The Manchester Consensus Conference of the British Hernia Society (BHS) [4] aimed to pinpoint a “blurry” condition characterized by chronic groin pain often evidenced in elite athletes. This consensus managed to black out all the previous unspecific terms agreeing in the use of a more specific “inguinal disruption” [4]. A real hernia is often unseen therefore making the term “hernia” not adequate for this chronic condition. Instead, we believe that the term ID accurately describes the tissue distress in the inguinal area following an important increase in local tension due to the high level of “twisting, turning, sprinting and kicking” that the athletes undertake during intense sport activity [4]. Consequently, these sportsmen have a disequilibrium in forces applying in the inguinal area, which is composed of unextendible structures (e.g. pubic bone, inguinal ligament) and relatively extendible structures (e.g. external inguinal ring, conjoint tendon, external oblique aponeurosis) in tight relation, with a following high risk of tissue tearing. In particular, the anterior aspect of the symphysis pubis is composed of a soft-tissue complex known as prepubic aponeurotic complex (P-PAC). P-PAC is composed of interconnections between the adductor tendons, rectus abdominis, inguinal musculo-aponeurotic structures, articular disc and pubic ligaments of the symphysis pubis [15] (Fig. 6). ID is therefore a complex condition that overlaps other clinical conditions (e.g. adductor muscle tendinitis, osteitis pubis or pubic symphysitis) although it is accepted that they can coexist [16, 17]. BHS proposed interesting 5-point diagnostic clinical criteria for ID (Table 2) [4]; however, clinical evidence is needed for validation. BHS also suggested a management algorithm for ID (Table 3). Specific rehabilitation programs and physiotherapy with associated rest and analgesia are strongly recommended for all athletes in the first instance [4, 18]. However, the BHS states that further discussion is needed about the conservative treatment options [4]. Patients should be submitted to at least 2 months of conservative treatment (Table 3); however, as supported by the authors, this therapeutic protocol is often considered inadequate for elite professional athletes’ demands of a fast recovery. Caudill et al. performed a systematic literature review analysing a total of 23 published surgical series for sports hernia further highlighting the role of surgery as a definitive treatment. A success rate of 63–97% is reported for both symptom relief and return to previous sport activity associated to surgical treatment (open or laparoscopic). In the same study also, comparable results are reported between open (92.8 ± 9.9%) and laparoscopic (96.0 ± 4.5%) repair based only on the criterion of return to sport activity [16].
Furthermore, Ekstrand et al. showed, in a randomized controlled trial (RCT) including 66 soccer players, that only surgical treatment (open approach) was associated to significant symptom improvement compared to conservative treatment (individual training, anti-inflammatory, analgesics and physical therapy) [19]. Additionally, Paajanen et al. reported that conservative treatment is less effective in reducing pain compared to surgery (TEP approach) with the latter associated to excellent immediate and long-term relief of pain [20].
This study supports the results of the two RCT that are mentioned above [19, 20], and in our opinion, laparoscopic surgery is the mainstay for non-responsive ID treatment. All the 198 patients of our series underwent unsuccessful conservative treatment with anti-inflammatory drugs, rest and physiotherapy for at least 6 weeks. The patients were athletes from various sports (Table 4) especially related to “twisting, turning, sprinting and kicking” movements as previously discussed. 92.4% of our patients were submitted preoperatively to dynamic abdominal wall ultrasound (dUS) with evidence of peritoneal fat ballooning during Valsalva manoeuvre in 88.4% of patients. MRI was performed in 8 patients (4.0%) in order to confirm an inguinal bulge not detected under US. The goal of imaging in ID is to accurately evaluate the muscular-aponeurotic structures of the inguinal area. MRI is considered the best tool (sensitivity 98%; specificity 89-100%) in patients with ID for injuries involving the rectus abdominis, the adductor tendon origin and the symphysis itself [21]. MRI is also useful in evaluating the regional bone structures as possible sites of associated osseous stress structures [21]. Despite the aforementioned role of MRI as a primary diagnostic tool, we decided to perform it only if a dUS was not fully diagnostic. In fact, we use dUS as a primary diagnostic tool in association to clinical evaluation for 2 reasons: primarily, because the dUS was always performed by a skilled radiologist with long-term experience on inguinal evaluation, and secondarily, because of the lower cost of dUS compared to MRI. Therefore, MRI was performed only in clinical doubt (8 patients in our series).
