Download Chirurg

“Sportershernia/plaatsen
matje”
Prof. dr. C.H.J. van Eijck
Afd. Heelkunde
Chirurg
Clubarts
Sportsman’s hernia
Sportsman’s hernia
• Chronic groin pain
– Incidence: 6%
– 60% during active soccer carier
– 50% > 20 weeks complaints
• Differential diagnosis
Differential diagnosis
Groin injury
• Muscle and tendon injury
– Tendon-bone or tendon-muscle
– Avulsion fracture
• Adductor longus, rectus femoris or
abdominis
• X-Pelvis, bone scan, ultrasound or MRI
Differential diagnosis
Groin injury
• Osteïtis pubis
– Painfull symfysis and adductortenoperiostitis
– Direct trauma
– Pelvic instability/Sacroiliacal abnormalities
• 25% Radiologic abnormalities
• X-Pelvis, bone scan, ultrasound or MRI
Osteïtis pubis
Osteïtis pubis
Differential diagnosis
Groin injury
• Stressfracture
– Ramus inferior os pubis (5%)
– Collum femoris
avascular necrosis
Femur head
• X-Pelvis, bone scan, (MRI)
Differential diagnosis
Groin injury
• Urologic diseae
– Prostatitis
– Epididymitis
– Urethritis
– Hydrocèle testis
– Non-descending testicle
• Rectal toucher, bact. culture, ultrasound
Differential diagnosis
Groin injury
•Hip en Spine disease
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–
–
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Osteochondritis lumbal verterbra
M. Scheuermann
Discus pathology., L1 en L2
Cam type femoroacetabular impingement
Congenital hipdysplasia
Epifysiolysis femur headkop
Avascular necrosis femur head
•X-LWK (+3/4), X-femur (Faux-profile), bone scan
and CT-scan (arthography)
Differential diagnosis
Groin injury
• Nerve entrapment/previous surgery
– N. ilio-inguinalis (symfysis)
– N. genitofemoralis (testicle)
Differential diagnosis
Groin injury
• Nerve entrapment/previous surgery
– N. ilio-inguinalis (symfysis)
– N. genitofemoralis (testicle)
– N. obturatorius (med. thigh and adductor
weakness)
• Proof blockade and/or EMG
N. obturatorius (med. thigh and
adductor weakness)
Nerve entrapment
N. obturatorius (med. thigh an
adductor weakness)
Physical examination
Groin injury
Renee Dannenburg
Physical examination
Groin injury
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•
•
•
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Lower back, SI Joint and hip
Abdominal muscles
Muscles of the upper legs
Rectal toucher
Palp funiculus and testicles
Physical examination
Groin injury
•
•
•
•
Lower back, SI Joint and hip
Abdominal muscles
Muscles of the upper legs
Rectal exam., palp funiculus and testicles
• Painfull int. and ext. annulus with
Painfull
and ext. annulus
with elevated
elevatedint.
intra-abdominal
pressure
intra-abdominal pressure
Sportsman’s hernia
•
•
•
•
Weakness of the post. inguinal wall
Symptomatic non-palpable hernia
Disruption of the ext. obl. aponeurosis
Pubalgy
Complaints
•
•
•
•
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Long existing groin pain
Pain around the external annulus
Combination with adductor-tendopathy
Good reaction on NSAID’s
Increased pain with elevated intraabdominal pressure
Pathofysiology
Sportsman’s hernia
Post wall inguinal canal: fascia
transversalis
No striated muscle fibers
Funiculus through the int. annulus
Pathofysiology
Sportsman’s hernia
Pathofysiology
Sportsman’s hernia
Post wall inguinal canal: fascia transversalis
No striated muscle fibers
Funiculus through the int. annulus
Weakness post. wall
Lat. Hernia
Tension peritoneum
Nerve entrapment
Treatment
Sportsman’s hernia
• Conservative
– Rest, Fysiotherapy and NSAID’s
Renee Dannenburg
Treatment
Sportsman’s hernia
• Conservative
– Rest, Fysiotherapy and NSAID’s
• Operative
– Strengthening of the post. Wall of
the inguinal canal
– Conventional (Lichtensteinplastiek)
– Laparoscopic
Patients
Sportsman’s hernia
• Since 1998 till present: n=240
• (Semi)professional n=98 (4 women)
• 76 soccer, 4 atletics , 3 tennis, 4 cycling, 11 misc.
• Amateur n=142 (3 women)
• 127 soccer, 15 misc.
Patients
Sportsman’s hernia
• Mean Age: 25 ± 4.5 year (17-36)
• Time complaints: 3 months till >2 years
Diagnostics
Sportsman’s hernia
• Herniografie (n=7)
– High false-negative percentage
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Ultrasonography (n=167)
X-pelvic and femur (n=68)
Bone scan (n=53)
CT-scan (n=22)
MRI (n=57)
Laparoscopy (n=1)
1
Indirect H .inguinalis
2
Patients
Sportsman’s hernia
• Open Lichtenstein n=3
• Laparoscopic TEP n=237
• Tenotomy n=12
• Left n=86
• Right n=89
• Both n=65
Total Extra Perinoneal (TEP)
Total Extra Perinoneal (TEP)
Total Extra Perinoneal (TEP)
Laparoscopy
TEP right
Total Extra Perinoneal (TEP)
Laparoscopy
Laparoscopy
Laparoscopy
Total Extra Perinoneal (TEP)
Total Extra Perinoneal (TEP)
Peroperative findings
Sportsman’s hernia
• (Min.) lateral hernia n=65
•
•
•
•
(Min.) medial hernia n=24
Preperitoneal lipoma n=39
Enlarged lymph nodes n=32
No abnormallities n=80
Complications
Sportsman’s hernia
• Sup. woundinfection (S.aureus) (n=4)
• Adductor longus tendinopathy (n=14)
 tenotomie (n=4)
• Mesh irritation/seroma (Prolene®)
(n=12)
• Mesh displacement ( n=4)
• Giant cell tumor re prox. femur (n=1)
• Sports recovery
Sportsman’s hernia
Time
Revalidation
Week 0 - 1
Week 1 - 2
Renee Dannenburg
Week 2 - 3
Week 3 - 5
Week 6
Sportsman’s hernia
Time
Purpose
Therapy
Week 0 - 1
Wound recovery
Pain management
Walking 5 km/h
Week 1 - 2
Optimizing scar tissue
Preventing muscle atrophia
Aqua training
Power walking
Cycle ergometer
Isometric training Rect. Abd.
Steps
Week 2 - 3
Dynamic training Rect. Abd.
Functional exercise
Sit-ups
Running
Lunges
Week 3 - 5
Sport specific training
Weight training
Normal training
Week 6
Normal training
Sportsman’s hernia
Sportsman’s hernia
• Recovery
– Without tenotomy: 4-8 weeks
– With tenotomy: 8- 16 weeks
Conclusion
The TEP is an efficient method for the
treatment of patients with a
Sportsman’s hernia
Dank voor jullie
aandacht en veel
succes verder