Dr. Ulrike Muschaweck

The Sportsmen´s Groin – Diagnostics & Therapy

The Minimal Repair Technique

Financial Disclosures

nothing to declare

Expert-Panel

6 experts 6 definitions 6 diagnoses 6 therapies

What are we talking about?

?Causes of groin pain in athletes are numerous

Sport hernia is one of the least understood poorly defined and under-researched maladies to affect the human body. The media has popularized the use of this diagnostic term, but the actual injury characteristics are poorly defined. Sports hernia reflects a compilation of diagnosis grouped together with a wide range of other pathologies that need to be excluded before this should be considered a diagnosis. (Nam A; Brody F. Management and therapy of sports hernia. AmCollSurg 2008)diagnosis of exclusion!?

diagnosis of exclusion!?

Sports hernia has been described as a common diagnosis in otherwise unexplained chronic groin pain (Farber AJ. Wilckens JH. Sports hernia: Diagnosis and therapeutic approach. J Am Acad Surg 2007)

attempted explanation…

Consensus summaryInguinal Disruption is a condition recognised by groin pain and is commonly seen in very active sports persons. It can be defined as pain in the inguinal region near the pubic tubercle, which may have an insidious or acute onset and where no obvious other pathology exists to explain the symptoms.

Br J Sports Med 2013

preferred terminology should be

Inguinal Disruption (ID)

diagnosis of exclusion?

Inguinal Disruption??

Pathology

What is a sportsmen‘s groin?

Weakness of the posterior wall of the inguinal canal (transversal fascia)

causes localized bulging

compresses an afferent nerve (genital branch of the genito-femoral nerve)

„Blue Line“ - thegenital branch ofthe genito-femoralnerve

Weakness of the posterior wall

It is not a hernia!

Pathology

Morphological findings of the genital branch

PathologyMorphological findings

Pathology

Cranial and medial displacement of the rectus abdominis muscle

Increasing tension at the pubic bone (Os pubis)

Pubalgia

Diagnosis

• Dull, sharp or burning pain • Radiation into inner upper thigh

(adductors), scrotum and/or lower back and pubic bone

Typical sign of a nerve irritation (genital branch of the genito-femoral nerve)

We need to listen to our patients!

Diagnosis

Clinical Examination

• A palpable bulge of the posterior wall of the inguinal canal and a dilatation of the internal inguinal ring (peritoneal protrusion) can be detected during “Valsalva-Maneuver” “Valsalva-Maneuver” by a skilled examiner.

• painful when exerting pressure on the posterior wall (transversal fascia)

We need to examine our patients!

Diagnosis

Imaging• Static and dynamic Ultrasound with a high-

frequency transducer 5-13 MHz- a distinct protrusion of the transverse fascia

during “Valsalva-Maneuver” “Valsalva-Maneuver” can be detected with experience- the size of the circumscribed weakness in

the area of the posterior wall can be measured

• MRI not significant (recumbent position)

We need verifiable parameters!

Diagnosis (Ultrasound)

Weakness of the posterior wall of the inguinal canal

Diagnosis (Dynamic US)

Treatment consideration

Primum nihil nocere - above all do not harm

Conservative Treatment

High dosages of NSAIDs (combined with B vitamins)

However: following diagnosis only a 4-6 week time frame remains for conservative treatment:

Otherwise there is an increased risk of subsequent chronic inguinal pain

Surgical Options

Mesh-free techniques

Gilmore TechniqueBassiniShouldiceMinimal Repair

Mesh techniques

LichtensteinTIPPPlug&PatchUHS/PHSMIC (TAPP/TEP)Combination with

- inguinal ligament tenotomy- adductor release tenotomy- ligament shaving

Surgical Results

Open mesh free (n = 226) 89 daysOpen mesh (n = 42) 100 days

TAPP/TEP (n = 472) 92 days

Return to normal activity:

What can happen.. after UHS

• Professional Goal keeper with groin pain• UHS-Repair 8/2011• „no lateral hernia sac detected during operation“• Post-operative chronic pain syndrome• Surgical revision and thermic denervation of N. ilioinguinalis and R.femoralis

11/2011 without any effect

What can happen….. after TAPP

• Professional football striker with groin pain • Minimal invasive surgery with TAPP and large pore mesh 2012• Persisting pain after operation

What can happen….. after Lichtenstein

• Professional football player with groin pain • Open repair with Lichtenstein and large pore mesh 2013• Persisting pain directly after surgery• Conservative pain treatment for 6 month

Is mesh repair the solution?

