Sportsman Hernia Guidelines

Guideline Recommendation for Sportsman Hernia – Diagnosis and Treatment

Surgical Endoscopy and other Interventional techniques (2011): 25: 2834-2843

Moshe Dudai MD FACS, Center for Laparoscopic Surgery, Tel Aviv, Israel

Background

For writing the guideline recommendations for the Sportsman Hernia (SH), a literature search using   PubMed and Medline through the years 1990 – 2008 was done. The code words used: Sportsmen Hernia, Sport Hernia, Athletes Hernia, Athletes Pubalgia, Groin Injury / Treatment, Surgery, Technique, Repair, Surgical finding, Pathology, Diagnosis, Etiology, Results, Complications
A 127 articles were found but only 43 were relevant: 4 – level I of evidence, 4 – level II of evidence, 3 – level III of evidence, 21– level IV of evidence, 2 – level V of evidence and 9 – Systematic Review.

Definition and Differential Diagnosis

The etiology of SH (Sportsman Hernia) exists only three decades or so, and has suffered from change and confusion regarding terms and pathology. It was during the 80's that Gillmor of England came out with a new etiology, Gillmor Groin, for sport injuries in the groin and abdominal muscles area with no indication of hernia. He successfully devised a surgical technique as a treatment based on modifications of the historic Bassini surgery.

Gillmor, as well as others, have realized that the case is one of abdominal wall pathology in the groin area, but it was hard to demonstrate it. The confusion was due to the existence of other pathologies around the Simphisis Pubis. Since those were easier to diagnose, they were all often thrown into 'one bag of pathologies' from a lack of ability to demonstrate the others. With time, especially after the introduction of laparoscopy, an understanding was reached that the problem was at the back part of the abdominal wall in the groin. Due to that, the pathological definition of PWD (Posterior Wall Deficiency) was accepted as equivalent to the pathology of SH, and has been supported by findings.

In recent years, since we are able to distinguish between these two pathology groups, two separate etiologies were crafted to deal with groin and abdominal muscles sport injuries: AP (Athlete Pubalgia) and SH.

The modern pathological definition for AP is Pubic Bone Stress Injury (PBSI ) and includes not only the Pubic Bone itself, but also the muscles and their tendons on both sides of the Simphisis Pubis ( in the past was mistakenly referred to as Osteitis Pubis.) Bone scan was used for diagnosis, but these days MRI allows for clear imaging of the pathologies for diagnosis (table#1). A clinical and imaging diagnosis is crucial since there is no need for surgical intervention. Conservative physiotherapy of Isometric Active Weight-Bearing Exercise will result in complete healing of almost all athletes. It is important to highlight that Adductors Strain is a part of this pathological syndrome and so tenotomy shouldn't be performed under any circumstances.

On the other hand, SH is a different pathology, Posterior Wall Deficiency – PWD, with different clinical manifestations and imaging findings. With anamnesis there are always reports of pain in the groin surfacing during extreme sport activity, usually when no proper buildup of durability was done. It is usual for the pain to subside after physiotherapy, anti-inflammatory treatment, and rest. It is also typical for the pain to re-surface shortly after the athlete has returned to activity.

Performing a deep palpation into the inguinal canal will prove the area to be sensitive, the External Inguinal Rind dilated. When performing a digital exam of the canal a soft bulging can be felt against the tip of the finger, and extreme sensitivity in result of applying pressure with the tip of the finger against the floor of the canal, where the Genito-Femoral N passes. With this
syndrome the nerve goes through entrapment under the IPT (Ileo-Pubic Tract) in the Internal Inguinal Ring area. Also, all the symptoms increase during coughing. The imaging findings and diagnosis is done in High Resolution, Dynamic US (table #1): A bulging of the Transversalis Fascia into the inguinal canal area, demonstrating herniated Pre-Peritoneal Lipoma into the inner Iinguinal ring and canal or the Obturator canal. Evidence of Genito-Femoral N entrapment can be demonstrated by edema behind the IPT on the level of Internal Inguinal ring. In some cases, tears and strain of the Conjoint tendon in its insertion to the Pubis can be demonstrated.

The modern pathological definition for AP is Pubic Bone Stress Injury (PBSI ) and includes not only the Pubic Bone itself, but also the muscles and their tendons on both sides of the Simphisis Pubis ( in the past was mistakenly referred to as Osteitis Pubis.) Bone scan was used for diagnosis, but these days MRI allows for clear imaging of the pathologies for diagnosis (table#1). A clinical and imaging diagnosis is crucial since there is no need for surgical intervention. Conservative physiotherapy of Isometric Active Weight-Bearing Exercise will result in complete healing of almost all athletes. It is important to highlight that Adductors Strain is a part of this pathological syndrome and so tenotomy shouldn't be performed under any circumstances.

On the other hand, SH is a different pathology, Posterior Wall Deficiency – PWD, with different clinical manifestations and imaging findings. With anamnesis there are always reports of pain in the groin surfacing during extreme sport activity, usually when no proper buildup of durability was done. It is usual for the pain to subside after physiotherapy, anti-inflammatory treatment, and rest. It is also typical for the pain to re-surface shortly after the athlete has returned to activity.

