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Groin pain and hernia exam final by dr. brian jacob
- 1. Groin Exam for the general surgeon: chief complaint – groin pain Brian Jacob, MD Big Sky, MT 2018
- 2. Dr. Brian Jacob Disclosures • Equity • International Hernia Collaboration, INC • LifeBond™ • ViaSurgical • Consultant • Medtronic • Intuitive • Ethicon • Verb • Board Member • SAGES • AHS Brian Jacob 2018 • Thanks to • Bard, Intuitive, Yuri, Columbia University • *Upcoming meetings* • AHS – Miami, Florida (March 12-15) • SAGES – Seattle, WA (April 11 – 15) • IHC 2018 - New Delhi, India …(May 3 to 5) • RAW – Ghent, Belgium • May 23 to 25
- 3. Chief complaint: •Groin pain Inguinal Hernia No Inguinal Hernia Brian Jacob 2018
- 4. Chief complaint: History •Groin pain Inguinal Hernia No Inguinal Hernia •Where is it located, exactly? •When did it start? •Why did it start? •Constant or intermittent? •What makes it worse or better? •Does it radiate / to where? •Severity (vas score 1 – 10)Brian Jacob 2018
- 5. Chief complaint: History •Groin pain Inguinal Hernia No Inguinal Hernia •When did it start? •Why did it start? •Constant or intermittent? •What makes it worse or better? •Does it radiate? •Severity (vas score 1 – 10) Sport / Exertion injury? If patient recognizes a single event… Brian Jacob 2018
- 6. Injury or athletic pubalgia: History documentation – let’s be consistent • Sport • S (starting event) • P (pain description, mapping, photo) • O (objective exam) • R (radiology) • T (treatment intervention) Brian Jacob 2018
- 7. Chief complaint: Exam •Groin pain Inguinal Hernia No Inguinal Hernia •Back •Hip •Abdomen •Groin/ hernias / pubic tubercle •Legs •Photograph Brian Jacob 2018
- 8. Exam: Back • Palpate • Flexion • Extension • Rule out obvious disc disease •SI dysfunction •TLS ? • Thoraco-lumbar syndrome Brian Jacob 2018
- 9. Exam: Back SI dysfunction (lower back and groin) http://www.hughston.com/ Brian Jacob 2018
- 10. Exam: Back TLS (T12-L1) syndrome Brian Jacob 2018
- 11. Exam: Hip (for the hernia surgeon) •Flexion •Extension •Rotation •C-sign •FABER exam • Flexion/external rotation/abduction 1) FAI (femoral – acetabular impingement) 2) Intraarticular Tear of the Labrum Brian Jacob 2018
- 12. Flexion, Abduction, External Rotation Thank you Eduardo Parra-Davila Brian Jacob 2018
- 13. Brian Jacob 2018
- 14. Brian Jacob 2018
- 15. Labral Tear Brian Jacob 2018
- 16. Femoral Acetabular Impingement Brian Jacob 2018
- 17. MRI : hip arthrogram Brian Jacob 2018
- 18. Exam: Intra-Abdominal • Right side • Appendicitis (chronic relapsing) • Epiploica Appendigitis • Adhesions • Hidden hernias • Fallopian tubes, Ovaries • Endometriosis • Sigmoid or Ascending diverticulitis • Left side • Adhesions • Epiploica appendigitis • Hidden hernias • Fallopian tubes, Ovaries • Endometriosis • Sigmoid diverticulitis Brian Jacob 2018
- 19. Exam: Groins / legs (inguinal canals and pubic tubercles) • Internal rings (inguinal hernia exam) • Standing with Valsalva, and laying down • Round ligament or spermatic cord • Vulva or testicles • Rectus insertions • (sit-up maneuver or leg lifts)(reproducible symptoms or not?) • Pubic tubercles and symphysis (tender or not?) • Hip flexors, Aponeurotic plate, and adductor longus insertions • Adductor squeeze maneuver • Palpation between adductor tendons and rectus insertions • Hip flexors (iliopsoas tendons) with straight leg raises Brian Jacob 2018
- 20. “conjoint tendinopathy” • Lower part of the tranversus abdominis as it inserts into the crest of the pubis and pectineal line • Pain at internal ring • No hernia bulge Rectus insertions: Brian Jacob 2018
- 21. Rectus sheeth avulsion or tear • Lower part of the rectus tears or avulses off the pubic tubercle • Pain at insertion site • medial • Acute or chronic • No hernia bulge Rectus insertions: Brian Jacob 2018
- 22. Pubic Tubercle: the most underappreciated joint drandyfranklynmiller.com Brian Jacob 2018
- 23. Rectus, AdductorsMuscles Brian Jacob 2018
- 24. Bones Pubic tubercles, symphysis, acetabulum Brian Jacob 2018
- 25. Groin pain is not so simple: need MRI to help • Iliopsoas • Rectus • Pubic bone • Adductors http://www.clinicalsportsmedicine.com/ Brian Jacob 2018
- 26. Exam: Rectus insertions, iliopsoas, and adductors Brian Jacob 2018 Thank you Eduardo Parra-Davila
- 27. MRI: What can be the problem? •Main buckets : athletic pubalgia • Osteitis • Rectus sheeth insertion • Aponeurotic plate • Adductor longus tendon origin • Inguinal ligament • Weak floor with tension or pressure on nerves or fascia • (sportsman groin) MRI pelvis: Athletic Pubalgia Protocol at Mount Sinai, NYC Brian Jacob 2018
- 28. Osteitis • MRI axial Brian Jacob 2018
