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Systematic review: laparoscopic treatment of long-standing groin pain in athletes
  1. Hannu Paajanen1,
  2. Agneta Montgomery2,
  3. Thomas Simon3,
  4. Aali J Sheen4
  1. 1Department of Surgery, Kuopio University Hospital, Kuopio, Finland
  2. 2Department of Surgery, Skåne University Hospital, Malmö, Sweden
  3. 3GRN-Klinik Sinsheim, Heidelberg University Hospital, Heidelberg, Germany
  4. 4Department of Surgery, Central Manchester Foundation Trust, Manchester Royal Infirmary and University of Manchester, Manchester, UK
  1. Correspondence to
    Professor Hannu Paajanen, Department of Surgery, Kuopio University Hospital, PL 1777, Kuopio 70211, Finland; hannu.paajanen{at}kuh.fi

Abstract

Objectives No single aetiological factor has been proven to cause long-standing groin pain in athletes and no sole operative technique (either open or laparoscopic) has been shown to be the preferred method of repair. The aim of this systematic review was to determine whether there are any differences in the return to full sporting activity following laparoscopic repair of groin pain in athletes.

Data sources The minimal access approaches include laparoscopic transabdominal pre-peritoneal (TAPP) or endoscopic total extraperitoneal (TEP) techniques. A systematic literature search was performed in PubMed, SCOPUS, UpToDate and the Cochrane Library databases. Series reporting laparoscopic repair (TAPP/TEP) of groin pain in adult (>18 years) athletes were included. The primary outcome was return to full sporting activity and secondary outcomes included percentage success rates and complications of operations.

Results Only 18 studies fulfilled the search criteria with both laparoscopic and sports hernia repairs. The studies were mainly observational with some reporting comparative data, but no large randomised controlled trials were detected. The median return to sporting activity of 4 weeks (28 days) was the same for the TAPP as well as TEP techniques. No real difference in secondary outcome measures was shown. More reported cases to date in the literature used the TAPP technique compared with TEP repair (n=605 vs n=266).

Conclusions Laparoscopic surgery for elite athlete groin pain is increasingly becoming more common with almost 1000 patients reported since 1997. No particular laparoscopic technique appears to offer any advantage over the other.

  • Abdomen
  • Athlete
  • Chronic
  • Overuse
  • Injury
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Introduction

Inguinal injury, commonly seen in active sports persons, is a condition recognised by symptoms of chronic groin pain. It is a challenging problem among not only athletes but also members of the general population who undertake any form of amateur physical activity, both from a physiological and diagnostic perspective, as no true hernia exists.1–3 The prevalence of chronic groin pain in sportsmen is described as being between 5% and 10%. The currently acceptable nomenclatures used to describe this chronic pain syndrome include inguinal disruption (ID), athletic pubalgia (AP), sportsman's hernia, sports hernia or Gilmore's groin. A recent multidisciplinary consensus meeting understood this discrepancy and attempted to determine the current position on the nomenclature, definition, diagnosis, imaging modalities and management of sportsman's groin.4 The Consensus overwhelmingly agreed that the term ‘inguinal disruption’ (ID) best describes this entity, but it did not fully commit to the ‘preferred’ operative technique for it. In athletes, long-standing inguinal pain is recognised to be caused mainly by three different pathological entities: (1) injury of the posterior wall of the inguinal canal (ID or ‘sports hernia’), (2) various tendinopathies around the pubic tubercle or (3) the AP as a result of a pubic bone stress injury (figure 1). Therefore, in the present review, the term ID/AP is used for chronic groin pain in athletes.

Figure 1

Pain triangle describing the multifaceted nature of pain in athlete’s groin. The majority of patients may initially have (1) weakness of the posterior wall of inguinal canal (‘sports hernia’), (2) insertion tendonitis of adductors or (3) pubic bone marrow oedema, that is, osteitis pubis. The chronic pain may shift location and may also circle from adductors to pubic symphysis.

