Its ju just a hernia ! Mr. Sanjay Pandanaboyana MS, FRCS (UK), - PowerPoint PPT Presentation

Its ju just a hernia ! Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, Hepatobiliary and Pancrea?c Surgeon Auckland City Hospital

Its ju just a hernia ! • Sportsman's hernia • Laparoscopic versus open hernia repair • ACC and Inguinal hernia cover

Sportsma man's hernia Gilmore’s hernia Incipient hernia Athle3c Pubalgia Soccer player groin Sportsman's groin Hockey groin syndrome

Inguinal disrup-on

In Ingu guin inal d al disru isrup7on on No actual hernia !!! The pain typically aHer sports ac?vity, gets beJer with rest, returns with sports ac?vity Abnormal increased tension in the inguinal canal 1. Posterior wall weakness 2. Conjoint tendon damage 3. Tears in the inguinal ligament Generally above the inguinal ligament

In Ingu guin inal d al disru isrup7on on: Differ : Differen en7al d al diagn iagnosis osis • Acetabular injury • Pubic ramus fractures • Ostei?s pubis • Pubic Symphysi?s • Hip pathology

In Ingu guin inal d al disru isrup7on on: P : Pain ain z zon ones es

Pinpoint tenderness over the pubic tubercle Tenderness on the deep inguinal ring Tenderness on superficial inguinal ring Pain at the origin of adductor longus tendon Diffuse dull pain in the groin, radia?ng to the perineum and inner thigh

In Ingu guin inal d al disru isrup7on on: In : Inves7 es7ga7 a7on ons s • Ultrasound of the inguinal canal • MRI pelvis to exclude other pathology

vised? In Ingu guin inal d al disru isrup7on on: : Is su Is surger ery alw y always ad s advised Algorithm m for the ma manageme ment of inguinal disrup7on

Is surgery effec?ve? Randomised into Opera?ve (n=30) or physiotherapy group (n=30) Opera?ve repair was more effec?ve to decrease chronic groin pain aOer 1 month and up to 12 months of follow-up (P < 0.001). 90% in the opera?ve group returned to sports ac?vi?es vs. 27% in the nonopera?ve group. Laparoscopic mesh reinforcement was more efficient than conserva?ve therapy

Laparoscopic me mesh reinforceme ment

In Ingu guin inal h al hern ernia ia Laparoscopic or open surgery ?

• 34 RCT’s including 6804 pa?ents • Dura?on of opera?on: Longer in the laparoscopic group • Visceral and Vascular injuries more frequent in the Laparoscopic group 4.7% per 1000 • Postopera?ve pain: lower in the laparoscopic group • Length of hospital stay similar in both groups • Recurrence rates similar both groups • Chronic groin pain and numbness are significantly reduced by Laparoscopic approach

Concomi mitant femo moral and inguinal hernias • 11% of laparoscopic inguinal hernia repairs have concomitant femoral hernias • 51% of Femoral hernia repair pa?ents have concomitant Inguinal hernias

AC ACC and Inguinal Hernia Does a single strenuous event cause a inguinal hernia?

Does a sin Does a single s gle stren enuou ous e s even ent c cau ause a in se a ingu guin inal h al hern ernia? ia? Strenuous event ! Inguinal hernia !

520 hernia repair pa?ents sent ques?onnaires. 62% (320) response rate. 51% of the hernias were gradual in onset and in 42% of hernias there was a associa?on between a strenuous event and sudden onset of hernia. 91% of pa?ents reported groin pain at the ?me of the event 74% of pa?ents had indirect hernias in the sudden onset group.

Ot Other er s studies es • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann R Coll Surg Engl 78(4):367–368 • Pathak S, Poston GJ (2006) It is highly unlikely that the development of an abdominal wall hernia can be aYributable to a single strenuous event. Ann R Coll Surg Engl 88(2):168–171 • Hendry PO, Paterson-Brown S, de Beaux A (2008) Work related aspects of inguinal hernia: a literature review. Surgeon.6(6):361–365

ACC and RACS consensus stateme ment 2016 • The pa?ent reports that a single strenuous event has caused the hernia • Significant groin pain at the ?me of the event, enough cease ac?vity • On examina?on: Groin lump • Diagnosis is made within 10 days of the strenuous event • If strenuous event occurred at work, incident officially reported to work place

ACC and RACS stateme ment • Imaging i.e. Ultrasound is not necessary. Clinical diagnosis is sufficient • No dis?nc?on between direct and indirect hernia is needed Accurate documenta3on is essen3al !

Indica-on for surgery: Symptoma-c hernia !

Thank you