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Review
Systematic review: laparoscopic treatment of long-standing groin pain in athletes Hannu Paajanen,1 Agneta Montgomery,2 Thomas Simon,3 Aali J Sheen4 1
Department of Surgery, Kuopio University Hospital, Kuopio, Finland 2 Department of Surgery, Skåne University Hospital, Malmö, Sweden 3 GRN-Klinik Sinsheim, Heidelberg University Hospital, Heidelberg, Germany 4 Department of Surgery, Central Manchester Foundation Trust, Manchester Royal Infirmary and University of Manchester, Manchester, UK Correspondence to Professor Hannu Paajanen, Department of Surgery, Kuopio University Hospital, PL 1777, Kuopio 70211, Finland; hannu.paajanen@kuh.fi Accepted 6 April 2015
ABSTRACT Objectives No single aetiological factor has been proven to cause long-standing groin pain in athletes and no sole operative technique (either open or laparoscopic) has been shown to be the preferred method of repair. The aim of this systematic review was to determine whether there are any differences in the return to full sporting activity following laparoscopic repair of groin pain in athletes. Data sources The minimal access approaches include laparoscopic transabdominal pre-peritoneal (TAPP) or endoscopic total extraperitoneal (TEP) techniques. A systematic literature search was performed in PubMed, SCOPUS, UpToDate and the Cochrane Library databases. Series reporting laparoscopic repair (TAPP/TEP) of groin pain in adult (>18 years) athletes were included. The primary outcome was return to full sporting activity and secondary outcomes included percentage success rates and complications of operations. Results Only 18 studies fulfilled the search criteria with both laparoscopic and sports hernia repairs. The studies were mainly observational with some reporting comparative data, but no large randomised controlled trials were detected. The median return to sporting activity of 4 weeks (28 days) was the same for the TAPP as well as TEP techniques. No real difference in secondary outcome measures was shown. More reported cases to date in the literature used the TAPP technique compared with TEP repair (n=605 vs n=266). Conclusions Laparoscopic surgery for elite athlete groin pain is increasingly becoming more common with almost 1000 patients reported since 1997. No particular laparoscopic technique appears to offer any advantage over the other.
INTRODUCTION
To cite: Paajanen H, Montgomery A, Simon T, et al. Br J Sports Med 2015;49:814–818.
Inguinal injury, commonly seen in active sports persons, is a condition recognised by symptoms of chronic groin pain. It is a challenging problem among not only athletes but also members of the general population who undertake any form of amateur physical activity, both from a physiological and diagnostic perspective, as no true hernia exists.1–3 The prevalence of chronic groin pain in sportsmen is described as being between 5% and 10%. The currently acceptable nomenclatures used to describe this chronic pain syndrome include inguinal disruption (ID), athletic pubalgia (AP), sportsman’s hernia, sports hernia or Gilmore’s groin. A recent multidisciplinary consensus meeting understood this discrepancy and attempted to determine the current position on the nomenclature, definition, diagnosis, imaging modalities and management of sportsman’s groin.4 The Consensus overwhelmingly agreed that the term ‘inguinal
disruption’ (ID) best describes this entity, but it did not fully commit to the ‘preferred’ operative technique for it. In athletes, long-standing inguinal pain is recognised to be caused mainly by three different pathological entities: (1) injury of the posterior wall of the inguinal canal (ID or ‘sports hernia’), (2) various tendinopathies around the pubic tubercle or (3) the AP as a result of a pubic bone stress injury (figure 1). Therefore, in the present review, the term ID/AP is used for chronic groin pain in athletes. Many reports have described varying degrees of success of between 70% and 90% for open as well as for laparoscopic surgical techniques in repairing ID/AP.5–9 In conventional inguinal hernia surgery, laparoscopic repair has been shown to be superior to open repair in terms of early return to work, less postoperative pain, improved quality of life as well as a reduced incidence of chronic pain.10–13 Following this rationale and evidence, laparoscopic repair of ID/AP should technically achieve the same beneficial operative success and advantages as those for conventional inguinal hernias, with an early return to sporting activity being the primary aim. The minimal access approaches include laparoscopic transabdominal pre-peritoneal (TAPP) and endoscopic total extraperitoneal (TEP) techniques.8 9 In both techniques, a polypropylene mesh is introduced behind the injured groin area; this is known as a posterior pre-peritoneal or retroperitoneal approach (figures 2 and 3). The aim of this review is to focus on the outcome of the laparoscopic treatment of ID/AP in the literature to date. In this systematic review, we included adult athletes with long-standing groin pain treated by laparoscopic surgery. Comparison of TAPP versus TEP techniques with the primary outcome (return to full sporting activity) and secondary outcomes (success and complications of operation) was analysed.
