Groin Defects Seen At Laparoscopic Extra-peritoneal Dissection During Surgical Treatment of Athletic Pubalgia

Krzysztof J Wikiel, MD, George M Eid. University of Pittsburgh Medical Center.

Background: Over the past thirty years a new disease process, now known as athletic pubalgia or sports hernia has been acknowledged, nevertheless the etiology is still not fully understood. The patients suffering from this ailment, often young and active, present to the physician’s office with unilateral or bilateral chronic groin pain associated with physical activity without a clear diagnosis of a groin hernia. These pain symptoms can lead to reduction or withdrawal from the sports activity, which not only can affect the quality of life, but in some instances can cause career and financial losses, thus further study of this entity is important. Careful physical exam often reveals groin weakness which cannot explain the complexity of the patients’ symptoms. Though physical therapy and medical treatments are considered first line remedies by many, surgical treatment appears to have better, quicker, and more durable outcomes. Based on the available literature, procedures aimed at groin reinforcement such as laparoscopic reinforcement or other hernia repairs seem to relieve most if not all the symptoms in the majority of patients. Despite many surgeons intra-operatively noting rectus insertion or adductor anomalies, multiple hernia defects are often seen during dissections and the clinical significance of these findings is still not known.

Materials and Methods: Forty patients underwent an extra-peritoneal laparoscopic reinforcement of rectus abdominals and insertion of adductor muscles for athletic pubalgia in our practice from 2007 through 2011. These patients were divided into four subgroups based on level of engagement in their respective sports. These were professional, college, high school, or recreational level sports players. All patients underwent wide and bilateral groin dissection and the findings were cataloged.

Results: All of the patients presented with some defects upon wide groin dissection. Thirty-four patients (85%) presented with small bilateral indirect inguinal defects and 28 (70%)patients did not have any additional defects. Five patients (12.5%) were found to have only unilateral inguinal hernia defects. One patient presented with a small direct defect. In addition to the defects mentioned above, five patients (12.5%) had additional unilateral femoral hernias, whereas no patient had a solitary femoral hernia defect. Additionally, we noted that within the competitive sports player group (professional, college, high school level) all the patients had only small indirect bilateral defects.

Conclusions: Athletic pubalgia is a new diagnostic entity with poorly understood etiology. It mostly affects young active adults, often involved in competitive sports, and surgical methods appear most effective at offering the cure. In our experience all of the patients presented with groin defects, though not all were the same. It is our belief that these defects, although likely not the only component, play a significant role in pathophysiology of the sports hernia.