Surgical Pearls
The objective of surgery is to help the patient. The surgeon wants to repair the injury but at the same time To Do No Harm. To help me achieve these goals I follow the following rules during hernia surgery.
- Handle the tissues delicately and with care.
- Minimize the use of the cautery. The heat and current can damage remote tissues.
- Minimize the dissection of the spermatic cord.
- Use absorbable sutures as much as possible.
- Do not place sutures in the region of the pubic tubercle or near the medial
attachment of the inguinal ligament. - When repairing the inguinal floor, avoid placing sutures in the internal oblique
muscle. The iliohypogastric nerve sometimes courses through this muscle. Use
the transversalis for the repair. - Handle the nerves little as possible.
- Know where the nerves are.
- If neurectomy is required, excise the nerve distally and bury the nerve proximally.
- Homeostasis
- Have plans to do with any unforeseen problems.
- Be sure the patient understands the procedure and has reasonable expectations
Mesh Not Always a Good Option
View the image below to see why I do not use mesh unless necessary.
This athelete’s vas deferens was scarred to the mesh. It was difficult to remove the mesh without damage to the testicle.
The second image shows the mesh after it has been removed. The mesh is stiff and fibrotic.
Successful Recovery for High Jumper
I wanted to thank you for the amazing repair that you did on my sports hernia.
It has been a year this month and I just won the silver medal in the world championships! I am forever grateful and could not be happier.
Thank you,
Alison
Patient Recovers from Sports Hernia Surgery – Competes in Triathalon
Hello Dr. Brown,
I wanted to give you an update on how I’ve progressed since you repaired my torn right internal/external oblique muscles the first week of February (2011).
I approached my rehab conservatively concentrating on strengthening my core muscles, improving hip range of motion, and undergoing several head to toe deep tissue massage sessions to address problem areas such as my adductors. I was able to return to light swimming and biking in March and gradually added in some light trail running. My return to running has focused using proper form concentrating on forefoot striking with shorter strides (vs. heel striking and over-striding). I’ve also bought into the minimalist running shoe philosophy which aids in a more natural, shock absorbing, forefoot strike. This past Sunday I competed in my first triathlon since surgery and did surprisingly well, finishing 15th out of 107 in my age group!
Sports Hernia Rehabilitation
The Sport Hernia Rehab program for the Montreal Canadians is very similar to the one I advise, though more aggressive at the start:
Days 1 & 2:
- Rest
Days 2-7:
- Isometric exercises
- Abdominal crunches
- Straight leg raises
- Stationary bike
Sports Hernia Prevention
Sports Hernia Prevention & Adductor Tendon Injury Prevention
Of the injuries suffered by professional hockey players, injuries to the adductor tendons represent about 10% of the total. Hockey players with weak adductors have a much higher incidence of adductor muscle injuries. If an athlete is placed on a program that focuses on strengthening the adductor muscle group, the incidence of adductor injures falls by a factor of 5.
Warm up:
- Biking
- Adductor Stretches
- Side Lunges
- Pelvic tilts
- Strengthening
- Ball squeezes
- Concentric adduction
- Seated adduction
- Balance board
Source: Nicholas, Stephen J;Tyler, Timothy F. Adductor muscle strains in sport. Sports Med (2002) 32: 339-44.
Joey Gjertsen Back to Work
Joey Gjertsen with the San Jose Earthquake Soccer team recently suffered an injury to the adductor longus muscle that extended into the gracilis muscle. The tendons were treated and within a week he was healed and competing.
Treatment of Osteitis Pubis
Please visit the following link to learn more about the treatment of Osteitis Pubis: http://www.ncbi.nlm.nih.gov/pubmed/8526278
A Healing Diet for Sports Hernia Surgery
Jerry Deutsch has kindly put together the following nutrition information:
A Healing Diet for Sports Hernia Surgery
High biological value proteins that are easy to digest:
- White fish: tilapia, cod, dover sole
- White meat chicken, and turkey
- Micronized whey or whey isolate powder for smoothie preparation
Complex carbohydrates: White basmati rice, quinoa, thick rolled oats (which confer excellent soluble fiber) yams and sweet potatoes, winter squashes such as acorn, butternut and delicata varieties. Ezekiel bread (fully sprouted).
Difficult Diagnoses
Athletes often present with a long history of pain and multiple previous operations. This makes determining the exact source of the pain difficult. I often use trigger point injections to try to localize the pain. For example, assume an athlete presents with pain that is near the origin of the adductor longus tendon. If that tendon is injected with lidocaine (a local anesthetic) and the pain gets better, then that would be strong evidence that the adductor longus is the source of the pain. In a similar manner other structures can be injected such as the ilio inguinal nerve, the genital nerve, the spermatic cord, the symphysis pubis, etc With sequential trigger point injection, the etiology of chronic pain can often be identified then the appropriate treatment can be started.