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Its just a hernia !
Mr.SanjayPandanaboyanaMS,FRCS(UK),MPhilGeneral,HepatobiliaryandPancrea?cSurgeon
AucklandCityHospital
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Its just a hernia !
• Sportsman'shernia
• Laparoscopicversusopenherniarepair• ACCandInguinalherniacover
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Sportsman's hernia
Gilmore’sherniaIncipientherniaAthle3cPubalgiaSoccerplayergroinSportsman'sgroinHockeygroinsyndrome
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Inguinaldisrup-on
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Inguinal disrup7on Noactualhernia!!!ThepaintypicallyaHersportsac?vity,getsbeJerwithrest,returnswithsportsac?vityAbnormalincreasedtensionintheinguinalcanal1. Posteriorwallweakness2. Conjointtendondamage3. TearsintheinguinalligamentGenerallyabovetheinguinalligament
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Inguinal disrup7on: Differen7al diagnosis
• Acetabularinjury
• Pubicramusfractures• Ostei?spubis
• PubicSymphysi?s• Hippathology
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Inguinal disrup7on: Pain zones
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PinpointtendernessoverthepubictubercleTendernessonthedeepinguinalringTendernessonsuperficialinguinalringPainattheoriginofadductorlongustendonDiffusedullpaininthegroin,radia?ngtotheperineumandinnerthigh
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Inguinal disrup7on: Inves7ga7ons
• Ultrasoundoftheinguinalcanal• MRIpelvistoexcludeotherpathology
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Inguinal disrup7on: Is surgery always advised? Algorithm for the management of inguinal disrup7on
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Issurgeryeffec?ve?
RandomisedintoOpera?ve(n=30)orphysiotherapygroup(n=30)Opera?verepairwasmoreeffec?vetodecreasechronicgroinpainaOer1monthandupto12monthsoffollow-up(P<0.001).90%intheopera?vegroupreturnedtosportsac?vi?esvs.27%inthenonopera?vegroup.Laparoscopicmeshreinforcementwasmoreefficientthanconserva?vetherapy
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Laparoscopic mesh reinforcement
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Inguinal hernia
Laparoscopicoropensurgery?
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• 34RCT’sincluding6804pa?ents
• Dura?onofopera?on:Longerinthelaparoscopicgroup• VisceralandVascularinjuriesmorefrequentintheLaparoscopicgroup4.7%per1000
• Postopera?vepain:lowerinthelaparoscopicgroup• Lengthofhospitalstaysimilarinbothgroups• Recurrenceratessimilarbothgroups
• ChronicgroinpainandnumbnessaresignificantlyreducedbyLaparoscopicapproach
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Concomitant femoral and inguinal hernias
• 11%oflaparoscopicinguinalherniarepairshaveconcomitantfemoralhernias
• 51%ofFemoralherniarepairpa?entshaveconcomitantInguinalhernias
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ACC and Inguinal Hernia
Doesasinglestrenuouseventcauseainguinalhernia?
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Does a single strenuous event cause a inguinal hernia?
Strenuousevent! Inguinalhernia!
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520herniarepairpa?entssentques?onnaires.62%(320)responserate.
51%oftheherniasweregradualinonsetandin42%ofherniastherewasaassocia?onbetweenastrenuouseventandsuddenonsetofhernia.91%ofpa?entsreportedgroinpainatthe?meoftheevent74%ofpa?entshadindirectherniasinthesuddenonsetgroup.
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Other studies
• SmithGD,CrosbyDL,LewisPA(1996)Inguinalherniaandasinglestrenuousevent.AnnRCollSurgEngl78(4):367–368
• PathakS,PostonGJ(2006)ItishighlyunlikelythatthedevelopmentofanabdominalwallherniacanbeaYributabletoasinglestrenuousevent.AnnRCollSurgEngl88(2):168–171
• HendryPO,Paterson-BrownS,deBeauxA(2008)Workrelatedaspectsofinguinalhernia:aliteraturereview.Surgeon.6(6):361–365
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ACC and RACS consensus statement 2016
• Thepa?entreportsthatasinglestrenuouseventhascausedthehernia• Significantgroinpainatthe?meoftheevent,enoughceaseac?vity• Onexamina?on:Groinlump• Diagnosisismadewithin10daysofthestrenuousevent• Ifstrenuouseventoccurredatwork,incidentofficiallyreportedtoworkplace
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ACC and RACS statement
• Imagingi.e.Ultrasoundisnotnecessary.Clinicaldiagnosisissufficient
• Nodis?nc?onbetweendirectandindirectherniaisneeded
Accuratedocumenta3onisessen3al!
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Indica-onforsurgery:Symptoma-chernia!
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Thank you