Surg Endosc DOI 10.1007/s00464-014-3679-3
and Other Interventional Techniques
Laparoscopic hernia repair with adductor tenotomy for athletic pubalgia: an established procedure for an obscure entity Georgios Rossidis • Andrew Perry • Husain Abbas • Isaac Motamarry • Tamara Lux • Kevin Farmer • Michael Moser • Jay Clugston • Angel Caban • Kfir Ben-David
Received: 5 April 2014 / Accepted: 26 May 2014 Ó Springer Science+Business Media New York 2014
Abstract Introduction Athletic pubalgia is a syndrome of chronic lower abdomen and groin pain that occurs in athletes. It is the direct result of stress and microtears of the rectus abdominis inserting on the pubis from the antagonizing adductor longus muscles, and weakness of the posterior transversalis fascia and bulging of the inguinal floor. Methods Under IRB approval, we conducted a retrospective review of our prospectively competitive athlete patients with athletic pubalgia from 2007 to 2013. Results A cohort of 54 patients was examined. Mean age was 22.4 years. Most patients were football players (n = 23), triathlon (n = 11), track and field (n = 6), soccer players (n = 5), baseball players (n = 4), swimmers (n = 3), golfer (n = 1), and tennis player (n = 1). Fifty one were males and three were females. All patients failed medical therapy with physiotherapy prior to surgery. 76 % of patients had an MRI performed with 26 % having a right rectus abdominis stripping injury with concomitant strain at the adductor longus musculotendinous junction. 7 % of patients had mild nonspecific edema in the distal bilateral rectus abdominis muscles without evidence of a tear. Twenty patients had no findings on their preoperative MRI, Presented at the SAGES 2014 Annual Meeting, April 2-5, 2014, Salt Lake City, Utah G. Rossidis A. Perry H. Abbas I. Motamarry T. Lux A. Caban K. Ben-David (&) Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Rd., PO Box 100109, Gainesville, FL 32610-0109, USA e-mail: [email protected] K. Farmer M. Moser J. Clugston Department of Orthopedics, University of Florida College of Medicine, Gainesville, FL, USA
and only one patient was noted to have an inguinal hernia on MRI. All patients underwent laparoscopic totally extraperitoneal inguinal hernia repair with synthetic mesh and ipsilateral adductor longus tenotomy. All patients were able to return to full sports-related activity in 24 days (range 21–28 days). One patient experienced urinary retention and another sustained an adductor brevis hematoma 3 months after completion of rehabilitation and surgical intervention. Mean follow up was 18 months. Conclusion Athletic pubalgia is a disease with a multifactorial etiology that can be treated surgically by a laparoscopic totally extraperitoneal hernia repair with synthetic mesh accompanied with an ipsilateral adductor longus tenotomy allowing patients to return to sports-related activity early with minimal complications. Keywords Abdominal Hernia Pain Surgical \ Technical
Athletic pubalgia, or sports hernia, is a syndrome of chronic lower abdomen and groin pain that may occur in both athletes and non-athletes. Sports hernia is one of the least understood, poorly defined, and under-researched conditions in medicine. The term has been popularized by the media through the treatment of high profile athletes, but the actual characteristics of injury have not been well defined [1]. Among professional athletes, the estimated incidence of chronic groin pain is 0.5–6.2 %, and it is the most common among ice hockey and soccer players [2, 3]. Athletes performing rapid acceleration and deceleration movements and repetitive, high speed twisting, and cutting motions are especially vulnerable to this injury. Hence, soccer players have a 10–18 % incidence of chronic groin pain per year [3, 4]. Although the prevalence of chronic
123
Surg Endosc
lower abdominal and groin pain in the United States is highest among athletes in soccer, hockey, and American football, the incidence is not insignificant in athletes involved in sports such as basketball, cricket, tennis, and swimming. There are several causes of groin pain that may be related to disorders of the hip joint such as hip degenerative joint disease, labral tear, loose body, stress fracture, lumbar radiculopathy, injury to the muscles of the thigh or the abdominal adductor muscle, iliopsoas strain, avulsion fracture, adductor longus dysfunction, or tendon rupture. Unfortunately, the pathogenesis of chronic groin pain in athletes stresses the concept of muscular injury and disruption is believed to be an incipient hernia process in the posterior wall of the inguinal canal without a true muscle tear present [5–7]. First described as Gilmore’s groin [8], the injury is a combination of a torn external oblique aponeurosis, a torn conjoined tendon, and dehiscence between the inguinal ligament and the torn conjoined tendon. Taylor [9] further described the term ‘‘pubalgia’’ as the result of musculotendinous strains of adductor muscles and other muscles crossing the hip in the absence of an inguinal hernia on physical examination. Meyers et al. [10] emphasized the role of the adductor muscles and eluded on the pathogenesis of chronic groin pain. They described that the pubis serves as a point into which both the adductor muscles and rectus abdominis insert, causing one muscle to antagonize the other, leading to injury of the weaker abdominal muscles [10]. Hence, Meyers based his surgical approach on the same theory describing the tightening and broadening the abdominal muscular insertion but also loosening the attachment of the adductor longus [11]. We believe that chronic groin pain in athletes has a multifactorial etiology rather than a single etiology [12, 13]. Whether a proponent of muscular injury and tendinous disruption or that athletic pubalgia is the result of a defect in the posterior inguinal, this conundrum signifies that the disease represents a broad spectrum of pathoanatomy rather than a single entity and explains the efficacy of different surgical approaches utilized to treat this obscure entity. Hence, we report our laparoscopic hernia repair with ipsilateral adductor tenotomy treatment for competitive athlete patients with chronic athletic pubalgia.
