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PubMed2005

Is endoscopic totally extraperitoneal hernioplasty justified for the repair of groin hernia in female patients?

BACKGROUND: Groin hernia is an uncommon surgical pathology in females. The efficacy of the endoscopic approach for the repair of female groin hernia has yet to be examined. The current study was undertaken to compare the clinical outcomes of female patients who underwent open and endoscopic totally extraperitoneal inguinal or femoral hernioplasty (TEP). METHODS: From July 1998 to June 2004, 108 female patients who underwent elective repair of groin hernia were recruited. The patients were divided into TEP (n = 30) and open groups (n = 78) based on the type of operation. Clinical data and outcome parameters were compared between the two groups. RESULTS: The mean ages and hernia types were comparable between the two groups. All TEPs were successfully performed. The mean operative times were 52 min for unilateral TEP and 51 min for open repair. The difference was not statistically significant. Comparisons of the length of hospital stay, postoperative morbidity, pain score, and time taken to resume normal activities showed no significant differences between the two groups. A single patient in the TEP group experienced recurrence of hernia. CONCLUSIONS: The findings show equivalent postoperative outcomes after TEP and open repair of groin hernia in female patients. Because the wound scar after open repair is well concealed beneath the pubic hair and no superior clinical benefits are observed after TEP, open repair appears to be the technique of choice for the management of primary groin hernia in females. The TEP approach should be reserved for female patients with recurrent or multiple groin hernia.

Endoscopy↗

PubMed2004

Contralateral groin recurrence in patients with stage I Bartholin's gland squamous cell carcinoma and negative ipsilateral nodes: report on two cases and implications for lymphadenectomy.

BACKGROUND: Modalities of inguinal lymphadenectomy in patients with early stage Bartholin's gland squamous cell carcinoma (BGC) remain discussed. The aim of this paper is to report 2 patients with stage 1 BGC and negative ipsilateral groin nodes who developed a contralateral groin recurrence. CASES: Two patients treated for BGC and undergoing an ipsilateral groin nodes dissection (with absence of nodal involvement) presented contralateral groin recurrence. These recurrences were observed 14 and 3 months after the initial treatment in the first and second case. In the first case, the nodal recurrence was associated with a local vaginal recurrence. CONCLUSIONS: These 2 cases suggest that << cross >> groin nodal involvement can occur, even in patients with early stage BGC. Bilateral groin dissection should be performed in patients with BGC.

Adult↗

PubMed2005

Clinical implication of laparoscopic pelvic lymphadenectomy in patients with vulvar cancer and positive groin nodes.

OBJECTIVE: At present, no clear guidelines for the treatment of patients with vulvar cancer and positive groin nodes exist. In general, the decision for additional pelvic radiation is based on findings by imaging techniques and/or the number of groin nodes involved. The aim of this case series was to demonstrate that histologic result of laparoscopic removed pelvic lymph nodes can be used to select patients who should not undergo pelvic irradiation. METHODS: From July 1997 to October 2004, 12 consecutive patients with primary or recurrent vulvar cancer underwent laparoscopic pelvic lymphadenectomy following primary or secondary surgical treatment. RESULTS: There were 8 patients with primary cancer of the vulva and 4 patients with recurrent disease in the inguinal and/or pelvic lymph nodes. The mean age was 61 (26-83) years and the mean body-mass-index was 27.1 (20.8-36.6). Positive groin nodes were found in five patients on the right side and in five patients on the left side; in one patient, positive groin nodes were present in both sides. In another patient with a history of vulvar cancer and positive groin nodes the CT-scan indicated the presence of positive iliac and paraaortic lymph nodes. Only in two patients tumor involved lymph nodes were diagnosed by laparoscopic pelvic lymphadenectomy (one left-sided, one right-sided). The number of harvested pelvic lymph nodes was 13.7 (5-20) in unilateral and 27.8 (16-37) in bilateral lymphadenectomy. The histologic examination of removed pelvic lymph nodes confirmed pelvic radiation in only 2 out of 12 patients, whereas 10 patients were spared from whole pelvis irradiation. CONCLUSION: With respect to small sample size, laparoscopic lymphadenectomy seems to be a good tool to avoid unnecessary pelvic radiation in patients with vulvar cancer and confirmed positive groin nodes.