Many reports have described varying degrees of success of between 70% and 90% for open as well as for laparoscopic surgical techniques in repairing ID/AP.5–9 In conventional inguinal hernia surgery, laparoscopic repair has been shown to be superior to open repair in terms of early return to work, less postoperative pain, improved quality of life as well as a reduced incidence of chronic pain.10–13 Following this rationale and evidence, laparoscopic repair of ID/AP should technically achieve the same beneficial operative success and advantages as those for conventional inguinal hernias, with an early return to sporting activity being the primary aim. The minimal access approaches include laparoscopic transabdominal pre-peritoneal (TAPP) and endoscopic total extraperitoneal (TEP) techniques.8 ,9 In both techniques, a polypropylene mesh is introduced behind the injured groin area; this is known as a posterior pre-peritoneal or retroperitoneal approach (figures 2 and 3).

Figure 2

Anterior (left) and posterior (right) view of the groin area. Both in transabdominal pre-peritoneal and total extraperitoneal procedures the mesh is placed in the pre-peritoneal retropubic space (broken oval line) and it covers most of the injured groin areas, that is, (1) posterior wall of the inguinal canal, (2) pubic insertion of rectus abdominis muscle, (3) the periosteum of pubic symphysis and insertion of adductors, and (4) insertion of inguinal and lacunar ligaments, as well as the internal ring.

Figure 3

Endoscopic total extraperitoneal view of disrupted groin (left) and covered with polypropylene mesh (right). This patient had muscle injury at the insertion of rectus abdominis muscle and tendon near the pubic bone (needle mark), and weakness of the posterior wall of the inguinal canal.

The aim of this review is to focus on the outcome of the laparoscopic treatment of ID/AP in the literature to date. In this systematic review, we included adult athletes with long-standing groin pain treated by laparoscopic surgery. Comparison of TAPP versus TEP techniques with the primary outcome (return to full sporting activity) and secondary outcomes (success and complications of operation) was analysed.

Methods

The PRISMA guidelines for systematic reviews were consulted when designing this review.14 The research analysis was to report and understand the outcomes in the increasing use of laparoscopic surgery for the treatment of athlete’s groin pain. The following primary outcome was return to full sporting activity. Secondary outcomes included postoperative recovery, complications and rate of success (%). Data were obtained from cohort studies meeting the inclusion criteria as outlined below.

Study eligibility criteria

Reported series undertaking minimal access surgery to treat long-standing pain (ID/AP) in adult (>18 years) athletes with at least the primary outcome measure were included in the review. Searches were performed to obtain all the relevant articles on the topic of sportsman's groin pain including investigations, management and, in particular, surgical repair, using medical subject headings and free-text terms (see below). No language restrictions were applied to the searches. Generic and specially developed search filters were both employed when necessary. Hand searching of journals not indexed on the biomedical databases was not carried out. The search included pathophysiological mechanisms behind the condition, diagnostic methods and results from endoscopic treatment. The review was conducted up to September 2014.

Search strategy and information resources

A literature search was performed in PubMed, SCOPUS (1960 onwards), UpToDate, Web of Science Core Collection, Cochrane Central Register of Controlled Trials (Issue 2 of 12 February 2015, the Cochrane Database of Systematic Reviews (Issue 3 of 12 March 2015) and Cochrane Health Technology Assessment Database (Issue 1 of 4 September 2014).

The search query we systematically used in all databases, excepting UpToDate, was (“sportsman's groin” OR “sportsman's hernia” OR “athletic pubalgia” OR “inguinal disruption” OR “athlete’s groin” OR “athlete’s groin pain” OR “pubic inguinal pain” OR “pubic inguinal pain syndrome” OR “Gilmore's groin”) AND (“laparoscopic surgery” OR “endoscopic surgery”). For UpToDate's limited search field, we simplified the query to (sportsman* OR athlet* OR Gilmore*) AND (groin OR hernia OR pubalgia OR inguinal OR pubic OR pain) AND (laparoscopic OR endoscopic) AND surgery. The following limits were applied: English language and human. Electronic and bibliographic searches of all retrieved articles were performed to identify further studies of interest.