Method Starting in August 2007, all competitive athletes who presented with chronic groin pain and/or athletic pubalgia to the University of Florida were offered a laparoscopic totally extraperitoneal inguinal hernia repair with synthetic mesh and ipsilateral adductor longus tenotomy. Under an institutionally approved protocol, a retrospective review of
123
Fig. 1 Port placement
our prospective database of competitive athlete patients with athletic pubalgia was performed from August 2007 to January 2011. We identified all patients undergoing a laparoscopic totally extraperitoneal inguinal hernia repair with synthetic mesh and ipsilateral adductor longus tenotomy for chronic groin pain or athletic pubalgia. The demographics, presenting clinical symptoms, radiological characteristics, surgical procedures, early and late postoperative morbidity, and disease outcomes were analyzed in all patients who underwent this treatment modality. Our standard surgical approach for these patients includes a laparoscopic totally extraperitoneal inguinal hernia repair via a 12-mm infraumbilical trocar and two low profile 5 mm ports placed in the midline between the infraumbilical port and the pubic symphysis (Fig. 1). The pubic symphysis and Cooper’s ligaments are then identified for better orientation (Fig. 2). The lateral preperitoneal wall is dissected to allow placement of the mesh along the lateral wall. The cord structures are dissected to rule out a true inguinal hernia and the peritoneal fold is reduced (Fig. 3). The structures and the internal ring are again inspected (Fig. 4), and placement of a polypropylene mesh is performed by anchoring the synthetic mesh to the Cooper’s ligament and the abdominal wall with the use of a 5 mm titanium helical fixation device (Fig. 5). Upon completion of the laparoscopic inguinal mesh placement, an oblique incision is made in the groin along the area marked preoperatively directly over the insertion of the adductor longus to the pubis. The incision is carried down through the subcutaneous tissue to the adductor longus tendon which is often times inflamed and/or chronically scarred. An adductor longus tenotomy is created 1 cm from the tendinous insertion to the pubis (Fig. 6). Once the tendinous insertion is divided, the tenotomy is completed and the incision is approximated in two layers. Patients
Surg Endosc
Fig. 2 The pubic symphysis (blue arrow) and the right and left Cooper’s ligaments (black arrows) are identified (Color figure online)
Fig. 3 The peritoneal fold is reduced from the cord structures
Fig. 5 Polyproprelene mesh placement reinforcing the inguinal floor
Fig. 6 Adductor longus tenotomy. The tendon is released from its tendinous insertion around 1 cm from the pubis. The lines represent the course of the tendon from the thigh to the pubis
recover in the post-anesthesia care unit and are discharged on the same day. All patients follow a strict physical rehabilitation program that is summarized in Table 2. The program allows return to sports-related activity in 21 days. The patients resume full activity between 21 and 28 days. Patients are followed at 4 weeks postoperatively, then at 3 and 6 months with 6 months intervals subsequently. Statistics were performed utilizing t test or Chi square when appropriate. Significance was defined as p \ 0.05.
Results
Fig. 4 The cord structures, the internal ring (circle) are dissected and no hernia is evident
A cohort of 54 patients was examined. Mean age was 22.4 years. Most of the patients were football players (n = 23), triathlon (n = 11), track and field (n = 6),
123
Surg Endosc Table 1 Patient demographics Demographics
Number
Patients
54
Gender Male Female Average age (years)
51 3 22.4
Sport Football
23
Triathlon
11
Track
6
Soccer
5
Baseball Swimming
4 3
Golf
1
Tennis
1
Preoperative MRI
41
Preoperative physical therapy
54
Table 2 Postoperative physical rehabilitation schedule Athletic pubalgia postoperative rehabilitation schedule POD 0 to 7 Resume activities of daily living (ADLs) Abstain from lifting exercises/activities that increase intraabdominal pressure
patients failed medical therapy with physiotherapy prior to the surgical consultation. 76 % of patients had an MRI performed. The MRI findings were as follows: 26 % of patients had a right rectus abdominis stripping injury with concomitant strain at the adductor longus musculotendinous junction. 7 % of patients had mild nonspecific edema in the distal bilateral rectus abdominis muscles without evidence of a tear. Two patients had evidence of marrow edema in the left pubic body, and two patients had evidence of obturator externus strain and osteitis pubis. Twenty patients had no findings on their preoperative MRI, and only one patient was noted to have an inguinal hernia present on MRI. All patients underwent laparoscopic totally extraperitoneal inguinal hernia repair with synthetic mesh and ipsilateral adductor longus tenotomy. All patients followed a strict rehabilitation regimen (Table 2), and all patients were able to return to full sports-related activity in 24 days (range 21–28 days). One patient experienced urinary retention, another developed subsequent pain 6 months following his initial operation requiring a contralateral adductor longus tenotomy, and one patient sustained an adductor brevis hematoma 3 months after the completion of rehabilitation and surgical intervention. Mean follow up was 18 months. The mean operating time was 78 min with a mean estimated blood loss of was 17.8 mL. All of the patients were discharged on the same day. Average follow up is 18.