Adult↗

PubMed2002

Chronic pain after laparoscopic and open mesh repair of groin hernia.

BACKGROUND: The aim of this study was to compare the incidence of chronic pain or discomfort after laparoscopic totally extraperitoneal (TEP) repair and open mesh repair of groin hernia, and to assess the impact of such pain on patients' physical activity. METHODS: A postal questionnaire was sent to patients who had TEP or open mesh repair of groin hernia between January 1998 and December 1999. The patients were asked about any persistent pain or discomfort in relation to the groin hernia repair and whether this pain or discomfort restricted their ability to undertake physical or sporting activity. RESULTS: Of the 560 available patients 454 (81.1 per cent) replied. Laparoscopic TEP repair was performed in 240 patients (52.9 per cent) and open mesh repair in 214 (47.1 per cent). Of the 454 patients, 136 (30.0 per cent) reported chronic groin pain or discomfort, which was significantly more common after open repair than after laparoscopic repair (38.3 versus 22.5 per cent; P < 0.01). Chronic groin pain or discomfort restricted daily physical or sporting activity in 18.1 per cent of the patients. The patients who had open repair complained of significantly more restriction of daily physical activity than patients who underwent laparoscopic repair (walking, P < 0.05; lifting a bag of groceries, P < 0.01). CONCLUSION: Chronic pain or discomfort was reported by 30.0 per cent of patients after groin hernia repair and was significantly more common after open mesh repair than after laparoscopic TEP repair. It restricted physical or sporting activities in 18.1 per cent of the patients and significantly more so after open mesh repair.

Adult↗

PubMedDate not supplied

Postoperative complications after vulvectomy and inguinofemoral lymphadenectomy using separate groin incisions.

The focus of this study was to document postoperative complications after vulvectomy and inguinofemoral lymphadenectomy using separate incisions. Data from 172 consecutive patients with newly diagnosed carcinoma of the vulva were studied. One hundred and one patients primarily treated with modified radical vulvectomy and complete inguinofemoral lymphadenectomy using separate groin incisions (n = 187) were included in this study. One or more complications were documented in 77 of the 101 (76%) patients. Complications after groin dissection were observed in 66% of the patients. The main complications were wound breakdown (17%) and/or infection (39%) of the groin, lymphocyst formation (40%), and lymphedema (28%). In 98 of 187 (52%) groin dissections, one or more complications were documented. The presence of lymph node metastases, postoperative radiation, age older than 65 years, and removal of the vena saphena magna were not significant risk factors for the occurrence of complications. The occurrence of early complications after groin dissection was significantly related to the late-complication lymphedema (P = 0.002). Our results confirm relatively high rates of wound breakdown, infection, lymphocyst formation, and lymphedema even with separate groin incisions. The occurrence of early complications was related to lymphedema. No other risk factors could be identified.

Age Distribution↗

PubMed1999

Herniography in women under 40 years old with chronic groin pain.

OBJECTIVE: To find out the prevalence of symptomatic non-palpable groin hernias in women under 40 years old with undiagnosed chronic groin pain. DESIGN: Retrospective analysis. SETTING: University hospital, Sweden. SUBJECTS: 116 women 14-39 years old (mean 27) with chronic undiagnosed groin pain who underwent herniography 1977-1994. INTERVENTIONS: Intraperitoneal injection of 80 ml iodine contrast medium (200 mg I/ml) RESULTS: Hernias were found in 28 patients (24%): 17 in the right groin alone, 6 in the left groin alone and 5 bilaterally. 19 patients had hernias on the symptomatic side only. 17 patients had indirect inguinal hernias and 7 had direct inguinal hernias (which are claimed to be extremely rare in women). CONCLUSION: A hernia is a relatively common finding during herniography in young women with groin pain.

