La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK...
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Transcript of La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK...
Dr. Ulrike Muschaweck
The Sportsmen´s Groin – Diagnostics & Therapy
The Minimal Repair Technique
Financial Disclosures
nothing to declare
Expert-Panel
6 experts 6 definitions 6 diagnoses 6 therapies
What are we talking about?
?Causes of groin pain in athletes are numerous
Sport hernia is one of the least understood poorly defined and under-researched maladies to affect the human body. The media has popularized the use of this diagnostic term, but the actual injury characteristics are poorly defined. Sports hernia reflects a compilation of diagnosis grouped together with a wide range of other pathologies that need to be excluded before this should be considered a diagnosis. (Nam A; Brody F. Management and therapy of sports hernia. AmCollSurg 2008)diagnosis of exclusion!?
diagnosis of exclusion!?
Sports hernia has been described as a common diagnosis in otherwise unexplained chronic groin pain (Farber AJ. Wilckens JH. Sports hernia: Diagnosis and therapeutic approach. J Am Acad Surg 2007)
attempted explanation…
Consensus summaryInguinal Disruption is a condition recognised by groin pain and is commonly seen in very active sports persons. It can be defined as pain in the inguinal region near the pubic tubercle, which may have an insidious or acute onset and where no obvious other pathology exists to explain the symptoms.
Br J Sports Med 2013
preferred terminology should be
Inguinal Disruption (ID)
diagnosis of exclusion?
Inguinal Disruption??
Pathology
What is a sportsmen‘s groin?
Weakness of the posterior wall of the inguinal canal (transversal fascia)
causes localized bulging
compresses an afferent nerve (genital branch of the genito-femoral nerve)
„Blue Line“ - thegenital branch ofthe genito-femoralnerve
Weakness of the posterior wall
It is not a hernia!
Pathology
Morphological findings of the genital branch
PathologyMorphological findings
Pathology
Cranial and medial displacement of the rectus abdominis muscle
Increasing tension at the pubic bone (Os pubis)
Pubalgia
Diagnosis
• Dull, sharp or burning pain • Radiation into inner upper thigh
(adductors), scrotum and/or lower back and pubic bone
Typical sign of a nerve irritation (genital branch of the genito-femoral nerve)
We need to listen to our patients!
Diagnosis
Clinical Examination
• A palpable bulge of the posterior wall of the inguinal canal and a dilatation of the internal inguinal ring (peritoneal protrusion) can be detected during “Valsalva-Maneuver” “Valsalva-Maneuver” by a skilled examiner.
• painful when exerting pressure on the posterior wall (transversal fascia)
We need to examine our patients!
Diagnosis
Imaging• Static and dynamic Ultrasound with a high-
frequency transducer 5-13 MHz- a distinct protrusion of the transverse fascia
during “Valsalva-Maneuver” “Valsalva-Maneuver” can be detected with experience- the size of the circumscribed weakness in
the area of the posterior wall can be measured
• MRI not significant (recumbent position)
We need verifiable parameters!
Diagnosis (Ultrasound)
Weakness of the posterior wall of the inguinal canal
Diagnosis (Dynamic US)
Treatment consideration
Primum nihil nocere - above all do not harm
Conservative Treatment
High dosages of NSAIDs (combined with B vitamins)
However: following diagnosis only a 4-6 week time frame remains for conservative treatment:
Otherwise there is an increased risk of subsequent chronic inguinal pain
Surgical Options
Mesh-free techniques
Gilmore TechniqueBassiniShouldiceMinimal Repair
Mesh techniques
LichtensteinTIPPPlug&PatchUHS/PHSMIC (TAPP/TEP)Combination with
- inguinal ligament tenotomy- adductor release tenotomy- ligament shaving
Surgical Results
Open mesh free (n = 226) 89 daysOpen mesh (n = 42) 100 days
TAPP/TEP (n = 472) 92 days
Return to normal activity:
What can happen.. after UHS
• Professional Goal keeper with groin pain• UHS-Repair 8/2011• „no lateral hernia sac detected during operation“• Post-operative chronic pain syndrome• Surgical revision and thermic denervation of N. ilioinguinalis and R.femoralis
11/2011 without any effect
What can happen….. after TAPP
• Professional football striker with groin pain • Minimal invasive surgery with TAPP and large pore mesh 2012• Persisting pain after operation
What can happen….. after Lichtenstein
• Professional football player with groin pain • Open repair with Lichtenstein and large pore mesh 2013• Persisting pain directly after surgery• Conservative pain treatment for 6 month
Is mesh repair the solution?
