Systematic review: laparoscopic treatment of long-standing groin pain in athletes.

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.

Anatomy and terminology of groin pain: Current concepts.

Groin pain is a common symptom in athletes. The complex anatomy of the area and the various terms used to describe the etiology behind groin pain have led to a confusing nomenclature. To solve this problem, three consensus statements have been already published in the literature: the Manchester Position Statement in 2014, the Doha agreement in 2015, and the Italian Consensus in 2016. However, when revisiting recent literature, it is evident that the use of non-anatomic terms remains common, and the diagnoses sports hernia, sportsman's hernia, sportsman's groin, Gilmore's groin, athletic pubalgia, and core muscle injury are still used by many authors. Why are they still in use although rejected? Are they considered synonyms, or they are used to describe different pathology? This current concepts review article aims to clarify the confusing terminology by examining to which anatomical structures authors refer when using each term, revisit the complex anatomy of the area, including the adductors, the flat and vertical abdominal muscles, the inguinal canal, and the adjacent nerve branches, and propose an anatomical approach, which will provide the basis for improved communication between healthcare professionals and evidence-based treatment decisions.

Intestinal perforation secondary to blunt inguinal trauma in a soccer player: a case report.

BACKGROUND: Intestinal perforation caused by blunt trauma to an inguinal hernia is a very uncommon event. CASE REPORT: We present the case of a 55-year old man who suffered trauma to the inguinal area while playing soccer and later developed intense abdominal pain with no categorical signs of peritoneal irritation. Computed tomography scan at arrival showed a right inguinal hernia, with partial protrusion of the ileum, inflammatory changes of the mesenteric fat tissue inside the hernial sac, and free intraperitoneal fluid. Several hours later he developed hypotension and fever. An emergency laparotomy was performed, revealing ileum perforation with peritonitis. Intestinal perforation was repaired without intestinal resection. After surgery, the patient developed severe septic shock with multiple organ failure. He recovered without sequelae and was discharged 3 weeks later. CONCLUSION: This case emphasizes the potential clinical complications associated with this condition.

Groin pain beyond the hip: how anatomy predisposes to injury as visualized by musculoskeletal ultrasound and MRI.

OBJECTIVE: The purpose of this article is to show ultrasound and MRI examples of the normal anatomic structures and their resulting modifications from trauma and disease. CONCLUSION: Although groin pain from hip pathology is well recognized, lower anterior abdominal wall and anterior pelvis structures can be interrelated sources of pain.

Doxycycline sclerotherapy for post-traumatic inguinal lymphocele in a child.

Lymphoceles are abnormal collections of lymphatic fluid caused by a disruption in the lymphatic channels and leakage of lymph. This most commonly occurs after surgical procedures, but occasionally lymphoceles may be the result of trauma, more commonly penetrating trauma. Lymphoceles resulting from blunt trauma are rare in both adults and children. In the adult population, there are few published case reports, and management principles vary. To date, there are no reports of traumatic lymphoceles in the paediatric population, and therefore there is no precedent for treatment. Here, we report the case of a young boy who developed an inguinal lymphocele from a bicycle handle bar injury which was successfully treated with doxycycline sclerotherapy.

Athletes with inguinal disruption benefit from endoscopic totally extraperitoneal (TEP) repair.

PURPOSE: Inguinal disruption, a common condition in athletes, is a diagnostic and therapeutic challenge. The aim of this study was to evaluate the effect of endoscopic totally extraperitoneal (TEP) repair in athletes with inguinal disruption, selected through a multidisciplinary, systematic work-up. METHODS: An observational, prospective cohort study was conducted in 32 athletes with inguinal disruption. Athletes were assessed by a sports medicine physician, radiologist and hernia surgeon and underwent subsequent endoscopic TEP repair with placement of polypropylene mesh. The primary outcome was pain reduction during exercise on the numeric rating scale (NRS) 3 months postoperatively. Secondary outcomes were sports resumption, physical functioning and long-term pain intensity. Patients were assessed preoperatively, 3 months postoperatively and after a median follow-up of 19 months. RESULTS: Follow-up was completed in 30 patients (94%). The median pain score decreased from 8 [interquartile range (IQR) 7-8] preoperatively to 2 (IQR 0-5) 3 months postoperatively (p < 0.001). At long-term follow-up, the median pain score was 0 (IQR 0-3) (p < 0.001). At 3 months, 60% of patients were able to complete a full training and match. The median intensity of sport was 50% (IQR 20-70) preoperatively, 95% (IQR 70-100) 3 months postoperatively (p < 0.001), and 100% (IQR 90-100) at long-term follow-up (p < 0.001). The median frequency of sport was 4 (IQR 3-5) times per week before development of symptoms and 3 (IQR 3-4) times per week 3 months postoperatively (p = 0.025). Three months postoperatively, improvement was shown on all physical functioning subscales. CONCLUSIONS: Athletes with inguinal disruption, selected through a multidisciplinary, systematic work-up, benefit from TEP repair.

[Inguinal pain in sportmen: clinical and radiological examinations]. / Douleurs inguinales chez le sportif: examen clinique et radiologique.

Pain of the inguinal region is a frequent but difficult diagnostic problem. It may be induced by accidents, overload due to sports or profession as well as daily life activities. Numerous anatomic structures of the inguinal or hip region may be injured, but one should also think about adjacent structures as the bowel, uro-genital system, spine and nerves. The goal of this article is to describe which clinical and imaging parameters allow to establish a correct diagnosis for each patient.

Laparoscopic repair of groin pain in athletes.

