletes
[ 21 ] . The majority (63%) were professional or college athletes. Follow-up
regarding symptoms at 13.6 months found successful return to sport in
91% of athletes. Initially, adductor release was not a part of the management
algorithm, and, as a result, fi ve athletes have subsequently required
adductor releases for recalcitrant adductor symptoms. Currently, adductor
release as described by Meyers [ 20 ] is done in selected patients that have
signi fi cant adductor pathology at the time of inguinal fl oor reinforcement.
Postoperative Care and Rehabilitation
Operative repair of a sports hernia/athletic pubalgia is only one
component to the treatment of the disease process and, equally important
in the athlete’s full return to competition, in our view, is the use of a
Table 16.2. Reported outcomes of repair of sports hernia pubalgia.
Author Type repair
No. of
cases
Length of
follow-up
Return
to sport
Polglase [
23 ] Primary 64 8 months 63%
Gilmore [
24 ] Primary 300 – 97%
Steele [
25 ] Primary 47 – 77%
Meyers [
20 ] Primary “pelvic fl oor
repair”
5,218 24 months 95.3%
Muschawek [
14 ] Primary “minimal repair” 129 –
Joesting [
26 ] Open mesh 45 12 months 90%
Brown [
26 ] Open mesh 98 – 97%
Brunt [
22 ] Open mesh 132 13.6 months 91%
Van Veen [
18 ] Laparoscopic mesh 55 24 weeks 91%
Ziprin [
19 ] Laparoscopic mesh 17 – 94%
Evan [
27 ] Laparoscopic mesh 287 3 months–4 years 90%
Paajanen [
28 ] Laparoscopic mesh 30 3 months 90%
191
16. Athletic Groin Pain and Sports Hernia
structured postoperative rehabilitation program. The program that we
have utilized consists of a set of exercises that focus on strengthening the
core and lower body (Table 16.3 ) [ 22 ] . Attention to adductor fl exibility
and strength is essential and involves an incremental increase in activity
over a period of 5–8 weeks ( fi ve phases).
Summary
Sports hernia/athletic pubalgia is a complex entity that requires a
systematic approach to the diagnostic evaluation and treatment. Surgeons
who treat these athletes must understand the broader differential diagnosis
Table 16.3. Postoperative rehabilitation program after sports hernia repair.
Phase 1 week 1
Walking, starting with short distances, and progressing up to 45–60-min walks once
per day
Light stretching (hamstring, quadriceps, calf and low back as tolerated)
Phase 2 week 2
Active hip range of motion exercises
Walking on inclined treadmill, backward walking
Begin bike workouts with slow continuous progression to interval sprint work
Wall sits with Swiss ball
Phase 3 week 3
Continue exercises from phase 2
Active release technique/deep tissue massage of hip and leg musculature
Pool walking
Monitored sports-speci fi c skill development activities
Phase 4 week 4
Continue exercises from phase 3
Advance hip fl exor stretching with progression into resistance strengthening,
progressive resistive exercises
Lower abdominal strengthening and lower extremity strengthening exercises to
include body weight squats, step-ups, etc.
Begin increasing sport-speci fi c activities (more intense skating, running sprints,
limited contact drills)
Phase 5 weeks 5–6
Continue exercises from phase 4
Transition to weight room and strength and conditioning program
Full practice, scrimmage with team
End-stage exercises with an emphasis on maintaining proper muscles length and
abdominal strength through adherence of a core stabilization program
For a more detailed description of rehab exercises, see [
22 ]
192
N. Stoikes and L.M. Brunt
of groin pain in athletes and the fact that this is not a true inguinal hernia.
Treatment is based on a spectrum of management options that requires a
multidisciplinary approach, and careful patient selection for surgery is a
key component of the management algorithm. Multiple surgical
techniques exist that may achieve a successful outcome, and regardless
of the approach, the rehabilitation after surgery is integral to return of the
athlete to competition.
References
1. Ekstrand J, Hilding J. The incidence and differential diagnosis of acute groin injuries
in male soccer players. Scand J Med Sci Sports. 1999;9:98–103.
2. Pettersson R, Lorenzton R. Ice hockey injuries: a 4 year prospective study of a Swedish
elite ice hockey team. Br J Sports Med. 1993;27:251–4.
3. Stuart MJ, Smith A. Injuries in Junior A ice hockey: a 3 year prospective study. Am J
Sports Med. 1995;23:458–61.