METHODS The PRISMA guidelines for systematic reviews were consulted when designing this review.14 The research analysis was to report and understand the outcomes in the increasing use of laparoscopic surgery for the treatment of athlete’s groin pain. The following primary outcome was return to full sporting activity. Secondary outcomes included postoperative recovery, complications and rate of success (%). Data were obtained from cohort studies meeting the inclusion criteria as outlined below.
STUDY ELIGIBILITY CRITERIA Reported series undertaking minimal access surgery to treat long-standing pain (ID/AP) in adult
Paajanen H, et al. Br J Sports Med 2015;49:814–818. doi:10.1136/bjsports-2014-094544
1 of 6
Downloaded from http://bjsm.bmj.com/ on June 24, 2015 - Published by group.bmj.com
Review SEARCH STRATEGY AND INFORMATION RESOURCES
Figure 1 Pain triangle describing the multifaceted nature of pain in athlete’s groin. The majority of patients may initially have (1) weakness of the posterior wall of inguinal canal (‘sports hernia’), (2) insertion tendonitis of adductors or (3) pubic bone marrow oedema, that is, osteitis pubis. The chronic pain may shift location and may also circle from adductors to pubic symphysis. (>18 years) athletes with at least the primary outcome measure were included in the review. Searches were performed to obtain all the relevant articles on the topic of sportsman’s groin pain including investigations, management and, in particular, surgical repair, using medical subject headings and freetext terms (see below). No language restrictions were applied to the searches. Generic and specially developed search filters were both employed when necessary. Hand searching of journals not indexed on the biomedical databases was not carried out. The search included pathophysiological mechanisms behind the condition, diagnostic methods and results from endoscopic treatment. The review was conducted up to September 2014.
A literature search was performed in PubMed, SCOPUS (1960 onwards), UpToDate, Web of Science Core Collection, Cochrane Central Register of Controlled Trials (Issue 2 of 12 February 2015, the Cochrane Database of Systematic Reviews (Issue 3 of 12 March 2015) and Cochrane Health Technology Assessment Database (Issue 1 of 4 September 2014). The search query we systematically used in all databases, excepting UpToDate, was (“sportsman’s groin” OR “sportsman’s hernia” OR “athletic pubalgia” OR “inguinal disruption” OR “athlete’s groin” OR “athlete’s groin pain” OR “pubic inguinal pain” OR “pubic inguinal pain syndrome” OR “Gilmore’s groin”) AND (“laparoscopic surgery” OR “endoscopic surgery”). For UpToDate’s limited search field, we simplified the query to (sportsman* OR athlet* OR Gilmore*) AND (groin OR hernia OR pubalgia OR inguinal OR pubic OR pain) AND (laparoscopic OR endoscopic) AND surgery. The following limits were applied: English language and human. Electronic and bibliographic searches of all retrieved articles were performed to identify further studies of interest.
STUDY SELECTION, DATA EXTRACTION AND RISK OF BIAS Two authors independently identified studies for inclusion and differences were resolved by consensus discussion. In the case of multiple publications of the same study population, only the latest publication was included. Studies that met the inclusion criteria were reviewed in full text, along with those for which it was unclear whether the criteria had been met. Data extraction was performed using a standard proforma. The following information was obtained: author, publication date, study size, intervention (TAPP or TEP), mesh used, outcomes assessed, length of follow-up, statistical method and results. Where patients were lost to follow-up, the remaining numbers have been represented as a numerical fraction, if appropriate. To standardise the
Figure 2 Anterior (left) and posterior (right) view of the groin area. Both in transabdominal pre-peritoneal and total extraperitoneal procedures the mesh is placed in the pre-peritoneal retropubic space (broken oval line) and it covers most of the injured groin areas, that is, (1) posterior wall of the inguinal canal, (2) pubic insertion of rectus abdominis muscle, (3) the periosteum of pubic symphysis and insertion of adductors, and (4) insertion of inguinal and lacunar ligaments, as well as the internal ring. 2 of 6
Paajanen H, et al. Br J Sports Med 2015;49:814–818. doi:10.1136/bjsports-2014-094544
Downloaded from http://bjsm.bmj.com/ on June 24, 2015 - Published by group.bmj.com
Review Figure 3 Endoscopic total extraperitoneal view of disrupted groin (left) and covered with polypropylene mesh (right). This patient had muscle injury at the insertion of rectus abdominis muscle and tendon near the pubic bone (needle mark), and weakness of the posterior wall of the inguinal canal.
number of patients that fully recovered after surgery, a percentage value was applied.
