The Inguinal Ligament Release Procedure A New Concept A New Procedure for Sportsman s Groin
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1 The Inguinal Ligament Release Procedure A New Concept A New Procedure for Sportsman s Groin David M Lloyd MBBS, FRCS, MD Consultant Surgeon Leicester Royal Infirmary
2 Surgery for Groin Pain AIMS Demonstrate groin anatomy laparoscopically and challenge 500 years surgical and anatomical doctrine Introduce the concept that groin pain arises from the inguinal ligament Demonstrate that releasing the ligament improves the symptoms of groin pain Present the results of the Inguinal Ligament Release Procedure
3 My Background Laparoscopic and Hepatobiliary Surgeon 10,000 laparoscopic procedures 5,000 laparoscopic hernia procedures Special interest in groin anatomy
4 Laparoscopy A Different View Direct and Indirect Hernias Hesselbach s Triangle Direct Inguinal Hernias Deep Inguinal Ring Indirect Inguinal Hernias
5 Laparoscopic View Right Direct Right Indirect
6 Left Transversalis Sling and LDH 1559 Casper Stromayr (in Practica Copiosa) distinguished between indirect and direct hernia
7 Some Direct Hernias occur Lateral to the Vessels Photographs of Left Inguinal Hernias Lateral Side Medial Side
8 Direct Hernia occurring Lateral to the Vessels
9 Inguinal Hernia of the Third Kind Third type of inguinal hernia Common finding laparoscopically Challenges 500 years surgical doctrine
10 Laparoscopy for Groin Pain? Rationale Excellent views of anatomy Different perspective on causes and pathology Challenges standard procedures
11 Groin Pain Current Concepts Strain of the inguinal, lacunar, pectineal ligament complex Weakening of posterior wall no detectable hernia (no obvious clinical lump) Groin Disruption Tear in ext oblique Tear in conjoined tendon Dehiscence of conjoined tendon Inguinal/Other Nerve Entrapment Obturator Nerve Entrapment Osteitis Pubis Psoas Bursitis
12 Clinical Presentation of Groin Strain
13 Sportsman s Groin Clinical Examination PT
14 Sportsmans Groin Anatomy Upper Groin Lower Groin/Thigh
15 Lacunar Ligament and Pectineus Pectineus
16 Groin Pain Learning Points to Remember: Usually no palpable hernia Many ligamental attachments Pubic bone aponeurosis formed by Rectus sheath Conjoined tendon Inguinal ligament Pectineal ligament/ pectineus Adductors Longus Brevis Gracilils Magnus
17 Case Study Ian Marshall Everton 1 0 Leicester City Ref: Steve Lodge League Position: 16th FA Carling Premiership 97/98 - Game 35 Saturday 18 April 1998 Goodison Park, Merseyside Att: 33,642 MATCH FACTS GOALSCORERS Debuts EVERTON: Madar (2) Leicester City: Marshall (38)
18 Inguinal Ligament Release Procedure 1. Laparoscopic Assessment 2. Divide scar tissue, inguinal ligament, pectineal fascia 3. Reinforce the groin with soft non-reactive mesh August Volume 18 - Issue 4 - pp doi: /SLE.0b013e fcc SURGICAL Laparoscopy Endoscopy & PERCUTANEOUIS TECHNIQUES Laparoscopic Inguinal Ligament Tenotomy and Mesh Reinforcement of the Anterior Abdominal Wall: A New Approach for the Management of Chronic Groin Pain Lloyd, David M et al, 2008 Lloyd, David M. MD, FRCS; Sutton, Christopher D. MD, FRCS; Altafa, Aminah MBChB; Fareed, Kaleel MBChB; Bloxham, Lisa BSc; Spencer, Laura MRCS; Garcea, Giuseppe MD, MRCS 2008 Lippincott Williams & Wilkins, Inc
19 Laparoscopic Views: Disruption of Inguinal and Lacunar Ligament left right
20 Laparoscopic Views: Very Inflamed Right Lacunar Ligament
21 Dividing the Inguinal Ligament and Pectineus Fascia
22 Inguinal Ligament Release Elite Athletes
23 Disruption Right Lacunar Ligament
24 Chronic Groin Pain after Open Surgery Release of Scar Tissue and Sutures
25 Release Procedure Laparoscopic findings at 6 months
26 Inguinal Ligament Release Procedure (n = 600) Results: Experience in 600 cases On going prospective Audit Published Results 73 cases British Journal of SPORTS MEDICINE 2009 Original article The inguinal release procedure for groin pain: initial experience in 73 sportsmen/women C D Mann, C D Sutton, G Garcea, D M Lloyd 21 January doi: /bjsm British Journal of Sports Medicine 2009;43: Copyright 2009 BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine.
27 Inguinal Ligament Release Procedure Gregorz Raziak 14 days post surgery
28 Inguinal Ligament Release Procedure Hughes Vassell Carrick Etherington Staunton Allback Kelly Williams Balshaw Pelu
29 Inguinal Ligament Release Procedure
30 Published Results Functional Limitation Functional limitation pre- and post-operatively (p<0.001). Reproduced with permission of British Journal of Sports Medicine.
31 Published Results Symptom Severity Score Symptom severity score pre- and post-operatively in all patients (p=0.005), football players (p<0.001), rugby players (p<0.001), and professional sportsmen (p<0.001). Reproduced with permission of British Journal of Sports Medicine.
32 Published Results Frequency of Symptoms Frequency of symptoms in all patients pre-operatively and at follow-up (p<0.001). (Reproduced with permission of British Journal of Sports Medicine)
33 Results Failure 3% Haematoma/Seroma 5% Infection 2/598 Acceptable but continued mild symptoms 8% Recurrent Surgery (20%) Audited 34 elite athletes 14 Gilmore type surgery 5 Germany 8 Manchester 7 Elsewhere 30 back playing at 4 weeks
34 Inguinal Release for Groin Pain Additional Learning Points to Remember: Many Ligamental Attachments Aponeurosis on Pubic bone Abandon term sportsman s hernia Osteitis Pubis over-diagnosed Pain is ligamental - Lacunar ligament? Fit the symptoms and signs to the diagnosis Not a treatment for adductor strain, although adductor symptoms do improve after a release
35 Rehabilitation Week 1 Gentle exercise Begin mobilisation Stretching Light gym work Week 2 Increase activity Biking swimming Increase gym work Week 3 Weight training Jogging/side stepping? Resume light ball training Week 4 Aim to fully train Return to sport
36 Inguinal Ligament Release Procedure Conclusions Laparoscopy allows better evaluation of groin anatomy/pathology There is a third type of inguinal hernia Avoids groin incision which may cause neuralgia Helps to re-enforce weakness of whole groin region Allows early and full rehabilitation 80% players return to activity within 4 weeks Excellent for recurrent pain even after previous groin surgery Very good procedure for groin pain with published results
37 Inguinal Ligament Release Procedure thank you
38 Neuralgia Medial Thigh Pain
39
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