The primary aim in ID is to improve the symptoms and enable a fast return to sport activity. Surgery, regardless of open or laparoscopic approach, is considered quite effective for fast return to sport activity [16]. However, time for return to full sport activity is different between laparoscopic and open repair. Srinivasan et al. reported in a small series of 15 patients treated laparoscopically a rate of 87% of training starting at 4 weeks after surgery and return to full activity within 6 weeks with no recurrent symptoms at 12.1 months (range 6–60 months) [22]. Ingoldby reported that 13 of 14 athletes (92.9%), who underwent laparoscopic surgery for ID, returned to training in 4 weeks [23]. Open repair is instead generally associated to return to full activity at 6 months post-surgery as reported by Ahumada et al. in a case series of 12 patients [24], at 14 weeks post-surgery as reported by Kumar et al. in a case series of 27 patients [25] and at 6 months post-surgery as reported by Malycha et al. in a case series of 44 patients [26].
Furthermore, patients submitted to open approach require to be relatively inactive for the initial four postoperative weeks [24]. Therefore, both open and laparoscopic approaches are effective for ID treatment; however, laparoscopy offers the advantage of a faster rehabilitation, an earlier return to unrestricted activities of daily living and earlier return to full sport activity. According to our results, in a series of 198 patients, 187 patients (94.4%) started full sport activity at 4 weeks with a total of 195 patients (98.5%) active at 9 months. Our results are compliant to literature results [20, 22, 23], showing furthermore the advantage of laparoscopy, in our case series with the TAPP technique, over open approach. Moreover, we believe that the TAPP technique is superior to open approach because it permits to explore the abdominal cavity in order to exclude concurrent clinical entities (such as adherences from previous surgeries), and it is associated to a reduced risk of post operatory neuralgia related to nerve sparing surgery. However, no significant difference has been described between TAPP and TEP regarding operative time and post-operative neuralgia [27].
Although the surgical site depends on the reported symptoms and diagnosis of ID [4, 16, 22], the authors believe that TAPP repair should be performed bilaterally in ID even if the symptoms are monolateral in order to have a better outcome. As previously described, athletes are constantly submitted to “twisting, turning, sprinting and kicking” actions that may result in local tears of the P-PAC with consequent disequilibrium of forces applying in the inguinal area and disruption of the inguinal-pubic region. Therefore, performing a TAPP procedure monolaterally could not fully balance and stabilize the anatomical region. Also, in elite professional athletes, the treatment must be radical in order to return sooner to full sport activity with no risk of contralateral occurrence of symptoms. Further studies are necessary to demonstrate the relationship between bilateral repair and the clinical outcome.
Post-surgical inguinal pain is the most frequent complication associated to inguinal hernia repair. Several improvements in anatomic knowledge, adoption of “tension free” techniques and the use of lightweight mesh are associated to reduced post-surgical pain [28]. In particular, Li et al. reported in a metanalysis of 5389 patients that the lightweight mesh repair was associated to a significant minor incidence of chronic postoperative pain [OR = 0.72, 95% CI (0.57, 0.91)] and to a reduced feeling of foreign body compared to heavyweight mesh repair [OR = 0.50, 95% CI (0.37, 0.67)] regardless of the surgical approach [28]. In our case series, we performed hernia repair using a lightweight tailored non-absorbable polypropylene monofilament mesh (BULEV B®; 48 g/m2 ± 10%). Furthermore, Sajid et al. demonstrated in a meta-analysis of 1001 patients the reduced risk for developing chronic groin pain associated to glue mesh fixation, compared to tacker mesh fixation (RR 4.64; 95% CI, 1.85–11.66, P < 0.001), [29]. We performed both the fixation of the mesh and the closure of the peritoneal flap with n-hexyl/cyanoacrylate glue (IFABOND®).
In this study, the main complication was post-surgical pain as described in literature. At 4 weeks, 11 patients (5.6%) referred chronic inguinal pain with delayed return to sport activity. These 11 patients were submitted to medical treatment and physiotherapy. Chronic inguinal pain resolution and return to sport activity was reported by 5 patients after 3 months, 1 after 6 months and 2 after 9 months. Only 3 patients (1.5%) were unable to return to elite sport activity because of non-responsive chronic inguinal pain. In addition, in a long-term follow-up of 13 years, we reported a total of 5 cases (2.5%) of ID recurrence in previously asymptomatic patients.
Since this is a retrospective study, it was not possible to characterize the temporal dynamics of postoperative pain intensity and this could be considered a limitation of this study. All the pain symptoms were retrieved by analysing past clinical reports and contacting patients at the time of the study. Furthermore, the first 15 patients of this series were not submitted to a preoperative dUS due to a not fully standardized diagnostic and treatment protocol for ID. This could be considered another possible limitation of this study.
Despite the fact of being retrospective, this study could give important details further confirming previously published data in literature. This study evaluates a wide surgical period (13 years) with a long-term follow-up. Moreover, all cases have been highly standardized by performing high-quality ultrasound preoperative evaluation and a standardized surgical procedure in a single surgeon setting.
To our knowledge, this series is the widest described single operator TAPP experience in ID in literature. We further demonstrate the efficacy and safety of TAPP technique in ID treatment.