Adolescent↗

PubMed1996

Versatility of the thin groin flap.

The groin flap is one of the most usable flaps. It provides a large amount of skin coverage with an easily concealed donor site. However, when the flap is used to reconstruct areas of the neck, hand, or foot, a secondary procedure for defatting is usually necessary. Thinner flaps are thought to be more useful in these areas. We present an anatomical study of the thin groin flap, including its dissection and defatting, and 12 clinical cases using the thin groin flap for neck (n = 7), foot (n = 4), and scalp (n = 1) reconstruction. The largest successful flap measured 13 x 30 cm. Eight flaps survived completely, two had partial necrosis, and two had total necrosis. Complications were thought to be caused by dissection around the pedicle. Meticulous dissection and thinning are required to create the thin groin flap. Excellent aesthetic results requiring no secondary defatting procedures are possible with this new thin groin flap.

Adolescent↗

PubMed2003

Groin pain in athletes.

Groin pain in athletes is not infrequently a cause of frustration and aggravation to both doctor and patient. Complaints in the groin region can prove difficult to diagnose, particularly when they are of a chronic nature. These injuries are seen more commonly in sports that require specific use (or overuse) of the proximal musculature of the thigh and lower abdominal muscles. Some of the more common sports would be soccer, skiing, hurdling, and hockey. The differential diagnosis can cover a rather broad area of possibilities. Most common groin injuries are soft-tissue injuries, such as muscular strains, tendinitis, or contusions. More difficult areas to pinpoint are such entities as osteitis pubis, nerve entrapment, the so-called "sports hernia," or avulsion fractures, to name but a few. The evaluation of such patients includes a familiarity with the sport and possible mechanism of injury (i.e., taking a careful history), meticulous physical examination of the groin, abdomen, hips, spine, and lower extremities. Diagnostic examinations may or may not prove helpful in formulating a final diagnosis. Some patients may be required to undergo procedures, such as laparoscopic evaluation of the region to obtain adequate information that allows a proper diagnosis and treatment plan. This article describes many of the possible causes of groin pain in athletes. The list is quite lengthy, and only the more common problems will be discussed in detail.

Athletic Injuries↗

PubMed2004

Early results with use of gracilis muscle flap coverage of infected groin wounds after vascular surgery.

INTRODUCTION: Management of a nonhealing femoral wound after vascular surgery can pose a challenging problem, particularly when there is prosthetic material involved. We prefer to use pedicled gracilis muscle flaps (PGMFs) to cover problematic groin wounds when more conventional management is not possible. METHODS: We describe the technique for using PGMFs to provide groin coverage, report a summary of our short-term and long-term results, and describe why we prefer this reconstructive technique. RESULTS: Twenty PGMFs were placed in 18 patients to treat nonhealing and infected groin wounds. Exposed prosthetic vascular reconstructions were covered with the PGMF in 14 wounds, and in situ autogenous vascular reconstructions were covered in four. Seven wound infections were polymicrobial, 10 had a single gram-positive organism, and one had a single gram-negative organism. Pseudomonas cultured out in four wounds, and Candida in one wound. Two patients had a virulent combination of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus. Complete healing was initially achieved in all wounds, and no patient died within 30 days of surgery. Two PGMFs failed, at 2 weeks and 2 months, respectively, one from tension on the flap pedicle and one from acute inflow occlusion. Underlying prosthetic reconstruction was salvaged in 12 of 14 wounds; the remaining wounds with autogenous reconstructions or exposed femoral vessels all closed successfully. At a mean follow-up of 40 +/- 10 months there were no recurrent groin infections. Seven patients died, at 2.5, 3, 8, 12, 14, 22, and 28 months, respectively. CONCLUSION: PGMF transposition is an effective option to cover infected or exposed femoral vessels or salvage prosthetic graft material in the groin. In appropriately selected patients, when complete graft removal and extra-anatomic bypass is not an acceptable option, gracilis muscle flap coverage is a viable alternative. The technique is relatively simple, and morbidity from PGMF harvest is minimal.