POD 1-Begin walking 1 mi/day and increase as tolerated. Resistive exercises POD 7 to 10
Discussion
Posterior pelvic tilt Mild resistive exercises (pool walking, partial squats, standing hip adduction/abduction/flexion/extension, heel raising) Gentle Stretching (side bending, hip extension, psoas/groin/ hamstring/quads) POD 10 Begin light jogging and deep tissue massage of adductor muscle bellies Progressive resistive Exercises POD 11 to 21 Hip flexion, adduction, abduction, extensions (add weight in 2 lb. increments) Pool exercises (running backward/forward, cariocas, side slides, jumping jacks-no arms, scissors, swimming-flutter kicks only Jogging (–1 mile; including backwards) Strength training: sprinting (50 yd., no sudden start/stop), crossovers/straddles, Fig. 8’s, lunges, plyometrics, Stairmaster (20 min), calisthenics Upper body exercises Sport specific activities
soccer players (n = 5), baseball players (n = 4), swimmers (n = 3), golfer (n = 1), and tennis player (n = 1). Fifty one were males and three were females (Table 1). All
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A patient’s history and physical examination of chronic groin pain will often reveal pain that is unilateral, sharp, or burning in nature and radiates to the proximal thigh, low back, lower abdominal muscles perineum, or scrotum. Pain is exacerbated by sudden accelerating movements, cutting or twisting, side-stepping, or sit-ups [14]. The athlete is usually pain free with inactivity but pain returns immediately with return to sport. Often physical examination reveals tenderness over the medial inguinal canal and the conjoined tendon, the distal rectus insertion, or the pubic tubercle. The athlete will often have pain with resisted situps and resisted hip adduction. Plain radiographs will rule out degenerative conditions of the hip pine and sacroiliac joints and can also identify osteitis pubis, which causes symmetric bone resorption and symphyseal widening. Bone scans can diagnose stress fractures that are too subtle to be identified on plain radiographs. However, MRI is now the preferred diagnostic modality, with dedicated protocols to investigate chronic groin pain and sports hernias [15]. MRI is very useful because it can identify osteitis pubis, stress fractures, hip abnormalities, but it can also show subtle abnormalities in
Surg Endosc
the musculofascial layers of the abdominal wall, findings that correlate well with surgical findings [16]. Dynamic ultrasound can also be useful in the hands of a skilled ultrasonographer as it can detect a distinct protrusion of the transversalis fascia during a Valsalva maneuver [17]. Unfortunately, the disadvantage of this modality is the fact that it is very highly operator dependent. Lastly, herniography is a study that involves injection of contrast dye in the peritoneal cavity and fluoroscopic views, while the patient performs Valsalva maneuvers. The study is considered positive in the presence of contrast flow outside the normal contours of the peritoneum. The high false positive rate and the 3–6 % rate of complications have hindered the widespread use of this modality [18, 19]. Both traditional open and laparoscopic surgical approaches have been described in the literature for the treatment of sports hernias. Steele et al. [20] described their modified Bassini repair with mesh in soccer and rugby players with 77 % return to full activity in 4 months. Malycha and Lovell described an open reinforcement of the posterior inguinal wall in two layers using prolene suture. In 80 % of their patients, they noticed a bulge of the posterior inguinal wall. Their results showed 93 % return to full activity in 6–8 weeks [5]. Brannigan et al. [21] performed a modified Shouldice repair in 85 soccer players. The group’s main observation was separation of the conjoined tendon from the inguinal ligament. Their results showed 96 % return to full activity in 15 weeks [21]. Meyers challenged the notion of an inguinal hernia repair as a surgical approach. He noted that the main issue was the external oblique aponeurosis defect in 48 % of their patients and a ‘‘thin’’ rectus abdominis muscle insertion in 17 % of the patients supporting the notion that an inguinal repair may not repair the problem. Hence, he has advocated an open pelvic floor repair, with reattachment of the inferolateral edge of rectus abdominis muscle with its fascial attachment to the pubis and adjacent anterior ligament and an adductor tendon release in 23 % of the patients [10]. Laparoscopic approaches have gained popularity in the last years, and more studies involving laparoscopic approaches appeared in the literature. The proponents of a laparoscopic approach argue for a better exposure of the posterior inguinal wall and reinforcement of the entire wall of the groin, from the pubis to the anterior superior iliac spine under no tension with the use of mesh. This tension free technique, compared to most open techniques involving suturing mobile muscles to noncontractile structures, offers the benefit of faster recuperation and earlier return to full activity. Srinivasan and Schuricht [22] reported 87 % return to full activity in 3–6 weeks after a total extraperitoneal repair. Genitsaris et al. [23] described a larger cohort consisting of 131 soccer players undergoing a transabdominal preperitoneal procedure, with a mean follow up of
