Herniography in athletes with groin pain

In the years 1974 to 1981, herniography was performed in 78 athletes with groin pain. The investigation comprised 101 painful groin sides in 23 athletes with bilateral symptoms. Before herniography, a hernia was palpated in only eight (7.9 percent) groins with pain. Hernias were found at herniography in 84.2 percent of the symptomatic groin sides and in 49.1 percent of the asymptomatic groin sides. Sixty-three hernia operations were performed. The herniographic and operative diagnoses corresponded well. Direct hernias dominated among the operated athletes, and were found in 55.6 percent of those below 30 years of age. Altogether 69.8 percent of the operated patients were cured by hernia repair and another 20.6 percent were improved. Tenoperiostitis of the adductor muscles was the most frequent diagnosis in those not cured by operation and among the nonoperated patients. Herniography was of great value in selecting those patients who needed a repair. A broad differential diagnostic approach when examining these patients is of the utmost importance.     

Bassini's hernial repair and adductor longus tenotomy in the treatment of chronic groin pain in athletes

A prospective study was initiated to evaluate the surgical treatment of chronic groin pain resistant to conservative treatment. Forty-one patients were treated using Bassini's hernial repair and percutaneous adductor longus tenotomy between 1984 and 1998. All patients were males aged 17 to 34 years and were mainly soccer players. Twenty-seven patients underwent a unilateral and 14 a bilateral procedure. All patients had resumed their sporting activities on average 6.9 months after surgery (range 6 to 15 months). Thirty-seven performed at the same level and 4 at a reduced level. Only one patient performed at a lower level due to persistent groin pain. We conclude that, when conservative treatment for pubic pain in athletes fails, a combination of hernial surgery and adductor longus tenotomy can provide successful results.     

Surgical treatment of chronic groin pain in athletes

Purpose

Conservative treatment of chronic groin pain is prolonged and recurrence is quite common. Coexistence of sports hernia and adductor tendinitis/tendinosis in a single patient is noted in the literature. In our study we evaluated our operative treatment that should enable pain elimination and fast return to sports activities.

Methods

We performed a prospective study over a six-year period. Ninety-nine (99) patients, all male, with chronic groin pain, resistant to conservative treatment, underwent a surgical procedure.

Results

Seventy athletes with sports hernia returned to sports in an average 4.23 weeks (range three–16). Adductor tendinosis symptoms were present in 24 patients (2 %) with sports hernia. Twenty-four patients that had an additional adductor tenotomy performed returned to sports in an average 11.6 weeks (range ten–15). Five patients with isolated adductor tendinosis (7 %) returned to sports in an average 13.4 weeks (range 12–16). All athletes except two (2.8 %) treated for sports hernia were satisfied with the results of treatment and could continue their previous level of activity.

Conclusion

Any surgical procedure used for treating chronic groin pain should address the common causes of pain in this region. Adductor tendinosis can be present in up to 24.2 % of cases with sports hernia or may be isolated in 7 % of cases with chronic groin pain and must be treated by tenotomy. Resection of the genital branch of genitofemoral nerve and ilioinguinal nerve neurolysis should also be performed in patients with sports hernia.     

Successful endoscopic treatment of chronic groin pain in athletes

Background Chronic groin pain, especially in professional sportsmen, is a difficult clinical problem. Methods From January 1999 to August 2005, 55 professional and semiprofessional sportsmen (53 males; mean age, 25 ± 4.5 years; range, 17–36 years) with undiagnosed chronic groin pain were followed prospectively. All the patients underwent an endoscopic total extraperitoneal (TEP) mesh placement. Results Incipient hernia was diagnosed in the study athletes: 15 on the right side (27%), 12 on the left side (22%), and 9 bilaterally (16%). In 20 patients (36%), an inguinal hernia was found: 3 direct inguinal hernias (5%) and 17 indirect hernias (31%). All the athletes returned to their normal sports level within 3 months after the operation. Conclusions A TEP repair must be proposed to patients with prolonged groin pain unresponsive to conservative treatment. If no clear pathology is identified, reinforcement of the wall using a mesh offers good clinical results for athletes with idiopathic groin pain.     