4. Emery C, Meeuwisse W. Risk factors for groin injuries in hockey. Med Sci Sports
Exerc. 2001;33:1423–33.
5. Tyler T, Nicholas S, Campbell R, McHugh M. The association of hip strength and
fl exibility with the incidence of adductor muscle strains in professional ice hockey
players. Am J Sports Med. 2001;29:124–8.
6. Brunt L, Quasebarth M, Bradshaw J, Barile R. Outcomes of a standardized approach
to surgical repair and postoperative rehabilitation of athletic hernia. AOSSM Annual
Meeting 2007:Calgary 2007.
7. Nam A, Brody F. Management and therapy for sports hernia. J Am Coll Surg.
2008;206:154–64.
8. Anderson K, Strickland AM, Warren R. Hip and groin injuries in athletes. Am J Sports
Med. 2001;29:521–33.
9. Caudill P, Nyland J, Smith C, Yerasimides J, Lach J. Sports hernias: a systematic
literature review. Br J Sports Med. 2008;42:954–64.
10. Muschawek U, Berger LM. Sportsmen’s groin - diagnostic approach and treatment
with the minimal repair technique. Sports Health. 2010;2:216–21.
11. Meyers WC, Yoo E, Devon ON, et al. Understanding “sports hernia” (athletic
pubalgia): the anatomic and pathophysiologic basis for abdominal and groin pain in
athletes. Oper Tech Sports Med. 2007;15:165–77.
12. Meyers WC, Greenleaf R, Saad A. Anatomic basis for evaluation of abdominal and
groin pain in athletes. Oper Tech Sports Med. 2005;13:55–61.
13. Minnich JM, Hanks JB, Muschawek U, Brunt LM, Diduch DR. Sports hernia:
diagnosis and treatment highlighting a minimal repair technique. Am J Sports Med.
2011;39:1341–9.
14. Muschawek U, Berger L. Minimal repair technique of sportsmen’s groin: an innovative
open-suture repair to treat chronic groin pain. Hernia. 2010;14:27–33.
193
16. Athletic Groin Pain and Sports Hernia
15. Irshad K, Feldman L, Lavoie C, Lacroix V, Mulder D, Brown R. Operative management
of “hockey groin syndrome”: 12 years experience in national hockey league players.
Surgery. 2001;130:759–66.
16. Brown R, Mascia A, Kinnear DG, Lacroix VJ, Feldman L, Mulder DS. An 18 year
review of sports groin injuries in the elite hockey player: clinical presentation, new
diagnostic imaging, treatment, and results. Clin J Sport Med. 2008;2008:221–6.
17. Paajanen H, Syvähuoko I, Airo I. Totally extraperitoneal endoscopic (TEP) treatment
of sportsman’s hernia. Surg Laparosc Endosc Percutan Tech. 2004;14:215–8.
18. van Veen RN, de Baat P, Heijboer MP, et al. Successful endoscopic treatment of
chronic groin pain in athletes. Surg Endosc. 2007;21:189–93.
19. Ziprin P, Prabhudesai DG, Abrahams S, Chadwick SJ. Transabdominal preperitoneal
laparoscopic approach for the treatment of sportsman’s hernia. J Laparoendosc Adv
Surg Tech A. 2008;18:669–772.
20. Meyers WC, McKechnie A, Philippon MJ, Homer MA, Zoga AC, Devon ON.
Experience with “sports hernia” spanning two decades. Ann Surg. 2008;248:656–65.
21. Brunt LM. Management of sports hernia and athletic pubalgia. In: Kingsnorth A,
LeBlanc K, editors. Management of abdominal wall hernias. New York: Springer;
2012 (in press).
22. Brunt LM, Barile R. My approach to athletic pubalgia. In: Byrd TW, ed. Operative Hip
Arthroscopy. 3rd ed: Springer; 2012; pp. 57–67.
23. Polglase AL, Frydman GM, Farmer KC. Inguinal surgery for debilitating chronic
groin pain in athletes. Med J Aust. 1991;155:674–7.
24. Gilmore J. Groin pain in the soccer athlete: fact, fi ction, treatment. Clin Sports Med.
1998;17:787–92.
25. Steele P, Annear P, Grove JR. Surgery for posterior inguinal wall de fi ciency in athletes.
J Sci Med Sport. 2004;7:415–21.
26. Joesting DR. Diagnosis and treatment of sportsman’s hernia. Curr Sports Med Rep.
2002;1:121–4.