5 years. A staggering 97 % of the patients returned to full activity within only 2–3 weeks. It is interesting to mention that this study reported the presence of a direct hernia in 62 % of the patients, a far higher incidence than most other studies [23]. Paajanen et al. [24] had similar results in a cohort of 41 patients with 94 % return to full activity within 4 weeks. However, Muschaweck and colleagues [7] in Munich, Germany challenged the superiority of the laparoscopic procedures. They described an open minimal repair technique approach performed under local anesthesia repairing the splitting of the transversalis fascia from the area of the defect toward the internal ring. The defect is then reapproximated in a running fashion from medial to lateral toward the internal ring and then the suture is reversed toward the pubic bone. The free lip created is then sutured to the inguinal ligament. The last step involves lateralization of the rectus abdominis with another suture, and creation of a collar around the pampiniform plexus and nerves at the internal ring using the internal oblique to prevent irritation of the nerves and subsequent pain [7]. They report excellent results in 98 professional athletes with a 14 day duration to pre-injury sports activities and no complications. They support that the absence of mesh improves elasticity of the groin muscles, there are no meshrelated complications, no need for general anesthesia, and there is no urinary retention that is associated with laparoscopic repairs [25]. Surgical management is known to be the best modality in the treatment of athletic pubalgia, an entity that remains obscure and not well understood. There is now an abundance of literature to suggest that open and laparoscopic approaches can both treat groin pain in athletes with excellent results. We described a minimally invasive surgical technique that addresses the two notions regarding athletic pubalgia. Our surgical approach reinforces the posterior inguinal floor, and adductor longus tenotomy relieves the stress to the rectus abdominis. Our results show that with a strict postoperative rehabilitation program and our operative approach we can achieve very early return to the highest level of activity with no short or long term morbidity from the procedure.
Disclosure Drs. Rossidis, Perry, Abbas, Isaac, Lux have no conflicts of interest or financial ties to disclose. Dr. Moser is a consultant for Arthrex. Dr. Farmer is a consultant for Exactech, Arthrex, and Medshape. Dr. Clugston receives research funding from Banyan Biomarkers, Inc. Dr. Ben-David received research funding and is a consultant for Ethicon Endosurgery.
References 1. Nam A, Brody F (2008) Management and therapy for sports Hernia. J Am Coll Surg 206(1):154–164 2. Fon LJ, Spence RA (2000) Sportsman’s hernia. Br J Surg 87(5):545–552
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Surg Endosc 3. Anderson K, Strickland SM, Warren R (2001) Hip and groin injuries in athletes. Am J Sports Med 29(4):521–533 4. Ho¨lmich P, Uhrskou P, Ulnits L et al (1999) Effectiveness of active physical training as treatment for long-standing adductorrelated groin pain in athletes: randomised trial. Lancet 353(9151): 439–443 5. Malycha P, Lovell G (1992) Inguinal surgery in athletes with chronic groin pain: the ‘sportsman‘s’ hernia. Aust N Z J Surg 62(2):123–125 6. Polglase AL, Frydman GM, Farmer KC (1991) Inguinal surgery for debilitating chronic groin pain in athletes. Med J Aust 155(10):674–677 7. Muschaweck U, Berger L (2010) Minimal Repair technique of sportsmen’s groin: an innovative open-suture repair to treat chronic inguinal pain. Hernia 14(1):27–33 8. Gilmore J (1998) Groin pain in the soccer athlete: fact, fiction, and treatment. Clin Sports Med 17(4):787–793 9. Taylor DC (1991) Abdominal musculature abnormalities as a cause of groin pain in athletes. Am J Sports Med 19(4):421 10. Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR (2000) Management of severe lower abdominal or inguinal pain in high-performance athletes. PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med 28(1):2–8 11. Meyers WC, Lanfranco A, Castellanos A (2002) Surgical management of chronic lower abdominal and groin pain in highperformance athletes. Curr Sports Med Rep 1(5):301–305 12. Harmon KG (2007) Evaluation of groin pain in athletes. Curr Sports Med Rep 6(6):354–361 13. Ekstrand J, Hilding J (1999) The incidence and differential diagnosis of acute groin injuries in male soccer players. Scand J Med Sci Sports 9:98–103 14. Lovell G (1995) The diagnosis of chronic groin pain in athletes: a review of 189 cases. Aust J Sci Med Sport 27(3):76–79
