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athletic publagia
I am a 69 year old man with a history of a direct left inguinal hernia tissue repair in 1979 and right direct inguinal hernia mesh repair in 1998, both with excellent results. Unfortunately I carelessly did a dead lift of a carton of books and injured my groin area 2 and 1/2 years ago. I suspected a recurrent hernia but this was not the case and was referred for nerve blocks and adductor longus injections which were not helpful. I then did physical therapy including abdominal muscle strengthening which markedly aggravated the pain. I have pain sometimes from sitting and cannot comfortably exercise including bike riding. I was eventually diagnosed with athletic pubalgia/sports hernia and lipoma left spermatic cord at Vincera Institute due to bilateral mild pubic plate disruption.
I have been offered 5 surgical options and have to decide on one without the benefit of good clinical trial data (sort of like Covid)
1.Pelvic floor repair which I will try to describe to the best of my ability. Release or relaxation of the rectus muscle in order to imbricate or fold it over and then suturing it to fibrocartilagenous pubic aponeurotic plate and inguinal ligament in order to reinforce attachment and redistribute forces that may be generating pain. Removing cord lipoma will depend on its attachment, pedicle or broad based. My concern here is my tissue quality and the possibility of dehiscence even though the suture technique appears to be strong
2. Re securing partially detached pubic plate by suturing pre pubic aponeurotic plate to tubercle and pubic periosteum with non absorbable 3-0 ethicon and removing cord lipoma. My concern here is warning by the Hernia Society guidelines not to place sutures in pubic tubercle and periosteum as sources of chronic post operative pain.
3. Laparoscopic placement of mesh, avoiding need to redissect spermatic cord and possible adherent nerves from previous surgeries. The concern I have about this strategy is my injury and pain are all anterior to the pubic bone, whereas most of the reinforcement and support from posteriorly placed mesh would be posterior to the pubic bone.
4. Open bilayer repair with ultra pro mesh reinforcing rectus and adductor anteriorly and posteriorly
5. Cutting the adductor longus
If the superb experts are sheltering at home, perhaps they have time to comment on my challenging case. There may be other members with similar questions
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6 Replies
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Thank you
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@joseph
Dear Joseph.
Then I would advise you to have the operation that Dr Meyer suggested.
Regards.
Bill Brown MD -
Thank you Dr Brown for the courtesy of your reply. I would say my pain is above my inguinal ligaments, never actually in the thigh. I would also say that it is about halfway up my pubic bone bilaterally, slightly below hairline and tends to radiate upward to the top of the pubic bone and hairline. Although when at its worse it can effect the midline, it tends to be more lateral. The MRI is interpreted as pubic plate disruption and thinning/attenuation of the distal rectal muscles.
I sincerely appreciate all your help.
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@joseph
Dear Joseph.
The surgery should be directed to repair the injury that is causing pain.
If your adductor longus is the source of your pain, then you will have pain high on the inside of the thigh that gets worse when you squeeze your knees together.
If the symphysis pubis is the source of your pain,then you will have pain in the middle of the pubic hair above the base of the penis.
If you have a rectus or oblique injury is the source of your pain then you will have pain near the external inguinal ring.
Which injury do you think you have?
Regards.
Bill Brown MD -
Dear Dr Brown,
As always thank you for your prompt response
The 5 options included second opinions and what I saw on the internet. The options include:
1. simple suture reattachment of fibrocartilageneous aponeurotic pre pubic plate to pubic tubercle and body periosteum with non absorbable 3-0 ethic, 3 on each side and adductor longus relaxation but not cutting or tenotomy.
2. Meyers pelvic floor repair with rectal compartment release and securing rectus muscle to fibrocartilageneous pre pubic aponeurtoc plate and probable extension to inguinal ligament, sparing periosteum and adductor longus relaxation but not cutting or tenotom
3. laparoscopically placed retro rectus muscle pre peritoneal mesh
4 . simple cutting of adductor longus
5. bilayer UltraPro mesh inlayed and placed behind rectus muscle
If you have time your further comments would be greatly appreciated.
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The Vincera Institute is the right place to be. Did they offer the five options, or have you collected the five options from different places?
I’m not sure how you can get better advice than from Dr. Meyers. I would do what he recommends.
There are many Topics on the site about problems with Ultrapro mesh specifically, and mesh in general, and also many comments about how the use of mesh is not recommended for athletic pubalgia. Mesh is not used by experts to solve the athletic pubalgia problem.
Good luck. @drbrown
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