BACKGROUND: There has been increasing interest regarding the cause and treatment of groin pain in athletes. The most common finding is a deficiency of the posterior wall of the inguinal canal, often repaired with bilateral inguinal myorrhaphy. HYPOTHESIS: Laparoscopic repair will offer a shorter convalescent period and better results as compared with open myorrhaphy. STUDY DESIGN: Retrospective review of prospectively collected data. METHODS: Between October 1993 and October 2002, 131 athletes with groin pain unrelieved after 2 to 8 months of conservative management underwent bilateral laparoscopic repair with the transabdominal preperitoneal technique for hernias. In 123 (94%) patients, physical examination revealed a dilated external ring, unilateral or bilateral, of the inguinal canal, and in 8 patients (6%) it was normal. RESULTS: During laparoscopy, a deficiency of the posterior inguinal wall was seen in all athletes. All patients left the hospital 24 hours after the procedure, discontinued oral analgesics within 72 hours of surgery, and were back to full sporting activities within 2 to 3 weeks. Four patients (3%) complained of thigh pain. After a mean follow-up of 5 years (range, 4 months to 10 years), there was 1 recurrence (0.76%). CONCLUSIONS: Laparoscopic repair is an efficient method for the treatment of groin pain originating from a deficiency of the posterior inguinal wall, having fast recovery and excellent long-term results.

Small bowel perforation due to blunt trauma directly to the inguinal region: a case report.

We report on a patient with intestinal perforation caused by direct blunt trauma to the inguinal region. The patient had been previously diagnosed with an inguinal hernia. The perforation was managed surgically, and he subsequently underwent hernia repair. In our opinion, intestinal perforation caused by inguinal region trauma in patients with inguinal hernias is a rare and unfortunate situation but one that reveals the importance of inguinal hernia repair.

Vascular injury by tacks during totally extraperitoneal endoscopic inguinal hernioplasty.

Totally extraperitoneal laparoscopic hernioplasty is a consolidated approach for treating recurrent and bilateral inguinal hernias. However, it may be associated, albeit very rarely, with vascular lesions that can endanger the patient's life. A proper anatomic knowledge of the posterior aspect of the inguinal region and a perfect command of the laparoscopic technique are essential for avoiding and, if necessary, treating these lesions. We present an unusual case of an arterial lesion of the aberrant obturator artery of the corona mortis during fixation of the mesh with a tacker.

El empalamiento inguinal como reto diagnóstico y terapéutico para el médico y cirujano de urgencias / Inguinal impalement; diagnostic and therapeutic challenge for emergency medical and surgeon

Introducción: el objetivo de este trabajo es presentar un caso de empalamiento a través de la región inguinal. Las heridas por empalamiento son infrecuentes y, en ocasiones, de extrema gravedad, necesitan de una actuación rápida del personal médico de urgencias y del cirujano. Caso clínico: se presenta el caso de un varón de 40 años que sufrió un accidente laboral con empalamiento de un hierro de ferralla a través de la región inguinal derecha, el cuerpo extraño penetró en la cavidad abdominal. Se expone ampliamente el caso clínico, así como los procedimientos realizados en el diagnóstico y el tratamiento de este tipo de lesiones. Conclusiones: las heridas por empalamiento son infrecuentes y suponen un reto para el personal médico que atiende al afectado desde el primer momento, tanto por lo complejas que pueden ser, como por la necesidad de una actuación rápida, sin poder conocer a priori, en muchas de las situaciones, la extensión verdadera de las lesiones, que se evidenciará durante el posible acto operatorio(AU)

Introduction: the objective of this paper was to present a case of impalement through the inguinal region. The impalement injuries are infrequent and sometimes extremely serious. These injuries require prompt action of the emergency medical personnel and surgeon. Clinical case: a forty-year old man, who had an occupational accident resulting in impalement of an iron rebar through the right inguinal region and penetrating abdominal cavity. The clinical case and the procedures performed in the diagnosis and treatment of these injuries were presented in detail. Conclusions: The impalement injuries are rare and represent a challenge to the medical staff that treat the patient from the very beginning, because they can be very complex and require fast action and treatment. In many cases, the real dimension and severity of lesions at first is unknown and can only be assessed during surgery(AU)

Could skin retraction incision minimize nerve injury over the iliac crest?

The aim of this study is to elucidate the nerve passage over the iliac crest shifted by skin retraction in harvesting iliac bone graft. A total of 44 iliac crests obtained of 22 nonembalmed Korean fresh cadavers were dissected (six males and 16 females; age range, 57-91 years). In A group (22) of "reposed skin," a skin incision was made from the anterior superior iliac spine (ASIS) to the highest level of iliac crest (HLIC). In B group (22) of "medial retraction," skin was tugged medially 1.5 cm and an incision was made from ASIS to HLIC. In A group, the nerve branches were injured in 19 (86.4%) and 15 (68.2%) in B group. Most injured nerves crossed over the iliac crest and at the posterior half site of ASIS to HLIC. The involved nerves were the subcostal nerve, iliohypogastric nerve, and ilioinguinal nerve. Subcostal nerve was less inflicted with injury in B group (one branch, 4.5%) than A group (four branches, 18.2%). P value is 0.151. Iliohypogastric nerve was significantly least injured in B group (three branches, 13.6%) compared with A group (10 branches, 45.5%). P value is 0.022. An injuring rate of ilioinguinal nerve was almost the same between A group (13 branches, 59.1%) and B group (14 branches, 63.61%). P value is 0.760. In the procedure of harvesting iliac bone graft, it is suggested to make an incision on the skin retracted medially and on the anterior half site of ASIS to HLIC to avert an injury of superficial sensory nerves.