Laparoscopic repair for groin hernias

So where do things stand in 2003? Laparoscopic herniorrhaphy appears to result in less postoperative pain (acute and chronic) and in a shorter convalescence and an earlier return to work, compared with the open repair. It can be performed safely and with a low recurrence rate. However, it takes longer to do, is more difficult to learn, and costs more, all reasons why it is not more commonly performed. Currently, laparoscopic herniorrhaphy accounts for 15% to 20% of hernia operations in America and around the world. Who can blame the surgeon in a community practice for opting for the open mesh repair, operating on familiar anatomy, and using familiar techniques? Nevertheless, with efforts to cut costs by eliminating disposable equipment and honing skills to decrease operating time, laparoscopic herniorrhaphy will probably continue to be a contender, especially for the younger patient who wants to return to work quickly and for patients with bilateral and recurrent hernias. It is arguable that surgeons should possess skill in both open and laparoscopic techniques and should know the indications for each--some hernias are best repaired laparoscopically. That said, laparoscopic herniorrhaphy will most likely be performed by those with a special interest and proficiency in the technique. At the least, the laparoscopic revolution and laparoscopic hernia repair have helped elevate the study of hernia anatomy and herniorrhaphy to a position it deserves and this has made us all better hernia surgeons. What was once the stepchild of general surgery now occupies a more prominent and respectable place. With the continuing efforts of dedicated, energetic investigators, we should continue to see advances in the safe and effective repair of this most common of surgical maladies.     

Litigation following groin hernia repair in England

Purpose

Since 1995, litigation following surgical procedures has cost the National Health Service (NHS) over 1.3 billion GBP (Great British Pounds)/2.1 billion USD (United States Dollars)/1.4 billion Euros. Despite it being the most commonly undertaken general surgical operation, no study has examined clinical negligence claims in England following groin hernia repairs.

Methods

Data from the NHS Litigation Authority of all claims made from 1995 to 2009 was obtained and interrogated.

Results

In total, 398 claims were made. Of these, 209 cases had been settled, of which 144 (46.6%) were in favour of the claimant to a cost of 7.35 million GBP/12 million USD/7.93 million Euros. Testicular injury and chronic pain featured in 40% of all claims. Visceral injuries and injuries requiring corrective procedures were the only predictors of a successful claim (P = 0.015 and P = 0.002, respectively). Claims associated with visceral and vascular injuries were more likely to occur in laparoscopic than in open repairs. Sexual dysfunction and chronic pain resulted in the highest average payouts of 85,467 GBP/140,565 USD/92,177 Euros and 81,288 GBP/133,693 USD/87,674 Euros, respectively.

Conclusion

Patients should be fully informed of the incidence of testicular injury and chronic pain during the consent process. Approaches minimising visceral and vascular injury particularly in laparoscopic repair should be adopted to reduce litigation and improve patient care.     

The Lichtenstein repair for groin hernias

The Lichtenstein tension-free mesh repair opened a new era in groin hernia repair. Without the risk of serious morbidity, it is now readily performed using local anesthesia in patients previously considered unsuitable for surgery. Fears of serious complications related to mesh implantation have proved to be without foundation. As a local anesthetic day care technique without the need for complex and expensive instrumentation, overall costs can be kept to a minimum without compromising the safety or the long-term success of the procedure. It is a straightforward technique to learn, with high patient acceptability and an exceedingly low recurrence rate. At present it must be considered the gold standard of groin hernia repair.     

The Shouldice repair for groin hernias

The Shouldice pure tissue repair for groin hernias, a tested and proven procedure, continues to provide great patient satisfaction. The complete dissection lends itself to the discovery of secondary hernias. The procedure is designed so that these secondary defects are easily incorporated into the repair. Mesh is employed infrequently, only in those cases where there is a lack of tissue or scarring has minimized flexibility. Performed under local anesthetic, complications are minimal and early return to work is a feature. With a more than 50-year history of thousands of successful operations annually, the Shouldice procedure should continue to merit consideration by all surgeons striving for excellence in hernia repair.     

The Kugel repair for groin hernias

The Kugel repair is a minimally invasive but nonlaparoscopic preperitoneal hernia repair. It has certain advantages over other repairs, but will require a little additional effort initially to learn the repair and the associated anatomy encountered in this approach. This anatomy has not, historically, been well taught in medical schools. This repair is an attempt to achieve the fastest recovery possible after groin hernia surgery while assuring a very low risk of recurrence.     