Study selection, data extraction and risk of bias

Two authors independently identified studies for inclusion and differences were resolved by consensus discussion. In the case of multiple publications of the same study population, only the latest publication was included. Studies that met the inclusion criteria were reviewed in full text, along with those for which it was unclear whether the criteria had been met. Data extraction was performed using a standard proforma. The following information was obtained: author, publication date, study size, intervention (TAPP or TEP), mesh used, outcomes assessed, length of follow-up, statistical method and results. Where patients were lost to follow-up, the remaining numbers have been represented as a numerical fraction, if appropriate. To standardise the number of patients that fully recovered after surgery, a percentage value was applied.

Statistical analysis

A p value <0.05 was considered too statistically significant. Where a p value was not specifically stated but ‘no significance’ published, this was recorded accordingly. Significant heterogeneity made combined analysis scientifically unsound, and therefore no meta-analysis could be performed.

Results

Some 48 articles were examined of which 18 articles were specifically focused on ID/AP and laparoscopic repair (figure 4). These included a total of 871 patients. There were eight studies that used the TAPP technique, totalling 605 patients (table 1). Ten studies reported the TEP technique but with a fewer total number of patients (n=266; table 2). No randomised controlled trials (RCTs) were reported to date, but some reports compared an open technique in a non-randomised report. There were no laparoscopic reports prior to 1997 identified.

Table 1

Laparoscopic transabdominal pre-peritoneal (TAPP) treatment of inguinal disruption/athletic pubalgia

Table 2

Totally endoscopic extraperitoneal (TEP) treatment of inguinal disruption

Figure 4

PRISMA chart (TAPP, transabdominal pre-peritoneal; TEP, total extraperitoneal).

Primary outcome measure

Nearly all the studies reported the primary outcome measure of the time taken to return to their chosen sporting activity. The median return to sporting activity for both techniques (TEP and TAPP) was not different (28 days). Operative results of the TAPP procedure demonstrate that 70–90% of athletes return to their sporting activity after 3–4 weeks (21–28 days; table 1). In the initial report by Ingoldby,15 7 out of 14 patients who had a TAPP repair denied any postoperative pain. Further evaluation depicted that training was resumed within 4 weeks (28 days) for 9 out of 14 patients who had an open repair and 13 out of 14 who underwent TAPP. Full contact training was restarted at a median of 5 weeks after surgery (range 1–6) for open and 3 weeks (range 1–9) for the TAPP procedure (p<0.05).15 Nearly all athletes (90%) in the studies reported were able to return to full, unrestricted athletic activity within 4 weeks or less (table 1).

The first report of professional athletes operated by the TEP technique was in 199716 (table 2). Encouragingly, all eight athletes reported nearly total relief of early postoperative symptoms at 4 weeks (28 days).16 In another report including 35 male patients using the TEP technique, 34 returned to their normal sporting activity after surgery.17 A further trial demonstrated that of the 30 athletes who underwent TEP, 27 (90%) returned to sports activities within 3 months of convalescence compared with 8 (27%) in the non-operative group (p<0.001).18

Secondary outcome measures

Overall, the long-term satisfaction of TAPP was high and long-term follow-up revealed none or very few adverse sequelae or recurrent symptoms.9 ,13 ,15 ,19–23 A very recent health-related quality of life survey after TAPP repair for ID/AP indicated that athletes had quality of life scores comparable to a normal population or even better.22 Many surgeons also confirmed that TEP was excellent for ID/AP in over 90% of athletes.16 ,17 ,20 ,24–29 In a recent randomised trial including 60 athletes with ID/AP, the efficacy of TEP compared with non-operative treatment was further confirmed.18 A recent review summarises that TEP repair is a good alternative in athletes with intractable groin pain who do not respond to non-operative treatment strategies.30 This review examined 10 publications that incorporated 196 patients from a literature search of electronic databases from January 1993 to November 2011. The follow-up time ranged from 3 to 80 months, with most patients recovering quickly and returning to sports early (90–100%). On long-term follow-up, 5% were unable to train and 3–10% of athletes were unable to compete.30