STATISTICAL ANALYSIS A p value
Review
Systematic review: laparoscopic treatment of long-standing groin pain in athletes Hannu Paajanen,1 Agneta Montgomery,2 Thomas Simon,3 Aali J Sheen4 1
Department of Surgery, Kuopio University Hospital, Kuopio, Finland 2 Department of Surgery, Skåne University Hospital, Malmö, Sweden 3 GRN-Klinik Sinsheim, Heidelberg University Hospital, Heidelberg, Germany 4 Department of Surgery, Central Manchester Foundation Trust, Manchester Royal Infirmary and University of Manchester, Manchester, UK Correspondence to Professor Hannu Paajanen, Department of Surgery, Kuopio University Hospital, PL 1777, Kuopio 70211, Finland; hannu.paajanen@kuh.fi Accepted 6 April 2015
ABSTRACT Objectives No single aetiological factor has been proven to cause long-standing groin pain in athletes and no sole operative technique (either open or laparoscopic) has been shown to be the preferred method of repair. The aim of this systematic review was to determine whether there are any differences in the return to full sporting activity following laparoscopic repair of groin pain in athletes. Data sources The minimal access approaches include laparoscopic transabdominal pre-peritoneal (TAPP) or endoscopic total extraperitoneal (TEP) techniques. A systematic literature search was performed in PubMed, SCOPUS, UpToDate and the Cochrane Library databases. Series reporting laparoscopic repair (TAPP/TEP) of groin pain in adult (>18 years) athletes were included. The primary outcome was return to full sporting activity and secondary outcomes included percentage success rates and complications of operations. Results Only 18 studies fulfilled the search criteria with both laparoscopic and sports hernia repairs. The studies were mainly observational with some reporting comparative data, but no large randomised controlled trials were detected. The median return to sporting activity of 4 weeks (28 days) was the same for the TAPP as well as TEP techniques. No real difference in secondary outcome measures was shown. More reported cases to date in the literature used the TAPP technique compared with TEP repair (n=605 vs n=266). Conclusions Laparoscopic surgery for elite athlete groin pain is increasingly becoming more common with almost 1000 patients reported since 1997. No particular laparoscopic technique appears to offer any advantage over the other.
INTRODUCTION
To cite: Paajanen H, Montgomery A, Simon T, et al. Br J Sports Med 2015;49:814–818.
Inguinal injury, commonly seen in active sports persons, is a condition recognised by symptoms of chronic groin pain. It is a challenging problem among not only athletes but also members of the general population who undertake any form of amateur physical activity, both from a physiological and diagnostic perspective, as no true hernia exists.1–3 The prevalence of chronic groin pain in sportsmen is described as being between 5% and 10%. The currently acceptable nomenclatures used to describe this chronic pain syndrome include inguinal disruption (ID), athletic pubalgia (AP), sportsman’s hernia, sports hernia or Gilmore’s groin. A recent multidisciplinary consensus meeting understood this discrepancy and attempted to determine the current position on the nomenclature, definition, diagnosis, imaging modalities and management of sportsman’s groin.4 The Consensus overwhelmingly agreed that the term ‘inguinal
disruption’ (ID) best describes this entity, but it did not fully commit to the ‘preferred’ operative technique for it. In athletes, long-standing inguinal pain is recognised to be caused mainly by three different pathological entities: (1) injury of the posterior wall of the inguinal canal (ID or ‘sports hernia’), (2) various tendinopathies around the pubic tubercle or (3) the AP as a result of a pubic bone stress injury (figure 1). Therefore, in the present review, the term ID/AP is used for chronic groin pain in athletes. Many reports have described varying degrees of success of between 70% and 90% for open as well as for laparoscopic surgical techniques in repairing ID/AP.5–9 In conventional inguinal hernia surgery, laparoscopic repair has been shown to be superior to open repair in terms of early return to work, less postoperative pain, improved quality of life as well as a reduced incidence of chronic pain.10–13 Following this rationale and evidence, laparoscopic repair of ID/AP should technically achieve the same beneficial operative success and advantages as those for conventional inguinal hernias, with an early return to sporting activity being the primary aim. The minimal access approaches include laparoscopic transabdominal pre-peritoneal (TAPP) and endoscopic total extraperitoneal (TEP) techniques.8 9 In both techniques, a polypropylene mesh is introduced behind the injured groin area; this is known as a posterior pre-peritoneal or retroperitoneal approach (figures 2 and 3). The aim of this review is to focus on the outcome of the laparoscopic treatment of ID/AP in the literature to date. In this systematic review, we included adult athletes with long-standing groin pain treated by laparoscopic surgery. Comparison of TAPP versus TEP techniques with the primary outcome (return to full sporting activity) and secondary outcomes (success and complications of operation) was analysed.
