Sports Hernia: A Comparison of the Different Surgical Techniques
Comparing different techniques is feasible in the presence of unique, univocal, and shared diagnostic taxonomy. Groin pain syndrome along with its three variants (traumatic, functional overload, long-standing or chronic) represents a wide variety of etiol
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Francesco Di Marzo
Multidisciplinary evaluation (orthopedist, radiologist, surgeon, physiotherapist, sport physiologist) is mandatory to make diagnosis with confidence and to manage the whole treatment pathway (from first physical examination to “return to play”), avoiding recurrence, failure, and partial resolution [1, 2]. The level of evidence for operative treatment of sports hernia is poorly known, and a recent literature review shows a low level of study quality [3]. Surgery offers a wide range of procedural options and is part of the groin pain syndrome treatment, but considering it as the final step is a conceptual error. This overview focuses on current surgical techniques, analyzing anatomical and step-by- step technical aspects. Classification of current techniques is extremely important to define common points and to evaluate any difference: Open technique without mesh positioning
Open with anterior mesh repair and combined adductor release if needed
Open all-suture repair Minimal repair technique
1. Primary tissue repair with suture 2. Mesh repair
Open technique with anterior onlay mesh positioning
F. Di Marzo, M.D. Department of General Surgery, Versilia Hospital - Azienda Usl Toscana Nord Ovest, Lido di Camaiore, Italy e-mail: [email protected]
Laparoscopic technique with posterior mesh positioning Transabdominal preperitoneal Totally extraperitoneal Laparoscopic inguinal ligament release At a glance, it’s easy to establish two different ways in classifying all the procedures; the first is to consider how to approach the transversalis fascia: 1. Open technique through a skin/subcutaneous/ aponeurosis incision 2. Videolaparoscopic/endoscopic technique through multiple micro-incisions, trocar positioning, and peritoneal flap creation (TAPP) or extraperitoneal space dissection (TEP) The second takes into account the type of repair:
The surgical strategy in laparoscopic technique is strictly tied to the use of a mesh in order to ensure a complete support to musculotendinous architecture of posterior wall without any correlation to nerves or inflammatory tissue (in the pubic area). The open technique seems to be more flexible, allowing to choose a primary or a mesh repair combined with selective neurectomy if needed.
© Springer International Publishing AG 2017 R. Zini et al. (eds.), Groin Pain Syndrome, DOI 10.1007/978-3-319-41624-3_13
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13.1 Open All-Suture Repair 13.1.1 Anatomical Background The rectus abdominis and adductor longus pull against the “pubic joint” with consequent weakness of posterior wall of the inguinal canal caused by force impairment (adductor’s strength overcomes rectus), without any nerve entrapment [4, 5]. Sports hernia is treated as a muscular problem with a reinforcement of distal insertion of rectus abdominis and inguinal canal posterior wall, broadening the insertional surface area (including the rectus, internal oblique, and transversus abdominis via the conjoint tendon) [6].
13.1.2 Surgical Technique The procedure is like a standard open
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