Performing a deep palpation into the inguinal canal will prove the area to be sensitive, the External Inguinal Rind dilated. When performing a digital exam of the canal a soft bulging can be felt against the tip of the finger, and extreme sensitivity in result of applying pressure with the tip of the finger against the floor of the canal, where the Genito-Femoral N passes. With this
syndrome the nerve goes through entrapment under the IPT (Ileo-Pubic Tract) in the Internal Inguinal Ring area. Also, all the symptoms increase during coughing. The imaging findings and diagnosis is done in High Resolution, Dynamic US (table #1): A bulging of the Transversalis Fascia into the inguinal canal area, demonstrating herniated Pre-Peritoneal Lipoma into the inner Iinguinal ring and canal or the Obturator canal. Evidence of Genito-Femoral N entrapment can be demonstrated by edema behind the IPT on the level of Internal Inguinal ring. In some cases, tears and strain of the Conjoint tendon in its insertion to the Pubis can be demonstrated.

In some of the athletes bout pathology of SH-PWD and AP-PBSI can coincide simultaneously. In this case AP should be treated firs conservatively by IAWBE and if symptoms persist than SH could be treated by surgery.

The section refers to the more recent manuscript dealings with SH and PWD pathology.

1. Anamnesis

  •  Groin pain starts during extreme sport activity, usually with no
  •  Proper buildup of durability; acceleration, deceleration, rotation
  •  Pain responds to conservative treatment, anti inflammatory
  •  Drugs and  rest
  •  Pain typically recurrs whenever returning to sport activity

Conclusion 2 , Recommendation B         

2.  Examination

  • Sensitivity by deep palpating of inguinal canal area
  • Dilated Ext. Inguinal Ring
  • Digital exam of the canal, a soft bulging can be felt against the tip of the finger
  • Extreme Pain by digital pressure on the canal floor, exaggerated by cough

Conclusion 2 , Recommendation B

3.  Imaging

  • Dynamic US: PWD findings:

                        – Bulging of the Transversalis Fascia into the inguinal canal
area
– Dilated open Internal Inguinal Ring
– Herniated Pre-Peritoneal Lipoma into the Internal Inguinal
ring and canal, Femoral or the Obturator canal
-Evidence of Genito-Femoral N entrapment; edema behind
the IPT on the level of Internal Inguinal ring.
-Tears and strain of the Conjoint tendon in its insertion to the
Pubis
– MRI: PBSI findings negative

Conclusion 1 , Recommendation A

– 3 months or more of inability to perform sport activity
– No evidence of hernia and others pathology
– Failure of two conservative trails
– The athlete has to fit the syndrome criteria and physical exam findings
– Dynamic US support the diagnosis

Conclusion 1 , Recommendation A

 •  Lap.
–  Shorter recovery and return to sport activities,
– less recurrences,
– better approach to the pathology
Conclusion 1 , Recommendation A

   • TEP
–  better approach for bilateral,
– less PO pain
Conclusion 2 , Recommendation B
  

• Bilateral
– mostly the pathology is  bilateral,
– isometric repair of the lower abdomen
Conclusion 2 , Recommendation B

• Dissection:
– From the SP to ASIS
– Adhesiolysis of all adhesions on PW and cord elements
– Dissect free the Internal Ring (IR) and any hernia sac remnant on the cord elements
– Dissect out any PP Lipoma from the Inguinal, Femoral and Obturator canal
– Divide the IPT at the level of the IR and neurolysis the GF N
Conclusion 3 , Recommendation A

• Mesh placement
– 10-13X15cm tailored to the length of the Groin; reduce excess mesh and folding and enhance incorporation
– Light mesh, large porosity: reduce PO pain in heavy sport activities
– Medial fixation to Rectus M, SP and Cooper Lig., not lateral; elude early sport activity and prevent late detachment from the Rectus. M in heavy sport activities

Conclusion 2 , Recommendation B

– JP closed system vacuum drain inserting through the port site for 6-8 hour PO; enhance mesh incorporation and recovery time
Conclusion 4 , Recommendation C

• PO Rehabilitation
– Early ambulation; immediate PO
– 4-5 days PO return to gradual sport activities
– 3 to 4 weeks gradual scale training program to competitive sport activity
Conclusion 2 , Recommendation B

• PO persistence/ recurrence of symptoms
– 5% average
– 2% Lap
Conclusion 4

The etiology and pathology of the SH and PWD become evident and differ from the AP and PBSI, level 2. The history, symptoms and physical findings are repeatable, level 2. Dynamic US made by expert can confirm the diagnosis, level 1. Lap is superior to open surgery, level 1, and TEP over TAPP, level 2, and the pathology has to be treated bilaterally, level 2. The dissection of the groin and mesh placement should take into consideration the specifics pathological findings of SH-PWD and the specific sport needs for the PO curse, level 3. Early mobilization and rapid gradual scale training, level 2, can lead to success rate of 98%, level 4.

Dynamic US made by expert to confirm the diagnosis – grade A. Lap. TEP Bilateral Groin PW repair and reinforcement with detailed reference to the specific SH pathological findings and needs, – grade B.

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