Adult↗

PubMed1985

Herniography in athletes with groin pain.

In the years 1974 to 1981, herniography was performed in 78 athletes with groin pain. The investigation comprised 101 painful groin sides in 23 athletes with bilateral symptoms. Before herniography, a hernia was palpated in only eight (7.9 percent) groins with pain. Hernias were found at herniography in 84.2 percent of the symptomatic groin sides and in 49.1 percent of the asymptomatic groin sides. Sixty-three hernia operations were performed. The herniographic and operative diagnoses corresponded well. Direct hernias dominated among the operated athletes, and were found in 55.6 percent of those below 30 years of age. Altogether 69.8 percent of the operated patients were cured by hernia repair and another 20.6 percent were improved. Tenoperiostitis of the adductor muscles was the most frequent diagnosis in those not cured by operation and among the nonoperated patients. Herniography was of great value in selecting those patients who needed a repair. A broad differential diagnostic approach when examining these patients is of the utmost importance.

Adult↗

PubMed1996

Reassessment of groin anatomy during the evolution of preperitoneal hernia repair.

BACKGROUND: Need to define accurately groin anatomy as visualized by the preperitoneal approach. METHODS: Dissections of the right groin in 135 fresh male cadavers carried out during autopsy examination. Documentation by photographs and notes. RESULTS: Classic descriptions of groin anatomy confirmed for the most part. Errors concerning the lacunar ligament and conjoined tendon identified. Accurate descriptions, applicable to groin hernia repair, provided of the iliopubic tract, transversus abdominis arch and aponeurosis, femoral canal, and related structures. CONCLUSIONS: Improved communication and understanding by and among surgeons regarding groin anatomy is needed.

Cadaver↗

PubMed2003

Primary skin closure of large groin defects after inguinal lymphadenectomy for penile cancer using an abdominal cutaneous advancement flap.

PURPOSE Large groin defects may be created after inguinal lymphadenectomy for bulky metastatic penile cancer. We describe a new method of primary closure of a large groin skin defect. MATERIALS AND METHODS In 3 patients with large volume inguinal lymph node metastases with skin breakdown and secondary infection extensive inguinal lymphadenectomy was done with wide surgical excision of skin and subcutaneous tissue. The procedures resulted in a large groin defect. Sartorius muscle was transferred to cover the femoral vessels. An abdominal advancement cutaneous flap was placed for soft tissue and skin coverage of the wound. RESULTS Primary closure of a large skin defect was possible using an abdominal advancement flap. In all patients the wound healed primarily with good cosmesis. A single patient underwent postoperative external beam radiation therapy to the flap site with no untoward effect on graft survival. CONCLUSIONS Large groin skin defects can be closed primarily using an abdominal advancement flap. This technique may also be used for bilateral groin defects. Compared with other types of flaps advocated for this purpose the main advantages of the procedure are simplicity, lower morbidity and superior cosmetic results.

Adult↗

PubMed2003

Groin recurrence in patients with vulvar cancer with negative nodes on superficial inguinal lymphadenectomy.