27. Evans DS. Laparoscopic transabdominal pre-peritoneal (TAPP) repair of groin hernia:
one surgeons’s experience of a developing technique. Ann R Coll Surg Engl.
2002;84:393–8.
28. Paajanen H, Brinck T, Hermunen H, Airo H. Laparoscopic surgery for chronic groin
pain in athletes is more effective than nonoperative treatment: a randomized clinical
trial with magnetic resonance imaging of 60 patients with sportsman’s hernia (athletic
pubalgia). Surgery. 2011;150:99–107.
Part IV
Current Debates in Inguinal
Hernia Repair
197
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_17,
© Springer Science+Business Media New York 2013
17. TAPP vs. TEP
Alfredo M. Carbonell II
The two most common techniques for laparoscopic inguinal hernia
repair are the transabdominal preperitoneal (TAPP) technique and the
totally extraperitoneal (TEP) technique. Although in the end both techniques
are used to place mesh in the preperitoneal space to cover the entire
myopectineal ori fi ce, they differ in how access to that space is obtained.
With the TAPP approach, the peritoneal cavity is entered, the peri-
toneum is incised horizontally, and the preperitoneal space is developed,
gaining access to the space of Retzius and Bogros. Mesh is placed to
cover the entire myopectineal ori fi ce, and the peritoneal fl ap is then
closed with either suture, staples, or tacks. Conversely, with the TEP
repair, a dissecting balloon is placed into the preperitoneal space at the
level of the umbilicus. The balloon is in fl ated, which potentiates the
preperitoneal space. The surgeon then works within the con fi nes of this
space to place the mesh, similar to the TAPP approach. At the conclusion,
the preperitoneal space is desuf fl ated and it collapses upon itself.
The Arguments for TAPP or TEP
Since, ultimately, the hernia recurrence rates are the same, the debate
as to which approach is best is largely predicated upon notions of
differences in cost, operative time, intraoperative complications, and
postoperative pain. There have been three prospective, randomized,
controlled trials comparing TAPP and TEP; thus, the majority of the data
are from prospective, nonrandomized, comparative trials of the two
techniques. The following section will explore some of the arguments
made in favor of one technique or the other and investigate what the
available literature shows.
198
A.M. Carbonell II
Learning Curve
Argument: TAPP Is Easier to Learn than TEP
The learning curve for any surgical procedure is surgeon speci fi c.
Historically, most have learned the TAPP technique fi rst, and then
transitioned to the TEP repair after some experience. In one study of
TAPP repairs, complications and recurrences decreased after the fi rst 50
patients [
1 ] . Another group performing TEP saw their complication and
recurrence rate drop dramatically after their fi rst 100 cases, while their
conversion rate only decreased after 700 cases, and operative times were
halved after the fi rst 1,000 cases [ 2 ] . If we assume that operative time is
a surrogate marker for technical mastery, a Cochrane database review
summarized that inexperienced operators (up to 20 procedures) had an
operative time of 70 min for TAPP and 95 for TEP. With experience
(30–100 procedures), the estimated duration was 40 min for TAPP and
55 min for TEP [ 3 ] . These data suggest that TAPP is in fact easier to
learn. Perhaps, this is due to the fact that the surgeon has a much wider
fi eld of view during TAPP and can see both inside the preperitoneal and
intraperitoneal space maintaining orientation. This may allow for easier
manipulation of the hernia sac and the intraperitoneal contents, compared
to the tight working space and trocar con fi guration constraints of the
TEP repair.
Operative Time
Argument: TEP is quicker to perform since the balloon
dissector does the dissection, and in the end, there is no
peritoneal fl ap requiring closure.
In an early randomized controlled trial of TEP ( n = 24) versus TAPP
( n = 28), there was an insigni fi cant 6-min time advantage in favor of TAPP
[ 4 ] . Other nonrandomized studies appear to show a slight time advantage
in favor of the TAPP repair as well [ 3 ] . Two more recent prospective trials
did not demonstrate a time difference whatsoever [ 5, 6 ] .
Conversion
Argument: TEP often requires conversion to TAPP.
Due to the nature of the techniques, a TEP is typically converted to
TAPP or open, while a TAPP is converted to open. Conversion with TEP
will occur when too large a tear is created in the peritoneum and in TAPP
when there is an inability to adequately develop or prepare the preperitoneal
space for mesh placement. Patients with prior preperitoneal space surgery,