Hernia (2015) 19:531–532 DOI 10.1007/s10029-013-1193-5
Importance and utility of laparoscopic inguinal exploration in cases with chronic groin pain Comment on: Laparoscopic diagnosis and management of a novel inguinopelvic hernia. Modeste K, Novitsky W. Hernia 2013 Jun 17: 419–422, doi:10.1007/s10029-012-0910-9 M. Bellver • F. Rotellar • P. M. Ortega • G. Zozaya
Received: 28 July 2013 / Accepted: 8 November 2013 / Published online: 8 December 2013 Ó Springer-Verlag France 2013
Dear Editors We read with interest the article published by Modeste and Novitsky in the latest issue of Hernia  and would like to make a brief comment with regard to the benefit of laparoscopic inguinal exploration in chronic groin pain. In the article, the authors reported a new type of ‘‘para-psoas’’ hernia after laparoscopic exploration of the inguinal region in a patient who presented with chronic groin pain. In their interesting conclusions, they recommend a laparoscopic exploration of the inguinal region in cases of chronic groin pain with no definitive physical and/or radiological diagnosis. In our hospital, two patients underwent surgery due to chronic groin pain symptoms mimicking inguinal hernia. Our first patient was a 69-year-old male with right groin pain that caused him major limitation for walking without improvement after NSAIDS treatment. Physical examination showed a doubtful right inguinal hernia. The second case was a 19-year-old male with chronic right groin pain that became incapacitating for walking especially after prolonged bipedestation or intense physical activity. Physical exam and US examination showed a doubtful hernia diagnosis. In both cases, we performed a TEP laparoscopic examination under which no (or any) inguinal hernia was
This comment refers to the article available at doi:10.1007/s10029-012-0910-9. M. Bellver (&) F. Rotellar P. M. Ortega G. Zozaya Department of General and Abdominal Surgery, University Clinic of Navarre, C/PIO XII 36, 7th Floor, Pamplona, Spain e-mail: [email protected]
found. However, an impaction of fatty and lymphatic tissue on a nervous branch in the inguinal fossa was observed (Fig. 1). In both procedures, the lymph node and the fatty tissue were removed, placing an inguinal preformed mesh (Fig. 2). Both patients experienced an immediate relief of their symptoms and no relapses have been observed after 24 and 3 months, respectively. In 2010, Campanelli  proposed a new medical term to replace ‘‘Sportman Hernia’’, as this condition also affects non-sporty people: Pubic Inguinal Pain Syndrome (PIPS) . The etiology and pathophysiology of this syndrome is uncertain and multifactorial. Many factors, such as nerve compression, bone pain, muscle pain and weakness of the abdominal wall, have been described in association with its causes. The clinical relevance of this ‘‘hodge-podge’’ (PIPS) is that it often simulates an inguinal hernia. For an accurate diagnosis, an inguinal US exploration is highly recommended . Traditionally, the role of surgery in PIPS has been considered controversial, as few patients benefit from the classical open approach . In fact, we would like to remark that neither Dr. Modeste’s nor our two patients would have been cured with an open procedure. Following the same argumental line of Dr. Modeste, we strongly believe that, in selected patients with PIPS and an unclear diagnosis of inguinal hernia, a laparoscopic approach to the inguinal region should be the method of choice. Unlike Dr. Modeste and others who proposed TAPP [1, 3, 5], we prefer the TEP approach due to its demonstrated better recovery [6, 7].
Hernia (2015) 19:531–532
With this comment we would like to congratulate the authors for their work and stress the importance of laparoscopic exploration in patients with chronic groin pain/ PIPS and a doubtful hernia diagnosis. Conflict of interest
Fig. 1 Red line Fatty lymph node, black arrow nervous compression
Fig. 2 Red line Fatty lymph node is removed in the inguinal fossa. Black Arrow Inguinal nerve without fatty lymph compression
1. Modeste K, Novitsky W (2013) Laparoscopic diagnosis and management of a novel inguina––pelvic hernia. Hernia 17:419–422 2. Campanelli G (2010) Pubic inguinal pain syndrome: the so-called sports hernia. Hernia 14(1):1–4 3. Morales-Conde S, Socas M, Barranco A (2010) Sportsmen hernia: what do we know? Hernia 14(1):5–15 4. Al Polglase, Frydman GM, Farmer KC (1991) Inguinal surgery for debilitating chronic groin pain in athletes. Med J Aust 155:674–677 5. Yong PJ, Williams C, Allaire C (2013) Laparoscopic inguinal exploration and mesh placement for chronic pelvic pain. JSLS 17(1):74–81 6. Krishna A, Misra MC, Bansal VK, Kumar S, Rajeshwari S, Chabra A (2012) Laparoscopic inguinal hernia repair: transabdominal preperitoneal (TAPP) versus totally extraperitoneal (TEP) approach: a prospective randomized controlled trial. Surg Endosc 26(3):639–649 7. Bansal VK, Misra MC, Babu D, Victor J, Kumar S, Sagar R, Rajeshwari S, Krishna A, Rewari V (2013) A prospective, randomized comparison of long-term outcomes: chronic groin pain and quality of life following totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repair. Surg Endosc 27(7):2373–2382
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