OBJECTIVE: The objective of this study was to investigate the cause of groin recurrence in patients with vulvar cancer who had negative nodes in their superficial inguinal lymphadenectomy (SIL) specimens. METHODS: The records of patients with vulvar cancer treated at M. D. Anderson Cancer Center between 1986 and 1997 were reviewed to identify patients with squamous histology, clinical and surgical stage I or II, depth of invasion greater than 1 mm, and primary treatment consisting of radical wide excision and SIL. One hundred four patients met these criteria. Among these, nine experienced recurrent disease that involved one or both of the groins. All of the original hematoxylin and eosin (H&E)-stained slides were reviewed by one pathologist (AM). Then, each paraffin block containing nodal tissue was recut at 40 microm intervals to obtain five sections for H&E staining and two unstained sections to be used for cytokeratin immunostaining if necessary. RESULTS: The median age at diagnosis and primary surgery was 65 years and the median depth of invasion was 4 mm. Seven patients underwent bilateral, and two underwent unilateral, groin dissections. The median number of lymph nodes removed per groin was seven. The median time to recurrence was 22 months. A total of 785 additional H&E-stained slides were prepared and examined at 100x and 400x magnification. No micrometastases were identified, and there were no other suspicious findings. Therefore, immunohistochemical staining was not performed. At recurrence, one patient had a biopsy only, and eight had attempted surgical resection. In two patients, tumor was identified in fibroadipose tissue only; no lymph nodes were identified. Among the other six patients, the median number of lymph nodes resected at the time of the recurrence was five (range 1 to 10). At last report, six patients had died and three were alive and free of disease. Median follow-up for survivors was 63 months (range 42 to 71). CONCLUSION: These data strongly suggest that groin relapse in patients with negative nodes on SIL is caused by metastatic disease in unresected inguinal nodes. SIL as performed on the patients in this study did not eliminate all sites of nodal metastasis.

Adult↗

PubMed1998

Conversion of hemiarthroplasty to total hip arthroplasty: can groin pain be eliminated?

In this study 45 patients with groin or buttock pain after hemiarthroplasty were evaluated 2 to 7 years after conversion to total hip arthroplasty. Groin or buttock pain was completely relieved in 36 patients (80%) and partially relieved in an additional 4 patients (9%). After conversion surgery, 9 patients continued to have groin or buttock pain, but no factor could be identified that would predict an unsuccessful result. The hypothesis tested in this study was whether conversion of a hemiarthroplasty to a total hip arthroplasty eliminates groin pain. Because a significant number of patients (up to 20%) will continue to have some groin or buttock pain after conversion surgery, patients should be warned of this contingency before surgery.

Acetabulum↗

PubMed2000

Surgical management of groin pain of neural origin.

BACKGROUND: An approach to surgical management of the patient with groin pain is described based on our experience with 54 patients, six of whom had bilateral symptoms. History and physical examination are sufficient to relate the pain to one or more of the lateral femoral cutaneous (LFC), ilioinguinal (II), iliohypogastric (IH), or genitofemoral (GF) nerves. STUDY DESIGN: Retrospective analysis of patients with groin pain is reported, with emphasis on cause, involved nerves, and outcomes of operative management. The LFC was decompressed. The II, IH, and GF nerves were resected. Outcomes were graded as excellent, good, and poor in terms of pain relief and functional restoration. RESULTS: For the entire series of patients with painful groins, excellent relief of pain was achieved in 68% and restoration of function achieved in 72%. Ten percent had a poor result. The best results were for II and IH, which were 78% and 83% excellent for both pain relief and restoration of function, with 11% and 17% having a poor result, respectively. The worst results were for the small group of patients with a GF problem, 50% of whom had an excellent and 25% a poor result. Patients who were likely to get an LFC entrapment were those with a nerve located above or within the inguinal ligament. Complications included bruising and cautery injury to the LFC. CONCLUSIONS: Groin pain of neural origin can be relieved with a high degree of patient satisfaction by considering whether one or more of four different nerves are the source of that pain, by realizing that symptoms can be referred to regions other than the groin, such as the pelvic viscera (IH), the knee (LFC), and the testicle (GF), and by treating the appropriate nerve(s) by either neurolysis (LFC) or resection.

Adult↗

PubMed1999

External oblique aponeurosis nerve entrapment as a cause of groin pain in the athlete.