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15. Omar IM, Zoga AC, Kavanagh EC et al (2008) Athletic pubalgia and ‘‘sports hernia’’: optimal MR imaging technique and findings. Radiographics 28(5):1415–1438 16. Albers SL, Spritzer CE, Garrett WE, Meyers WC (2001) MR findings in athletes with pubalgia. Skelet Radiol 30(5):270–277 17. Orchard JW, Read JW, Neophyton J, Garlick D (1998) Groin pain associated with ultrasound finding of inguinal canal posterior wall deficiency in Australian Rules footballers. Br J Sports Med 32(2):134–139 18. Smedberg SG, Broome AE, Gullmo A, Roos H (1985) Herniography in athletes with groin pain. Am J Surg 149(3):378–382 19. Sutcliffe JR, Taylor OM, Ambrose NS, Chapman AH (1999) The use, value and safety of herniography. Clin Radiol 54(7):468–472 20. Steele P, Annear P, Grove JR (2004) Surgery for posterior inguinal wall deficiency in athletes. J Sci Med Sport 7(4): 415–421 discussion 422–3 21. Brannigan AE, Kerin MJ, McEntee GP (2000) Gilmore’s groin repair in athletes. J Orthop Sports Phys Ther 30(6):329–332 22. Srinivasan A, Schuricht A (2002) Long-term follow-up of laparoscopic preperitoneal hernia repair in professional athletes. J Laparoendosc Adv Surg Tech 12(2):101–106 23. Genitsaris M, Goulimaris I, Sikas N (2004) Laparoscopic repair of groin pain in athletes. Am J Sports Med 32(5):1238–1242 24. Paajanen H, Brinck T, Hermunen H, Airo I (2011) 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 150(1):99–107 25. Muschaweck UU, Berger LML (2010) Sportsmen’s groin-diagnostic approach and treatment with the minimal repair technique: a single-center uncontrolled clinical review. Sports Health 2(3):216–221
and Other Interventional Techniques
Laparoscopic hernia repair with adductor tenotomy for athletic pubalgia: an established procedure for an obscure entity Georgios Rossidis • Andrew Perry • Husain Abbas • Isaac Motamarry • Tamara Lux • Kevin Farmer • Michael Moser • Jay Clugston • Angel Caban • Kfir Ben-David
Received: 5 April 2014 / Accepted: 26 May 2014 Ó Springer Science+Business Media New York 2014
Abstract Introduction Athletic pubalgia is a syndrome of chronic lower abdomen and groin pain that occurs in athletes. It is the direct result of stress and microtears of the rectus abdominis inserting on the pubis from the antagonizing adductor longus muscles, and weakness of the posterior transversalis fascia and bulging of the inguinal floor. Methods Under IRB approval, we conducted a retrospective review of our prospectively competitive athlete patients with athletic pubalgia from 2007 to 2013. Results A cohort of 54 patients was examined. Mean age was 22.4 years. Most patients were football players (n = 23), triathlon (n = 11), track and field (n = 6), soccer players (n = 5), baseball players (n = 4), swimmers (n = 3), golfer (n = 1), and tennis player (n = 1). Fifty one were males and three were females. All patients failed medical therapy with physiotherapy prior to surgery. 76 % of patients had an MRI performed with 26 % having a right rectus abdominis stripping injury with concomitant strain at the adductor longus musculotendinous junction. 7 % of patients had mild nonspecific edema in the distal bilateral rectus abdominis muscles without evidence of a tear. Twenty patients had no findings on their preoperative MRI, Presented at the SAGES 2014 Annual Meeting, April 2-5, 2014, Salt Lake City, Utah G. Rossidis A. Perry H. Abbas I. Motamarry T. Lux A. Caban K. Ben-David (&) Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Rd., PO Box 100109, Gainesville, FL 32610-0109, USA e-mail: [email protected] K. Farmer M. Moser J. Clugston Department of Orthopedics, University of Florida College of Medicine, Gainesville, FL, USA
and only one patient was noted to have an inguinal hernia on MRI. All patients underwent laparoscopic totally extraperitoneal inguinal hernia repair with synthetic mesh and ipsilateral adductor longus tenotomy. All patients were able to return to full sports-related activity in 24 days (range 21–28 days). One patient experienced urinary retention and another sustained an adductor brevis hematoma 3 months after completion of rehabilitation and surgical intervention. Mean follow up was 18 months. Conclusion Athletic pubalgia is a disease with a multifactorial etiology that can be treated surgically by a laparoscopic totally extraperitoneal hernia repair with synthetic mesh accompanied with an ipsilateral adductor longus tenotomy allowing patients to return to sports-related activity early with minimal complications. Keywords Abdominal Hernia Pain Surgical \ Technical
Athletic pubalgia, or sports hernia, is a syndrome of chronic lower abdomen and groin pain that may occur in both athletes and non-athletes. Sports hernia is one of the least understood, poorly defined, and under-researched conditions in medicine. The term has been popularized by the media through the treatment of high profile athletes, but the actual characteristics of injury have not been well defined [1]. Among professional athletes, the estimated incidence of chronic groin pain is 0.5–6.2 %, and it is the most common among ice hockey and soccer players [2, 3]. Athletes performing rapid acceleration and deceleration movements and repetitive, high speed twisting, and cutting motions are especially vulnerable to this injury. Hence, soccer players have a 10–18 % incidence of chronic groin pain per year [3, 4]. Although the prevalence of chronic
123
Surg Endosc
