Veel voorkomende liespathologie CHJ van Eijck Afd. Heelkunde ErasmusMC
Groin injuries 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 rectus abdominis (pubic symphysitis) 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 Voor Na
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 Osteochondritis lumbal verterbra, M. Scheuermann Discus pathology. L 1 en L 2 Hip: dysplasia, impingment or labrum tear Epifysiolysis femur headkop Avascular necrosis femur head X-LWK (+3/4), X-femur (Faux-profile), bone scan and CT-scan
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
Physical examination Groin injury 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 Inguinal Painfull disruption int. and ext. annulus with Painfull elevated int. intra-abdominal and ext. annulus pressure with elevated intra-abdominal pressure
Inguinal disruption Athletic pubalgia Sports hernia Incipient hernia Gilmore s groin Groin disruption Sportmens groin
Inguinal disruption Weakness of the post. inguinal wall Disruption of the ext. obl. aponeurosis
Inguinal disruption In combination with Adductor muscle injuries Osteitis pubis Pubic symphisitis
Complaints Long existing groin pain, often radiating to the perineum and inner thigh Pain around the external annulus Combination with adductor-tendopathy Good reaction on NSAID s Increased pain with elevated intraabdominal pressure
Pathofysiology Inguinal disruption 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 Operative Strengthening of the post. wall of the inguinal canal Conventional (Lichtensteinplastiek) Laparoscopic
Patients Sportsman s hernia Since 1998 till present: n=255 (Semi)professional n=112 (3 women) 101 soccer, 4 atletics, 3 tennis, 4 cycling Amateur n=143 (2 women) 127 soccer, 2 basketball, 14 hockey
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=6) High false-negative percentage X-pelvic and femur (n=38) Ultrasonography (n=86) Bone scan (n=33) CT-scan (n=2) MRI (n=27) Laparoscopy (n=1)
Total Extra Perinoneal (TEP)
Total Extra Perinoneal (TEP)
Total Extra Perinoneal (TEP)
Total Extra Perinoneal (TEP)
Total Extra Perinoneal (TEP)
Total Extra Perinoneal (TEP)
Laparoscopy TEP right
Laparoscopy
Laparoscopy
Total Extra Perinoneal (TEP)
Total Extra Perinoneal (TEP)
Peroperative findings Sportsman s hernia (Minimal) lat. hernia n=56 (Minimal) med. hernia n=24 Preperitoneal lipoma n=32 Enlarged lymph nodes n=25 No abnormallities n=128
Complications Sportsman s hernia Sup. woundinfection (S.aureus) (n=1) Giant cell tumor re prox. femur (n=1) Adductor longus tendinopathy (n=36) tenotomie (n=3) Mesh displacement ( n=2) Mesh fibrosis, persistent pain (n=4) Recurrent hernia (n=1) Reoperation, mesh removal (n=1)
Sportsman s hernia Time Purpose Therapy Week 0-1 Week 1-2 Week 2-3 Wound recovery Pain management Optimizing scar tissue Preventing muscle atrophia Dynamic training Rect. Abd. Functional exercise Walking 5 km/h Aqua training Power walking Cycle ergometer Isometric training Rect. Abd. Steps Sit-ups Running Lunges Week 3-5 Sport specific training Weight training Normal training Week 6 Normal training
Sportsman s hernia
Recovery Sportsman s hernia 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
Sporter met chronische liesklachten Pijnlijke en/of beperkte endo- of exorotatie X-bekken + faux profile + verwijzing orthopeed bij verdenking heuppathologie Drukpijn os pubis Botscan/MRI bij verdenking osteitis pubis, pubic symphysitis Adductoren zwakte Echografie + Fysiotherapie, overweeg behandeling tenolyse Eerder operatie in lies (Lichtenstein, Pfannenstiel incisie) Overweeg proefblokkade en later neurectomie bij verdenking nerve entrapment Palpabele zwelling in lies Hernia inguinalis Drukpijn tpv annulus externus onder valsalva zonder palpabele zwelling Echografie Inguinal Disruption