Prosthetic repair in the treatment of groin hernias

Prosthetic repairs are an important development in herniology because of their excellent results. Reinforcement or replacement of the fascia transversalis is performed by interposition of a synthetic mesh between muscles and peritoneum aiming at the restoration of the tightness of the abdominal wall against the intra-abdominal pressure. All synthetic materials are not equally appropriate; Marlex mesh has been used exclusively in this report. The midline preperitoneal way allows the placement of large bilateral prostheses kept in place by intra-abdominal pressure; they need not be fixed nor associated with any suturing of the hernial hole. This is a very easy operation even in multirecurrent hernias. Because of the more disagreeable septic accidents after prosthetic repair, an important question is related to its indications, which must be selective. Randomized studies, comparing diverse techniques, are unlikely to lead to an exclusive choice because hernias are polymorphous lesions and also because of the time lag-factor and suturing must be followed up for 20 years. In socioeconomic terms, a prosthesis is the most appropriate treatment for hernias liable to recur. Nowadays it is impossible to reject the remarkable possibilities offered by prostheses in hernial surgery after the developments of the past 20 years.     

成人腹股沟疝开放无张力修补治疗87例体会

目的探讨成人腹股沟疝开放无张力修补方法的选择。方法根据Gilbert疝分级对成人腹股沟疝进行分型。对Gilbert疝分级Ⅰ型、Ⅱ型成人腹股沟疝共41例采用平片修补法进行修补,对Gilbert分级Ⅲ～Ⅶ型的成人腹股沟疝共46例采用腹膜前铺网进行修补。结果采用平片修补法41例平均手术时间（63．7±9．5）min,平均住院时间（5．6±2．9）d,术后尿潴留2例,切口血肿2例,术后疼痛2例。采用腹膜前铺网法46例,平均手术时间（52．4±8．3）min,平均住院时间（5．3±2．7）d,术后尿潴留4例,腹壁血肿1例。无疝复发病例。结论根据不同类型疝采用不同的无张力疝修补方法,可以降低疝复发及减少并发症。     

Recent advances in the repair of groin herniation

There have been several recent advances in the repair of groin herniation. Perhaps the greatest has been the eclipse of pure tissue repairs by tension-free hernioplasties, which are performed open or laparoscopically. Two ″right” ways have emerged. Preperitoneal prosthetic covering of Fruchaud's myopectineal orifice, from above or below is one. A subaponeurotic prosthetic keyhole, tightened to restore the musculofascial shutter mechanisms of the intermediate and compress the internal inguinal rings, while, medially, reinforcing the transversalis fascia is the other. This latter technique, with or without a preperitoneal plug, is now the gold standard worldwide.Modern prosthetic meshes incorporate rapidly, are well tolerated, and resist infection, even after strangulation. Their widespread adoption has been accelerated by the perceived need to resist wound tension. Furthermore, we now realize that muscle atrophy and damage to connective tissue, which are acquired by smoking or other insults to genetic expression, not only cause groin herniation but also interfere with its repair. Happily, these new concepts have reduced the main ″bugaboo,” recurrence, significantly. Other patient concerns therefore have received much needed attention. These include pain, rehabilitation, cost, education, and continuing access countrywide to the latest advances in care. Other ″minor” issues are also being examined. Ambulatory surgery, wherever possible with the use of local anesthesia, is the latest paragon, especially for elderly patients who now account for more than one half of the patients who are treated.[92]     

Lichtenstein repair for incarcerated groin hernias.

OBJECTIVE: To evaluate the use of Lichtenstein tension-free repair for incarcerated groin hernias. DESIGN: Prospective consecutive series. SETTING: Tertiary academic surgery department, Poland. SUBJECTS: 27 patients whose incarcerated groin hernias were operated on between November 1997 and June 2001. INTERVENTION: Tension-free hernia repair by the Lichtenstein technique. MAIN OUTCOME MEASURES: Morbidity, recurrence rates and mortality. RESULTS: There were 2 postoperative deaths unrelated to implantation of the mesh (myocardial and cerebral infarction). In 1 patient a subcutaneous fluid collection was noted and was successfully treated by evacuation of the fluid. The remaining 24 patients had no complications during follow-up (mean 18 months, range 2-42 months). CONCLUSION: Monofilament polypropylene mesh can be successfully used not only in elective operations, but also in emergency operations for incarcerated inguinal hernias.     

The PerFix plug repair for groin hernias

Since the mid-1990s, the PerFix plug hernioplasty has become one of the mainstays of a surgeon's operative armamentarium. The repair is a technically simple surgical operation, which can be used to treat most groin hernias. To demonstrate the simplicity and effectiveness of the plug technique, a 15-year experience with over 4400 patients is reported. Technical details are presented, including an in-depth discussion concerning PerFix plug preparation and placement.