BACKGROUND: Groin pain in sportsmen is a common management problem. The results of surgical exploration in 25 male athletes presenting with groin pain are described. METHODS: All patients had had failed non-operative management. All groins were explored via an inguinal incision and the patients were reviewed for the presence of pain, function and their own subjective opinion. RESULTS: Nineteen injuries were unilateral and six bilateral. One patient had an occult inguinal hernia and another had a patent processus vaginalis. In the others, defects were found in the external oblique aponeurosis through which neurovascular bundles containing terminal branches of the iliohypogastric nerve passed. These tears were repaired after division of the bundles. The mean time to referral was 29.3 weeks (range 4-79 weeks). After operation no pain or only mild pain was experienced in 28 groins. All had improved function. Twenty of 23 patients described the operation as good or excellent. The mean time to resumption of sporting activities after operation was 11.6 (range 4-20) weeks. CONCLUSION: Athletes' groin pain may be due to nerve entrapment in the external oblique aponeurosis. An awareness of this injury may reduce delays in operating leading to an earlier return to sport.

Adult↗

PubMed2001

Comparison of the FemoStop device and manual pressure in reducing groin puncture site complications following coronary angioplasty and coronary stent placement.

This study compared two techniques, the FemoStop device (RADI Medical Systems, Uppsala, Sweden) and manual pressure, currently used by nurses to achieve haemostasis at the groin puncture site following removal of femoral arterial sheaths in patients following coronary angioplasty and coronary stent placement. Participants were randomly allocated the FemoStop device or manual pressure. Participants' groins were observed for evidence of complications including haemorrhage, haematoma formation and pseudoaneurysm following removal of the femoral arterial sheath and the following day. Of the 274 participants recruited into the study, 5.5% (n = 15) were unable to be included as a result of the absence of data on the Angioplasty Record of Care Form (n = 5) or excessive bleeding at the groin puncture site (n = 10). This left 259 eligible participants. Of these, 18.1% (n = 47) did not have their groin puncture site inspected by a post-procedural observer, thereby reducing the number of participants eligible to complete all stages of the study to 212. The results showed that the presence of a haematoma on removal of the femoral arterial sheath had a significant relationship with the type of treatment used, with those participants in the FemoStop device group showing a greater incidence of haematoma development at the time of sheath removal than those in the manual pressure group. No significant difference was detected in haematoma formation or bleeding between the two groups as a result of the risk factors identified in the literature, including participant anxiety, weight or anticoagulant therapy. There was not any significant difference between the two groups in reported pain during removal of the femoral arterial sheath; however, there was a significant distinction in the amount of time taken to achieve haemostasis. The results showed that haemostasis was achieved more quickly in those participants in the manual pressure group than those in the FemoStop group. The results of this research study indicate that although manual pressure achieved haemostasis more quickly than the FemoStop device, both methods are as effective in reducing groin complications in patients following removal of the femoral arterial sheath following coronary angioplasty and stent placement.

Coronary Angiography↗

PubMed1999

Disruption of skin perfusion following longitudinal groin incision for infrainguinal bypass surgery.

OBJECTIVE: The objective of our study was to investigate whether such an incision results in a reduction in blood flow, and therefore haemoglobin oxygen saturation, across the wound. DESIGN: Microvascular oxygenation was measured with lightguide spectrophotometry in 21 patients undergoing femoropopliteal or femorodistal bypass procedures. A series of measurements were made in the groin, medial and lateral to the surface marking of the femoral artery. The mean oxygen saturation on each side was calculated, and the contra-lateral groin was used as a control. The measurements were repeated at 2 and 7 days postop. RESULTS: Oxygen saturation in the skin of the operated groins was increased significantly from baseline at 2 days postop (f = 25.80, p < 0.001) and had begun to return to normal by day 7. The rise was more marked on the lateral side of the wound than on the medial (f = 12.32, p < 0.001). There was no such difference in the control groins. All wounds healed at 10 days. CONCLUSIONS: These results show a significant difference in skin oxygenation between the lateral and medial sides of the groin following longitudinal incision. This may contribute to the relatively high incidence of postoperative infection in these wounds.

Aged↗