- 29. MRI: No osteitis Brian Jacob 2018
- 30. MRI: confirmed osteitis Brian Jacob 2018
- 31. Osteitis: which is yes vs no? Brian Jacob 2018
- 32. MRI: Aponeurotic plate avulsion Saggital mri view of left pubic tubercle Brian Jacob 2018
- 33. MRI: coronal view left adductor longus tear • Look for the fluid • (white on these images) Brian Jacob 2018
- 34. Positive MRI Management options •Acute injury: to surgery •Chronic injury: to physical therapy first •6 to 12 weeks of gradual rehab •Need to find one or two you like to refer to •NOT just a work out…. Brian Jacob 2018
- 35. Repair options for acute injuries: surgery •Prefer no mesh •Rectus sheeth avulsion •Reattach with 0 ethibonds •Aponeurotic plate avulsion •Reattach with 0 ethibonds •Adductor pain or tear or avulsion •Leave alone or tenotomy at level near pubic bone Brian Jacob 2018
- 36. http://ernestschilders.com/ “sportsman groin” (by exclusion of any other disruption sprain, injury, or hernia) Brian Jacob 2018
- 38. Repair options for weak floor (sportsman groin): •Diagnosis made with sonogram or MRI with Valsalva •Repair can be open or MIS with mesh •Concept is to release pressure on nerves and tissue, but in the end do a hernia repair • Lloyd release (TEP with medial release, mesh) • Moshe release (TEP with mid release, mesh) • Muscaleck (open release with primary repair) • Myers, Brunt, others (open releases with primary reconstruction, no mesh) Brian Jacob 2018
- 39. Nerves: Neuroanatomy (open) • Iliohypogastric nerve • Ilioinguinal nerve • Distal genital branch of the genitofemoral nerve • Femoral branch of the GF nerve • Vas deferens (paravasal fibers) Brian Jacob 2018
- 40. Brian Jacob 2018
- 41. Chief complaint: History •Groin pain No Inguinal Hernia •When did it start? •Why did it start? •Constant or intermittent? •What makes it worse or better? •Does it radiate? •Severity (vas score 1 – 10) Inguinal Hernia Brian Jacob 2018
- 42. Groin Pain with History of an inguinal hernia or a repair: Diagnostic Evaluation • Review All Operative Reports • Focused history and physical exam (with photo) • xray, Ultrasound • CT with marker •MRI with marker or AP protocol • Never , never assume a recurrence or a hernia is the cause of the pain until a thorough work up is completed •Mapping is strongly encouraged •Nociceptive vs neuropathic pain Brian Jacob 2018
- 43. • Nociceptive: • inflammation, meshoma, in one spot • Neuropathic: • nerve injury, scarring, radiating • Combination • Overlap of symptoms / signs • Psychological, social, genetic factors Ways to document type of Chronic Pain Brian Jacob 2018
- 44. A word about mapping with previous hernia history • I always draw on patients in exam room, and right before surgery.
- 45. Nerve Injury: Pain Mapping Brian Jacob 2018
- 46. Cases: Right groin pain for 6 years Localized, nonradiating, constant Brian Jacob 2017
- 47. Ct scan was normal Intraoperative exploration: (what did we find in OR??) Hidden right inguinal hernia in a male Brian Jacob 2017
- 48. 5 years of right groin pain. No previous surgery. Exam, Ct, and MRI all negative Brian Jacob 2017
- 49. Hidden right inguinal hernia in a female Brian Jacob 2017
- 50. Colon resection 5 years ago. No hernias. Chronic nociceptive pain. Brian Jacob 2017
- 52. Suture granuloma Brian Jacob 2017
- 53. 2 years of nociceptive left groin pain No previous surgery Started after a work out Brian Jacob 2017
- 54. 2 years of nociceptive left groin pain after open plug and patch Brian Jacob 2017
- 56. 14 years of both nociceptive and neuropathic Brian Jacob 2017
- 57. Brian Jacob 2017 Scrotum and testicle NO Pain
- 58. Brian Jacob 2017
- 59. Open right groin Staples and mesh found b/t external oblique + internal oblique Staples seem to be from inside to out (look closely) Pubic tubercle (right)
- 61. Brian Jacob 2017 WWYD ?
- 62. Brian Jacob 2017 Neuropathic pain after open hernia repair Pain management injections working Holding off on surgery
- 63. Brian Jacob 2017
- 64. Hidden inguinal hernias can really be hidden Brian Jacob 2017
- 65. Inguinodynia: tack Brian Jacob 2017
- 66. Inguinodynia: old mesh Brian Jacob 2017
- 67. Inguinodynia: recurrence Brian Jacob 2017
- 68. Inguinodynia: missed femoral hernia after open plug and patch Brian Jacob 2017
- 69. Let’s Review • History (work from back to hip to groin to leg)(then to abdomen and gyn) • Review of previous Op reports • Exam with mapping, put photo into EMR • Imaging (CT scan with marker or MRI)(or both) • Rule out back and hip issues • Label as nociceptive or neuropathic or both • Decide if pt needs injections, PT before offering surgery • Surgery catered to patient’s history and the above Brian Jacob 2017
- 70. Thank you