Release Reinforce Technique (RRT) for Sportsman Hernia
Moshe Dudai MD FACS
Ramat Aviv Medical Center, Tel Aviv Israel
At the late of 1986 we upgraded our Lap. TAPP technique for Sportsman Hernia (SH) to Endo. TEP with releasing of the Inguinal ligament (IL) in addition to reinforcing the Posterior Wall of the Groin. At 1998 independently David Lloyd from England started to add releasing of the IL to his Lap. TAPP technique for SH. We release the IL at the level of the Internal Ring (IR) while David Lloyd at the level of the Pubic Bone (PB). We will describe our Release Reinforce Technique (RRT) for the SH.
Background; SH is a relative new entity. Gilmore at the 1980’ was the first to describe the entity and located the pathology to the Posterior Wall (PW) of the Groin and published his surgical technique. In spite of progressing in understanding and treating the pathology, still there are some controversies. Quite all are in agreement that the pathologies are in the Posterior part of the Groin and the Wall. The same agreement is that the consequence of that is creating of High Pressure in the Inguinal Canal and on the Nerves (entrapment) during sport activities. The aim of the surgical repair is to deal with those consequences and avoiding them. All acceptable surgical techniques reinforcing the PW and same do more. Those who use the posterior approach and repair the PW use mesh while the anterior approach does suturing tissue repair (mesh in the inguinal canal increasing the pressure)
Methods; In our RRT we combining pressure releasing with PW and Groin reinforcing. If you do a vast release you have to reinforce the PW and Groin. On the other hand, if you reinforce the PW and Groin without releasing the pressure creators the patient can remain with the pain. There are same major pressure creators that have to be deal: A) The IL that become strained and inflamed by itself creates pressure in the inguinal canal and on the Nerves behind it (entrapment): Genital and Femoral. B) Due to the PW and Groin injury anatomical orifices are opened and frequently became herniated by lipomas that creates pressure: IR -Genital N, Femoral Canal -Common Femora N, Obturator canal- Obturator N. C) PW deficiency and weakening leading to bulging during sport activities, increasing the pressure in the inguinal Canal and puling on the nerves.
The main steps of the surgical procedure of the PPT are first releasing and then reinforcing: We select the Endo. TEP bilateral approach since it give wide open view of all the pelvic for identifying the variety pathology that are always bilateral. Starting with Adhesiolysis of many chronic and acute adhesions in the pelvis and groin. Following with Extraction of any herniated Lipoma from any opened orifice or tear; IR is herniated in some 90% of the cases of SH. Femoral Canal surprisingly is herniated by lipoma in 30% of cases, in some of them there is a pain in the knee area that disappeared after extraction the lipoma. The same story is with the Obturator Canal and Perineal pain. Dividing the inguinal ligament is the key factor of the procedure that add significant releasing functioning to the common reinforcement. We divide the IL at the lateral aspect of the IR between the Genital and Femoral Nerves. By that we release: entrapment pressure from Genital and Femoral N, tension in the Inguinal Canal and from the injured IL itself. For completing the procedure, we reinforce all the PW, PB and Rectus M. with wide light PPP mesh 15X13cm and fixating it with absorbable tacks; 3 in the Rectus M, 1 in the PB and 1 in the Cupper Lig. This reinforcement gives strength and support to the PW and prevent the pressure in the Inguinal Canal and nerves puling creates by the bulging during sport activates, and re-establish the stability of the groin. A closed system vacuum drain, for decompressed the preperitoneal space, is left for few hours.
Discussion: Most of the surgical procedure for treating the SH, mainly reinforcing the PW and not or partially dealing with pressure releasing. Effective pressure releasing will eliminate the pain during sport activity and it must be add to reinforcement of the Groin. The injured IL is a major factor in pressure creating in the SH injury. The injured IL become strained and edematous, creating tension in the Inguinal canal and entrapping the Genital and Femoral Nerves behind it, that in addition to itself pain sensitivity. Dividing the IL add a great advantage to the procedure for reliving pain during sport activities. This is beside of other needed surgical maneuvers of lipomas extraction and Adhesiolysis. After completing all steps of pressure releasing it is mandatory to reinforce the Groin including the PW, PB and Rectus M with a wide light mesh. This will give strength to the groin and re-establish the stability needed also for the healing of the accompany Pubic Bone Stress Injury (PBSI). The PPT procedure is completed by post Op. Sport Muscles Rehabilitation Program (SMRP) adapted to the severity of the PBSI. The PPT was applied as well for patients with Groin Hernia that suffered in addition from chronic pain in the legs and thighs. We thought that IL- Ileo Pubic Tract release will eliminate chronic entrapment from the Nerves: Lat. Cutaneous of the thigh, Femoral and Genital. As was anticipate, most of them were relived from chronic pain lasting months and years.
The advantages of the RRT procedure with the addition of SMRP leads to very good results of less than 0.5% persistent pain after returning to sport activity.