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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F.J. Brody and J. Harr
layer starts at the pubic tubercle and extends superiorly to the deep ring.
A second layer of 2-0 Prolene imbricates the initial layer. At this point,
10 cc of 0.25 % bupivacaine is injected into the pubic tubercle. Mesh is
not placed since the intent of the repair is to lateralize the vector force
away from the pubic symphysis and tubercle.
The adductor tenotomy is performed to release the vector force that
extends inferiorly from the pubic bone to the large muscles of the thigh.
Conceptually, the tenotomy divides the vertical vector or the common
aponeurosis that incorporates the adductor tendon and rectus sheath.
This maneuver dissipates the distracting forces from the pubic bone.
Technically, a Deaver retractor is inserted through the inguinal wound,
and the subcutaneous tissues are retracted in an avascular plane above
the fascia of the adductor longus muscle (Fig. 36.4a ). The tendon is easily
palpated as a strong band extending from the pubic bone. Starting at
the 12 o’clock position and extending medially and inferiorly, the
tenotomy is performed 2 cm from the pubic tubercle (Fig. 36.4b ). The
tenotomy extends toward the 7 o’clock position and is performed in a
superficial manner, utilizing a right angle dissector to avoid injury to the
underlying muscle. The tenotomy separates the overlying tendon and
fascia from the underlying adductor longus muscle. Hemostasis is typically
well controlled with the electrocautery as long as the muscle is not
divided. Associated nerve fibers are encountered rarely in this plane
along the upper medial aspect of the adductor musculature. Once the
tenotomy is completed, hemostasis is verified. From the inferior aspect,
the pubic tubercle and the proximally divided tendons of the adductor
longus are injected with 10 cc of 0.25 % bupivacaine. After closing the
incision in layers, the patient is extubated and taken to recovery room in
stable condition (Videos 36.1 , 36.2 and 36.3 ) .
Outcome
Upon discharge, the patient’s activity was restricted to walking and
activities of daily living. After his first postoperative visit (14 days after
surgery), he was allowed to increase his activities slowly, which
involved cycling, jogging, and swimming. At 4 weeks, he resumed core
activities, including sit-ups and running an under 8-min mile. At 6
weeks, he initiated activities involving lateralizing movements, but fullspeed
activities were restricted. After approximately 8 weeks, the patient
resumed his normal activities, and ultimately returned for his final sea-