The majority of complications after laparoscopic surgery include minor wound infections or superficial trocar site bleeding. Recurrent groin pain may occur but severe postoperative neuralgias after ID/AP operations have not been reported to date. In Ingoldby's series, 2 players out of 14 had prolonged neuralgia, which settled by 2 months.15 In another study, 2 out of 30 patients who underwent surgery had long-term recurrences after the TEP procedure for ID/AP.31 Both patients had initially medially located groin pain typical for ID/AP. After TEP, immediate recovery was reported to be good, but later on more lateral hip pain was observed. Both patients developed femoroacetabular impingement and were reoperated on successfully with hip arthroscopy. After 2 years of follow-up, 6 athletes out of 30 (20%) used occasional pain medication for groin symptoms during exercise.31 This latter finding may indicate that the athletes with ID/AP are more vulnerable to recurrent groin symptoms in long-term follow-up.32 A detailed description of postsurgical rehabilitation programmes is generally lacking. Early, sharp, sudden movements after surgery should be avoided, and core and leg musculoskeletal inflexibility, weakness, poor endurance or poor coordination should be identified and corrected. After both open and laparoscopic repair, a gradually progressive 6-week rehabilitation programme was generally recommended.4

Discussion

Laparoscopic surgery for elite athlete's groin pain is becoming increasingly common with almost 1000 patients reported since 1997. The studies were mainly observational, with some reporting comparative data, but no large RCTs were detected. No real differences in return to sports activity or secondary outcome measures were found and no particular laparoscopic technique offers any advantage over the other. High-quality randomised trials comparing open and laparoscopic techniques, and the use of different meshes, are therefore highly desired.

No exact pathophysiological mechanism for chronic groin pain has so far been identified in ID/AP. The most common theories include adductor and/or rectus abdominis muscle tendinopathies, hip hyperextension injuries or disruption of the posterior wall of inguinal canal.1–6 Any form of tissue injury leading to a disruption of the posterior wall is analogous to an incipient direct inguinal hernia (with or without a bulge). To date, there are no histological, imaging or operative studies, which confirms 100% the causal relationship between microscopic or macroscopic tissue injury with the diagnosis of chronic pain in ID/AP. The combination of complex anatomy in the groin area, variability of presentation, and the non-specific nature of the signs and symptoms, can make the exact diagnosis of ID/AP difficult and at times indeterminable.33 MRI remains a highly sensitive imaging modality in the differential diagnosis and it should be utilised as a diagnostic aid when considering surgery for athletes with suspected ID/AP.4 ,34 ,35 In order to achieve the best diagnosis, an experienced multidisciplinary approach is perhaps required, with the combined skills and knowledge of an experienced physiotherapist, musculoskeletal radiologist, orthopaedic surgeon as well a hernia surgeon.4

Treatment of ID/AP is often considered difficult when using non-operative interventions. Two RCTs using conservative intervention protocol on a heterogeneous group of patients reported conflicting levels of success.36 ,37 If conservative therapy does fail, surgical repair is now being recognised as an acceptable alternative. In our review, all studies indicated that laparoscopic treatment of ID/AP was effective in 80–90% of patients. It is important to remember, however, that there are only two RCTs reporting surgical versus non-operative treatment of ID/AP.18 ,38 The first study from Sweden included 66 soccer players.38 Patients were randomised into four groups: open operative repair with inguinal neurectomy, individual training, use of anti-inflammatory analgesics and physical therapy. The operative group showed a significant reduction of symptoms compared with the non-operative interventions, but this may have been attributed to the effect of the nerves being divided.38 The second RCT, which is of greater interest to this review, included 60 patients and showed that the TEP procedure was more efficient than physiotherapy for the treatment of ID/AP.18 Compared with the open surgical trial, no nerve division was carried out in this minimal access TEP technique. It is apparent from the literature, however, that the operative strategies recommended for ID/AP are based on the existing techniques used for conventional inguinal hernia repair. Chronic pain and persistent foreign body sensation affecting quality of life remain the area of interest when seeking the optimal technique for inguinal hernia surgery.39 Recurrent hernia surgery is under-reported in patients with ID/AP and perhaps this is related to the fact that no true palpable hernia exists, so any measurement of a possible recurrence automatically becomes difficult to define.