3D-MRI-Reconstruction

What does the patient want

no recurrence no pain no foreign material (if possible) no sick leave no general anaesthesia no hospital stay no negative long term effects no complications … and if, please treatable!

Selection of the Method

Criteria: - no hernia sack - but: distinct protrusion (bulge) of the

transverse fascia during “Valsalva-Maneuver”

- compression of an afferent nerve

Search for a procedure without the risk of mesh induced complications taking the

pathology of sportsmen`s groin into account

Hernia Centre Munich London

Surgery in local anaesthesia Admission in the morning/ Discharge in the

evening of the day of surgery

Development of a new technique for professional athletes -“Minimal Repair”- in 2002

Surgical Goals:

• Goal 1: Reducing pain quickly

• Goal 2: Retaining the slide bearing function of the abdominal wall

• Goal 3: Rapid return of exercise tolerance and peak performance for top athletes

Minimal Repair

Local Anaesthesia

1. Initial block ventral/cranial of the anterior iliac spine

2. Ropivacain 7,5 mg/ml 20–30 ml

3. Injection in the area of planned incision with Ropivacain 7,5 mg/ml 10ml

4. Intraoperative re-injection in the ilio-inguinal nerve and the genital branch of the genito-femoral nerve

• Only the defect is opened (sound tissue remains intact)

• Contains only preperitoneal fat, no hernia sack

• If necessary resection of the genital branch of the genito-femoral nerve

Surgical Steps

• Stabilizing the posterior wall

• Reducing the tension of the rectus abdominis muscle

• Suture line over the pubic bone

Surgical Steps

• Creating a muscular

collar to protect the

preserved nerve and

the plexus

pampiniformis

Surgical Steps

Postoperative Training Ability

• Weight lifting directly after surgery• Training (running, biking) is resumed as early as

post-operative day (POD) 2

• Beginning of training POD 3 - 4• Complete training possible for athletes, including

kicking and sprinting on POD 5 • Peak performance achieved between POD 10

and 14

„DO WHAT YOU WANT TO DO!!!!“

With the Minimal Repair technique, we observed neither minor nor major complications during a follow-up of 30 days.In 87 professional athletes repairs the time to return to pre-injury sports activity levels amounted to 14 days

This study shows that the Minimal Repair technique allows an excellent relief of groin pain with fast recovery to full sporting activities.

early results

Long-term results5 year follow–up after Minimal Repair in professional atheletes

Questionnaire and/or telephone interview

- still active athelete?

- did any symptoms return?

- pain score (NAS)

- pain quality/ intensity/ character?

- any need for medication for groin pain?

- limitation of performance?

- sensitivity of the groin/ numbness?

- was another operation performed?

- overall satisfaction?

Long-term results5 year follow–up after Minimal Repair in professional athelets

n = 65 hernia-repairs = 75% follow-up ratemedian age: 29 years (range 27-33y)median follow-up: 5.5 y

95,4%

4.6%

Nerve resection-R.genitalis 28%

preliminary results

Conclusion

Pathologies in the groin can be multifarious!

Sportmen`s groin is a entity of its own! Not a diagnosis by exclusion!

We need to listen and investigate our patients carefully!

Necessity for Surgery?

YES!

• Only if diagnosis shows weakness of the posterior wall with bulging (by a skilled examiner)

• If the pain is severe• If the athlete is handicapped• Failed conservative treatment

To avoid chronic pain syndrome

Overtreatment?

NO!

• Only the defect is repaired• No sound or intact structures are

destroyed• The cause of the pain is removed• Preservation of the slide bearing of the

abdominal wall • No loss of elasticity due to mesh

implantation• No risk of mesh induced complications

Minimal procedure with maximal effect

Is there any prevention???

NO!

Thank you very much!

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