METHODS The PRISMA guidelines for systematic reviews were consulted when designing this review.14 The research analysis was to report and understand the outcomes in the increasing use of laparoscopic surgery for the treatment of athlete’s groin pain. The following primary outcome was return to full sporting activity. Secondary outcomes included postoperative recovery, complications and rate of success (%). Data were obtained from cohort studies meeting the inclusion criteria as outlined below.
STUDY ELIGIBILITY CRITERIA Reported series undertaking minimal access surgery to treat long-standing pain (ID/AP) in adult
Paajanen H, et al. Br J Sports Med 2015;49:814–818. doi:10.1136/bjsports-2014-094544
1 of 6
Downloaded from http://bjsm.bmj.com/ on June 24, 2015 - Published by group.bmj.com
Review SEARCH STRATEGY AND INFORMATION RESOURCES
Figure 1 Pain triangle describing the multifaceted nature of pain in athlete’s groin. The majority of patients may initially have (1) weakness of the posterior wall of inguinal canal (‘sports hernia’), (2) insertion tendonitis of adductors or (3) pubic bone marrow oedema, that is, osteitis pubis. The chronic pain may shift location and may also circle from adductors to pubic symphysis. (>18 years) athletes with at least the primary outcome measure were included in the review. Searches were performed to obtain all the relevant articles on the topic of sportsman’s groin pain including investigations, management and, in particular, surgical repair, using medical subject headings and freetext terms (see below). No language restrictions were applied to the searches. Generic and specially developed search filters were both employed when necessary. Hand searching of journals not indexed on the biomedical databases was not carried out. The search included pathophysiological mechanisms behind the condition, diagnostic methods and results from endoscopic treatment. The review was conducted up to September 2014.
A literature search was performed in PubMed, SCOPUS (1960 onwards), UpToDate, Web of Science Core Collection, Cochrane Central Register of Controlled Trials (Issue 2 of 12 February 2015, the Cochrane Database of Systematic Reviews (Issue 3 of 12 March 2015) and Cochrane Health Technology Assessment Database (Issue 1 of 4 September 2014). The search query we systematically used in all databases, excepting UpToDate, was (“sportsman’s groin” OR “sportsman’s hernia” OR “athletic pubalgia” OR “inguinal disruption” OR “athlete’s groin” OR “athlete’s groin pain” OR “pubic inguinal pain” OR “pubic inguinal pain syndrome” OR “Gilmore’s groin”) AND (“laparoscopic surgery” OR “endoscopic surgery”). For UpToDate’s limited search field, we simplified the query to (sportsman* OR athlet* OR Gilmore*) AND (groin OR hernia OR pubalgia OR inguinal OR pubic OR pain) AND (laparoscopic OR endoscopic) AND surgery. The following limits were applied: English language and human. Electronic and bibliographic searches of all retrieved articles were performed to identify further studies of interest.
STUDY SELECTION, DATA EXTRACTION AND RISK OF BIAS Two authors independently identified studies for inclusion and differences were resolved by consensus discussion. In the case of multiple publications of the same study population, only the latest publication was included. Studies that met the inclusion criteria were reviewed in full text, along with those for which it was unclear whether the criteria had been met. Data extraction was performed using a standard proforma. The following information was obtained: author, publication date, study size, intervention (TAPP or TEP), mesh used, outcomes assessed, length of follow-up, statistical method and results. Where patients were lost to follow-up, the remaining numbers have been represented as a numerical fraction, if appropriate. To standardise the
Figure 2 Anterior (left) and posterior (right) view of the groin area. Both in transabdominal pre-peritoneal and total extraperitoneal procedures the mesh is placed in the pre-peritoneal retropubic space (broken oval line) and it covers most of the injured groin areas, that is, (1) posterior wall of the inguinal canal, (2) pubic insertion of rectus abdominis muscle, (3) the periosteum of pubic symphysis and insertion of adductors, and (4) insertion of inguinal and lacunar ligaments, as well as the internal ring. 2 of 6
Paajanen H, et al. Br J Sports Med 2015;49:814–818. doi:10.1136/bjsports-2014-094544
Downloaded from http://bjsm.bmj.com/ on June 24, 2015 - Published by group.bmj.com
Review Figure 3 Endoscopic total extraperitoneal view of disrupted groin (left) and covered with polypropylene mesh (right). This patient had muscle injury at the insertion of rectus abdominis muscle and tendon near the pubic bone (needle mark), and weakness of the posterior wall of the inguinal canal.
number of patients that fully recovered after surgery, a percentage value was applied.
STATISTICAL ANALYSIS A p value