The use of innovative meshes with new fixation techniques has been introduced in inguinal hernia surgery in order to minimise the aforementioned complications. The authors agree that such innovations should also be tested in sportsman's groin surgery. In a recent meta-analysis, Antoniou et al40 included 516 patients in seven RCTs comparing TAPP with TEP in inguinal hernias. It was concluded that TEP has shorter recovery time but slightly higher operative morbidity than TAPP. There was no difference in operative time or long-term neuralgia.40 Tolver et al11 analysed early pain response within the first postoperative week after TEP and TAPP surgery in inguinal hernia surgery. That study included 71 eligible studies with 14 023 patients with hernia, and no difference in pain intensity and duration when TEP and TAPP were compared was noticed. The weight of the mesh is one factor that could influence the outcome of chronic pain after inguinal hernia procedures. In a meta-analysis by Li et al,39 lightweight mesh repairs do have advantages in terms of less chronic postoperative pain and less sensation of a foreign body. Fixation of the mesh could theoretically cause pain for different reasons, as inguinal nerves could be damaged at the point of fixation. In endoscopic operations there are mainly three different methods for fixation, tacks, glue and non-fixation. In a meta-analysis of five RCTs by Sajid et al41 comparing tack to glue fixation in endoscopic hernia repairs, it was demonstrated that glue fixation reduced the risk for developing chronic pain compared with other fixation methods.42

In summary, knowledge from inguinal hernia surgery should be implemented in surgery for ID/AP when choosing an optimal operative technique. The total number of patients having undergone laparoscopic surgery for ID/AP reported to date, however, is very limited, and all the studies are relatively recent, being published well within the past 20 years. The considered optimal laparoscopic approach and technique for ID/AP today, based on published data in inguinal hernia surgery, may suggest using the TEP technique employing a lightweight mesh with glue or no fixation. An RCT comparing the open ‘minisuture’ repair to TEP in ID/AP would be desirable. Consequently, the endoscopic TEP and the open ‘minisuture’ technique are now being examined in a RCT incorporating an international specialised team of surgeons experienced in both techniques43 (Clinical Trials NCT01876342).

What are the new findings?

  • Laparoscopic or endoscopic surgery is mini-invasive for athletes, allowing quick return to sporting activity (success rate >90%).

  • The optimal laparoscopic approach for inguinal disruption (ID)/athletic pubalgia (AP) today, based on current evidence, suggests using the total extraperitoneal (TEP) technique employing a lightweight mesh with glue, or no fixation of mesh.

  • There are only a few randomised controlled trials (RCTs), with no single surgical technique demonstrating superiority in a comparative analysis.

  • An RCT comparing open ‘minisuture’ repair to TEP in ID/AP is underway in many European countries.

How might it impact on clinical practice in the near future?

  • This review would aid surgeons and sports physicians to decide which technique to use when suggesting surgical treatment to athletes with a diagnosis of chronic groin pain.

Acknowledgments

Head of Services, Librarian, MA, Tuulevi Ovaska kindly performed the literature search according to the PRISMA checklist.

References

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Footnotes

  • Contributors HP and AM were involved in planning, conducting, designing, and acquisition and analysis of data. AJS was involved in planning, designing and analysis of data. TS was involved in acquisition and analysis of data.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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