Combined Endoscopic and Conservative Treatment for Complicated Sportsman Hernia

Moshe Dudai, MD. Hernia Excellence, Ramat Aviv Medical Center, Tel aviv

Sport Groin injuries are very common among athletes but also in sport active people, treating in part conservatively and in part by Endoscopic surgery. Making the diagnosis for selecting the right treatment it is a challenge but in some of the cases you will need both of the treatments.

There are well defined two kinds of Sport Groin Injury (SGI); the Sportsman Hernia (SH) – Posterior Wall Deficiency (PWD) and the Athletes Pubalgia (AP) – Pubic Bone Stress Injury (PBSI). The different criteria for diagnosis and treatment of this two SGI were clearly described in the Guiltiness for Sportsman Hernia as chapter of the International Endo Hernia guidelines published in Surgical Endoscopy 2011. In general the symptoms of SH are more lateral in the groin, sharp pain radiated to the inner tight aspect with neurologic characteristic, while the AP is more central, dull continues pain with inflammatory characteristic. The background pathology of SH is sport trauma causing small and irreversible tears and weakening of the posterior inguinal wall facial sheets and the adjusted tendons while in the AP there is a stress injury with edema and inflammatory process in the Symphysis Pubis, Pubic bone and ligaments including the tendons of the attached muscles; Rectus, Pyramidal and Adductors. Beside of different findings by anamnesis and physical examination, Dynamic US can demonstrate the SH pathology and MRI the AP pathology.

According to the SH guiltiness and the recent update, surgery is superior to conservative treatment for SH –Level 1A of evidence- and Endoscopic Total Extra Peritoneal (TEP) retro- pubic and posterior wall mesh placement is the recommended treatment for SH with excellent results – Level 1A of evidence-. On the other hand conservative treatment of Active Isometric Weight Bering Exercises (AIWBE) is recommended for AP when quit all recovered in 8-12 weeks –Level 1A of evidence-.

In our experience we found that part of the athletes presenting with findings of both types of SGI with different level of severity. SH is expressed bilateral in all but PBSI expressed in different level of severity; grade 1-5. We were impressed that the SH was the first injury and because the athlete continue with extreme sport activities on top of the SH injury, others PBSI be caused. We worked in cooperation with physiotherapist to build up a program that is a combination of Endoscopic TEP posterior wall repair and reinforcement by mesh combined with muscles sport rehabilitation. We had found that the more effective and shorter recovery combination is starting with the surgery, repairing and giving strength to the groin that act as an anchor for the active healing process of the muscles and tendons.

Athletes suffered from SGI have to be diagnosed correctly of the subtype injury for selecting conservative or the surgical way of treatment. Some of the athletes having both SH and AP, in these combined treatments of Endoscopy with muscles sport rehabilitation has to be tailored to the severity of the injuries. Selecting the right treatment secures excellent results.

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