There are two different surgical procedures used to treat sports hernias. One is the open operation. The other is a laparoscopic procedure with mesh. Both can yield excellent results. Dr. Nguyen prefers the open operation.
During the laparoscopic operation, it is difficult to see all the nerves and tendons. Thus some damage may be missed and not treated. The laparoscopic procedure also involves placing a large piece of plastic mesh to reinforce the lower abdominal wall; the muscles are not repaired only patched; the mesh can potentially cause problems from shear stresses and nerve damage and shrinkage. The mesh is tough to remove if it becomes a problem.
The open procedure allows a full evaluation and repair of the damaged muscles. The nerves and tendons are then easily seen, evaluated, and treated. Mesh is not needed. The laparoscopic procedure has to be done under general anesthesia, whereas the open operation can be done easily with sedation and local anesthetic. General anesthesia is still an option for those patients that wish it.
All of the surgeons who have treated more than a few sports hernias are using the open procedure.
To fully treat the athlete, additional procedures are sometimes required, such as an adductor tenotomy or an ilioinguinal nerve neurectomy
Treatment of an Adductor Longus Tendon Injury
An adductor longus injury occurs when there is a simultaneous contraction of the oblique muscles and the adductor muscles. The adductor muscles are much stronger than the oblique muscles, so in this tug-of-war, the oblique muscles usually tear first. Occasionally the adductor longus tendon is injured. The adductor longus has an inadequate blood supply and a very narrow attachment to the pubic bone. Because of these factors, even a minor injury to the adductor longus tendon often will not heal, resulting in chronic pain. On physical examination, there is pain at the origin of the adductor longus tendon that is aggravated by active adduction of the hip against resistance. Sometimes the pain resolves with a steroid injection. If injections fail, then surgery is very effective. The tendon is released off of the bone and then reattached. There is no loss of strength. The range of motion is often improved. The adductor reconstruction can be done at the same time as the repair of the oblique muscles.
The ilioinguinal nerve travels through the inguinal canal on the anterior aspect of the spermatic cord. When there is a tear of the oblique muscles, the cord can prolapse through this defect, stretching the ilioinguinal nerve. The ilioinguinal nerve can become entrapment and painful. This entrapment can cause a positive Tinel’s sign at the level of the external inguinal ring. An ilioinguinal nerve block can help establish the diagnosis.
During the repair of the oblique muscles, the ilioinguinal nerve is evaluated. If necessary a release or a neurectomy can be performed. A neurectomy will result in some areas of numbness. Dr. Nguyen will discuss this with you in detail.
Other nerves will occasionally cause pain, including branches of the pudendal nerve, genital nerve, and the iliohypogastric nerve.
When there is poor coordination between the contraction of the oblique muscles and the adductor muscles, then there are shear stresses across the symphysis pubis. If this joint shifts, then osteitis pubis can develop.
Osteitis pubis causes chronic pain just above the base of the penis. The pain is aggravated by exercise. It can also be visualized on MRI or bone scans. In patients with osteitis pubis, there should be strong consideration given to a release of the adductor longus tendon. This decreases the shear forces. Dr. Nguyen will discuss this with you if necessary.
Each Athlete has an operation tailored to his/her needs and injury. The following describes the major points of a typical operation.
In the preoperative area, I reexamine the patient and answer any last-minute questions. The nurse then moves the Athlete to the operative suite. Anesthesia consists of a nerve block and sedation. Though if requested, general anesthesia is an option.
- A skin crease incision is made between the internal and external inguinal rings.
- The subcutaneous tissues are divided.
- The superficial epigastric vein is ligated if necessary.
- The external oblique fascia is identified and followed inferiorly and medially to the external inguinal ring.
- The external oblique is usually torn and separated along its fibers, starting at the superior lateral border of the external ring. If necessary, this tear is extended superiorly and laterally to the level of the internal ring. The spermatic cord (the round ligament in women) is just deep to the external oblique. The spermatic cord is circumferentially dissected free at the level of the pubis. A Penrose drain is looped around the spermatic cord. The spermatic cord is then freed back to the level of the internal inguinal ring.
- The spermatic cord is explored. If there is an indirect inguinal hernia sac present, then this is separated from the cord, and a high ligation is performed.
- Using the Penrose drain, the spermatic cord is retracted inferiorly out of the operative field. The inguinal floor can then be inspected. The floor of the inguinal canal is usually thin and torn.
- The inguinal floor is reconstructed by suturing the aponeurosis of transversus abdominis muscle to Poupart’s ligament using interrupted sutures. The sutures dissolve with time. Any redundancy of the internal inguinal ring is repaired. The conjoined tendon is reconstructed at the same time.
- Next, the inferior leaf of the external oblique fascia and the superior left of the external oblique are overlapped. The imbrication completely closes the external inguinal ring at its usual position. This closure reinforces this region and decreases the recurrence rate.
- The spermatic cord is left in the subcutaneous tissues.
- The subcutaneous fascia and skin are closed with absorbable sutures.
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