Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

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D.S. Edelman
a true hernia in most instances; the presence of an inguinal hernia should
prompt an inguinal hernia repair.
Many times the examiner can elicit pain at the pubis while the athlete
does a Valsalva maneuver. I prefer to perform this exam with the patient
lying on my exam table while I place my index finger through the scrotum
onto the top of the external ring. I then have the athlete do bilateral
straight-leg raises while he lifts his shoulder off the table at the same
time. Pain with this maneuver is a diagnostic sign.
An ultrasound with Valsalva may demonstrate an inguinal hernia. If
the ultrasound is negative for a true inguinal hernia and the physical
exam is equivocal, a noncontrast MRI of the pelvis with attention to the
pubis is indicated. With athletic pubalgia, the MRI will show acute or
chronic inflammatory changes at the rectus muscle insertion onto the
anterior/superior pubis and/or at the adductor longus muscle insertion
onto the inferior pubis.
It is recommended initially to offer a trial of rest with NSAIDs, followed
by a course of rehabilitative physical therapy. If there is no
improvement or continued inability to perform the sport, surgery may be
indicated. There is much literature available on this subject.
I prefer the laparoscopic approach, as it has been shown to provide
improved recovery over open repair for conventional inguinal hernia
repair [ 24 ]. I also prefer implantation of biologic repair in this patient
population. Clarke et al. first reported the use of biologic mesh , small
intestine submucosa (SIS) , to repair the abdominal wall in dogs [ 25 ].
The resultant repair with SIS was well organized, with dense connective
tissue that was well incorporated into the adjacent fascia and skeletal
muscle. With this information and my extensive experience with laparoscopic
inguinal hernia repair, I have since implanted BPM laparoscopically
in 131 athletes. I reported the results of my first ten patients in
2006 [ 26 ]. No patient developed a recurrent “sports hernia,” and only
one patient did not have improvement in symptoms.
The laparoscopic approach offers an excellent visualization of the
rectus muscle and conjoined tendon insertion onto the pubis. I use a
10 × 15 cm biologic mesh, soak it in bupivacaine, and place it in the preperitoneal
space. The grasper positions the mesh over the myopectineal
space. I use 4–6 absorbable tacks to secure the mesh in place. I spray
fibrin sealant on and behind the mesh to secure it to the injured muscle
and periosteum. If there is an adductor injury, I make a separate 4 cm
skin incision over the affected side, along the inguinal crease. I expose
the adductor muscle and make micro-cuts in the tendon. I then use a
4 × 7 cm biologic mesh and tack it to the inferior pubis and suture it to