3D-MRI-Reconstruction
What does the patient want
no recurrence no pain no foreign material (if possible) no sick leave no general anaesthesia no hospital stay no negative long term effects no complications … and if, please treatable!
Selection of the Method
Criteria: - no hernia sack - but: distinct protrusion (bulge) of the
transverse fascia during “Valsalva-Maneuver”
- compression of an afferent nerve
Search for a procedure without the risk of mesh induced complications taking the
pathology of sportsmen`s groin into account
Hernia Centre Munich London
Surgery in local anaesthesia Admission in the morning/ Discharge in the
evening of the day of surgery
Development of a new technique for professional athletes -“Minimal Repair”- in 2002
Surgical Goals:
• Goal 1: Reducing pain quickly
• Goal 2: Retaining the slide bearing function of the abdominal wall
• Goal 3: Rapid return of exercise tolerance and peak performance for top athletes
Minimal Repair
Local Anaesthesia
1. Initial block ventral/cranial of the anterior iliac spine
2. Ropivacain 7,5 mg/ml 20–30 ml
3. Injection in the area of planned incision with Ropivacain 7,5 mg/ml 10ml
4. Intraoperative re-injection in the ilio-inguinal nerve and the genital branch of the genito-femoral nerve
• Only the defect is opened (sound tissue remains intact)
• Contains only preperitoneal fat, no hernia sack
• If necessary resection of the genital branch of the genito-femoral nerve
Surgical Steps
• Stabilizing the posterior wall
• Reducing the tension of the rectus abdominis muscle
• Suture line over the pubic bone
Surgical Steps
• Creating a muscular
collar to protect the
preserved nerve and
the plexus
pampiniformis
Surgical Steps
Postoperative Training Ability
• Weight lifting directly after surgery• Training (running, biking) is resumed as early as
post-operative day (POD) 2
• Beginning of training POD 3 - 4• Complete training possible for athletes, including
kicking and sprinting on POD 5 • Peak performance achieved between POD 10
and 14
„DO WHAT YOU WANT TO DO!!!!“
With the Minimal Repair technique, we observed neither minor nor major complications during a follow-up of 30 days.In 87 professional athletes repairs the time to return to pre-injury sports activity levels amounted to 14 days
This study shows that the Minimal Repair technique allows an excellent relief of groin pain with fast recovery to full sporting activities.
early results
Long-term results5 year follow–up after Minimal Repair in professional atheletes
Questionnaire and/or telephone interview
- still active athelete?
- did any symptoms return?
- pain score (NAS)
- pain quality/ intensity/ character?
- any need for medication for groin pain?
- limitation of performance?
- sensitivity of the groin/ numbness?
- was another operation performed?
- overall satisfaction?
Long-term results5 year follow–up after Minimal Repair in professional athelets
n = 65 hernia-repairs = 75% follow-up ratemedian age: 29 years (range 27-33y)median follow-up: 5.5 y
95,4%
4.6%
Nerve resection-R.genitalis 28%
preliminary results
Conclusion
Pathologies in the groin can be multifarious!
Sportmen`s groin is a entity of its own! Not a diagnosis by exclusion!
We need to listen and investigate our patients carefully!
Necessity for Surgery?
YES!
• Only if diagnosis shows weakness of the posterior wall with bulging (by a skilled examiner)
• If the pain is severe• If the athlete is handicapped• Failed conservative treatment
To avoid chronic pain syndrome
Overtreatment?
NO!
• Only the defect is repaired• No sound or intact structures are
destroyed• The cause of the pain is removed• Preservation of the slide bearing of the
abdominal wall • No loss of elasticity due to mesh
implantation• No risk of mesh induced complications
Minimal procedure with maximal effect
Is there any prevention???
NO!
Thank you very much!
www.herniacenter.eu