lower abdominal and groin pain in the United States is highest among athletes in soccer, hockey, and American football, the incidence is not insignificant in athletes involved in sports such as basketball, cricket, tennis, and swimming. There are several causes of groin pain that may be related to disorders of the hip joint such as hip degenerative joint disease, labral tear, loose body, stress fracture, lumbar radiculopathy, injury to the muscles of the thigh or the abdominal adductor muscle, iliopsoas strain, avulsion fracture, adductor longus dysfunction, or tendon rupture. Unfortunately, the pathogenesis of chronic groin pain in athletes stresses the concept of muscular injury and disruption is believed to be an incipient hernia process in the posterior wall of the inguinal canal without a true muscle tear present [5–7]. First described as Gilmore’s groin [8], the injury is a combination of a torn external oblique aponeurosis, a torn conjoined tendon, and dehiscence between the inguinal ligament and the torn conjoined tendon. Taylor [9] further described the term ‘‘pubalgia’’ as the result of musculotendinous strains of adductor muscles and other muscles crossing the hip in the absence of an inguinal hernia on physical examination. Meyers et al. [10] emphasized the role of the adductor muscles and eluded on the pathogenesis of chronic groin pain. They described that the pubis serves as a point into which both the adductor muscles and rectus abdominis insert, causing one muscle to antagonize the other, leading to injury of the weaker abdominal muscles [10]. Hence, Meyers based his surgical approach on the same theory describing the tightening and broadening the abdominal muscular insertion but also loosening the attachment of the adductor longus [11]. We believe that chronic groin pain in athletes has a multifactorial etiology rather than a single etiology [12, 13]. Whether a proponent of muscular injury and tendinous disruption or that athletic pubalgia is the result of a defect in the posterior inguinal, this conundrum signifies that the disease represents a broad spectrum of pathoanatomy rather than a single entity and explains the efficacy of different surgical approaches utilized to treat this obscure entity. Hence, we report our laparoscopic hernia repair with ipsilateral adductor tenotomy treatment for competitive athlete patients with chronic athletic pubalgia.
Method Starting in August 2007, all competitive athletes who presented with chronic groin pain and/or athletic pubalgia to the University of Florida were offered a laparoscopic totally extraperitoneal inguinal hernia repair with synthetic mesh and ipsilateral adductor longus tenotomy. Under an institutionally approved protocol, a retrospective review of
123
Fig. 1 Port placement
our prospective database of competitive athlete patients with athletic pubalgia was performed from August 2007 to January 2011. We identified all patients undergoing a laparoscopic totally extraperitoneal inguinal hernia repair with synthetic mesh and ipsilateral adductor longus tenotomy for chronic groin pain or athletic pubalgia. The demographics, presenting clinical symptoms, radiological characteristics, surgical procedures, early and late postoperative morbidity, and disease outcomes were analyzed in all patients who underwent this treatment modality. Our standard surgical approach for these patients includes a laparoscopic totally extraperitoneal inguinal hernia repair via a 12-mm infraumbilical trocar and two low profile 5 mm ports placed in the midline between the infraumbilical port and the pubic symphysis (Fig. 1). The pubic symphysis and Cooper’s ligaments are then identified for better orientation (Fig. 2). The lateral preperitoneal wall is dissected to allow placement of the mesh along the lateral wall. The cord structures are dissected to rule out a true inguinal hernia and the peritoneal fold is reduced (Fig. 3). The structures and the internal ring are again inspected (Fig. 4), and placement of a polypropylene mesh is performed by anchoring the synthetic mesh to the Cooper’s ligament and the abdominal wall with the use of a 5 mm titanium helical fixation device (Fig. 5). Upon completion of the laparoscopic inguinal mesh placement, an oblique incision is made in the groin along the area marked preoperatively directly over the insertion of the adductor longus to the pubis. The incision is carried down through the subcutaneous tissue to the adductor longus tendon which is often times inflamed and/or chronically scarred. An adductor longus tenotomy is created 1 cm from the tendinous insertion to the pubis (Fig. 6). Once the tendinous insertion is divided, the tenotomy is completed and the incision is approximated in two layers. Patients
Surg Endosc
Fig. 2 The pubic symphysis (blue arrow) and the right and left Cooper’s ligaments (black arrows) are identified (Color figure online)
Fig. 3 The peritoneal fold is reduced from the cord structures
Fig. 5 Polyproprelene mesh placement reinforcing the inguinal floor
Fig. 6 Adductor longus tenotomy. The tendon is released from its tendinous insertion around 1 cm from the pubis. The lines represent the course of the tendon from the thigh to the pubis
recover in the post-anesthesia care unit and are discharged on the same day. All patients follow a strict physical rehabilitation program that is summarized in Table 2. The program allows return to sports-related activity in 21 days. The patients resume full activity between 21 and 28 days. Patients are followed at 4 weeks postoperatively, then at 3 and 6 months with 6 months intervals subsequently. Statistics were performed utilizing t test or Chi square when appropriate. Significance was defined as p \ 0.05.
Results
Fig. 4 The cord structures, the internal ring (circle) are dissected and no hernia is evident
A cohort of 54 patients was examined. Mean age was 22.4 years. Most of the patients were football players (n = 23), triathlon (n = 11), track and field (n = 6),
123
Surg Endosc Table 1 Patient demographics Demographics
Number
Patients
54
Gender Male Female Average age (years)
51 3 22.4
Sport Football
23
Triathlon
11
Track
6
Soccer
5
Baseball Swimming
4 3
Golf
1
Tennis
1
Preoperative MRI
41
Preoperative physical therapy
54
Table 2 Postoperative physical rehabilitation schedule Athletic pubalgia postoperative rehabilitation schedule POD 0 to 7 Resume activities of daily living (ADLs) Abstain from lifting exercises/activities that increase intraabdominal pressure
patients failed medical therapy with physiotherapy prior to the surgical consultation. 76 % of patients had an MRI performed. The MRI findings were as follows: 26 % of patients had a right rectus abdominis stripping injury with concomitant strain at the adductor longus musculotendinous junction. 7 % of patients had mild nonspecific edema in the distal bilateral rectus abdominis muscles without evidence of a tear. Two patients had evidence of marrow edema in the left pubic body, and two patients had evidence of obturator externus strain and osteitis pubis. Twenty patients had no findings on their preoperative MRI, and only one patient was noted to have an inguinal hernia present on MRI. All patients underwent laparoscopic totally extraperitoneal inguinal hernia repair with synthetic mesh and ipsilateral adductor longus tenotomy. All patients followed a strict rehabilitation regimen (Table 2), and all patients were able to return to full sports-related activity in 24 days (range 21–28 days). One patient experienced urinary retention, another developed subsequent pain 6 months following his initial operation requiring a contralateral adductor longus tenotomy, and one patient sustained an adductor brevis hematoma 3 months after the completion of rehabilitation and surgical intervention. Mean follow up was 18 months. The mean operating time was 78 min with a mean estimated blood loss of was 17.8 mL. All of the patients were discharged on the same day. Average follow up is 18.
POD 1-Begin walking 1 mi/day and increase as tolerated. Resistive exercises POD 7 to 10
Discussion
Posterior pelvic tilt Mild resistive exercises (pool walking, partial squats, standing hip adduction/abduction/flexion/extension, heel raising) Gentle Stretching (side bending, hip extension, psoas/groin/ hamstring/quads) POD 10 Begin light jogging and deep tissue massage of adductor muscle bellies Progressive resistive Exercises POD 11 to 21 Hip flexion, adduction, abduction, extensions (add weight in 2 lb. increments) Pool exercises (running backward/forward, cariocas, side slides, jumping jacks-no arms, scissors, swimming-flutter kicks only Jogging (–1 mile; including backwards) Strength training: sprinting (50 yd., no sudden start/stop), crossovers/straddles, Fig. 8’s, lunges, plyometrics, Stairmaster (20 min), calisthenics Upper body exercises Sport specific activities
soccer players (n = 5), baseball players (n = 4), swimmers (n = 3), golfer (n = 1), and tennis player (n = 1). Fifty one were males and three were females (Table 1). All
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A patient’s history and physical examination of chronic groin pain will often reveal pain that is unilateral, sharp, or burning in nature and radiates to the proximal thigh, low back, lower abdominal muscles perineum, or scrotum. Pain is exacerbated by sudden accelerating movements, cutting or twisting, side-stepping, or sit-ups [14]. The athlete is usually pain free with inactivity but pain returns immediately with return to sport. Often physical examination reveals tenderness over the medial inguinal canal and the conjoined tendon, the distal rectus insertion, or the pubic tubercle. The athlete will often have pain with resisted situps and resisted hip adduction. Plain radiographs will rule out degenerative conditions of the hip pine and sacroiliac joints and can also identify osteitis pubis, which causes symmetric bone resorption and symphyseal widening. Bone scans can diagnose stress fractures that are too subtle to be identified on plain radiographs. However, MRI is now the preferred diagnostic modality, with dedicated protocols to investigate chronic groin pain and sports hernias [15]. MRI is very useful because it can identify osteitis pubis, stress fractures, hip abnormalities, but it can also show subtle abnormalities in
Surg Endosc
the musculofascial layers of the abdominal wall, findings that correlate well with surgical findings [16]. Dynamic ultrasound can also be useful in the hands of a skilled ultrasonographer as it can detect a distinct protrusion of the transversalis fascia during a Valsalva maneuver [17]. Unfortunately, the disadvantage of this modality is the fact that it is very highly operator dependent. Lastly, herniography is a study that involves injection of contrast dye in the peritoneal cavity and fluoroscopic views, while the patient performs Valsalva maneuvers. The study is considered positive in the presence of contrast flow outside the normal contours of the peritoneum. The high false positive rate and the 3–6 % rate of complications have hindered the widespread use of this modality [18, 19]. Both traditional open and laparoscopic surgical approaches have been described in the literature for the treatment of sports hernias. Steele et al. [20] described their modified Bassini repair with mesh in soccer and rugby players with 77 % return to full activity in 4 months. Malycha and Lovell described an open reinforcement of the posterior inguinal wall in two layers using prolene suture. In 80 % of their patients, they noticed a bulge of the posterior inguinal wall. Their results showed 93 % return to full activity in 6–8 weeks [5]. Brannigan et al. [21] performed a modified Shouldice repair in 85 soccer players. The group’s main observation was separation of the conjoined tendon from the inguinal ligament. Their results showed 96 % return to full activity in 15 weeks [21]. Meyers challenged the notion of an inguinal hernia repair as a surgical approach. He noted that the main issue was the external oblique aponeurosis defect in 48 % of their patients and a ‘‘thin’’ rectus abdominis muscle insertion in 17 % of the patients supporting the notion that an inguinal repair may not repair the problem. Hence, he has advocated an open pelvic floor repair, with reattachment of the inferolateral edge of rectus abdominis muscle with its fascial attachment to the pubis and adjacent anterior ligament and an adductor tendon release in 23 % of the patients [10]. Laparoscopic approaches have gained popularity in the last years, and more studies involving laparoscopic approaches appeared in the literature. The proponents of a laparoscopic approach argue for a better exposure of the posterior inguinal wall and reinforcement of the entire wall of the groin, from the pubis to the anterior superior iliac spine under no tension with the use of mesh. This tension free technique, compared to most open techniques involving suturing mobile muscles to noncontractile structures, offers the benefit of faster recuperation and earlier return to full activity. Srinivasan and Schuricht [22] reported 87 % return to full activity in 3–6 weeks after a total extraperitoneal repair. Genitsaris et al. [23] described a larger cohort consisting of 131 soccer players undergoing a transabdominal preperitoneal procedure, with a mean follow up of
5 years. A staggering 97 % of the patients returned to full activity within only 2–3 weeks. It is interesting to mention that this study reported the presence of a direct hernia in 62 % of the patients, a far higher incidence than most other studies [23]. Paajanen et al. [24] had similar results in a cohort of 41 patients with 94 % return to full activity within 4 weeks. However, Muschaweck and colleagues [7] in Munich, Germany challenged the superiority of the laparoscopic procedures. They described an open minimal repair technique approach performed under local anesthesia repairing the splitting of the transversalis fascia from the area of the defect toward the internal ring. The defect is then reapproximated in a running fashion from medial to lateral toward the internal ring and then the suture is reversed toward the pubic bone. The free lip created is then sutured to the inguinal ligament. The last step involves lateralization of the rectus abdominis with another suture, and creation of a collar around the pampiniform plexus and nerves at the internal ring using the internal oblique to prevent irritation of the nerves and subsequent pain [7]. They report excellent results in 98 professional athletes with a 14 day duration to pre-injury sports activities and no complications. They support that the absence of mesh improves elasticity of the groin muscles, there are no meshrelated complications, no need for general anesthesia, and there is no urinary retention that is associated with laparoscopic repairs [25]. Surgical management is known to be the best modality in the treatment of athletic pubalgia, an entity that remains obscure and not well understood. There is now an abundance of literature to suggest that open and laparoscopic approaches can both treat groin pain in athletes with excellent results. We described a minimally invasive surgical technique that addresses the two notions regarding athletic pubalgia. Our surgical approach reinforces the posterior inguinal floor, and adductor longus tenotomy relieves the stress to the rectus abdominis. Our results show that with a strict postoperative rehabilitation program and our operative approach we can achieve very early return to the highest level of activity with no short or long term morbidity from the procedure.
Disclosure Drs. Rossidis, Perry, Abbas, Isaac, Lux have no conflicts of interest or financial ties to disclose. Dr. Moser is a consultant for Arthrex. Dr. Farmer is a consultant for Exactech, Arthrex, and Medshape. Dr. Clugston receives research funding from Banyan Biomarkers, Inc. Dr. Ben-David received research funding and is a consultant for Ethicon Endosurgery.
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