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PubMed2000

Groin hernia repair in Scotland.

BACKGROUND: The use of mesh for groin hernia repair has dramatically changed the way this common operation is performed. The aim of this study was to survey the methods of groin hernia repair in Scotland and to assess patient satisfaction with the operation. METHODS: Between 1 April 1998 and 31 March 1999 all patients who underwent groin hernia repair in the National Health Service in Scotland were identified. As well as looking at the type of hernia repair performed and postoperative morbidity, patients were sent a Short Form-36 about 3 months after the operation to assess satisfaction and return to normal activity. RESULTS: Information was obtained on 5506 (97 per cent) of patients who underwent groin hernia repair during the study period. Eighty-five per cent of patients had an open mesh repair and 4 per cent had a laparoscopic repair. Most operations (85 per cent) were performed using general anaesthesia on an inpatient basis (78 per cent), and 8 per cent were for repair of a recurrent hernia. Potentially serious intraoperative complications were rare (seven patients), although they were significantly (P < 0. 001) more likely to be associated with a laparoscopic approach or repair of a femoral hernia: relative risk compared with open inguinal hernia repair 33 (95 per cent confidence interval (c.i.) 6-197) and 22 (95 per cent c.i. 3-152) respectively. Wound complications were common and 10 per cent of patients required a district nurse to attend the wound. Patients expressed a high degree of satisfaction; 94 per cent would recommend the same operation to someone else if required. CONCLUSION: An open mesh repair using general anaesthesia has become the repair of choice for a groin hernia in Scotland. Despite a high incidence of wound complications, patients are satisfied with this operation.

Aged↗

PubMed2000

Evidence-based management of groin hernia in primary care--a systematic review.

BACKGROUND: National clinical guidelines on the surgical management of groin hernia have been published by the Royal College of Surgeons of England. There is also a need for guidance on the management of pre- and post-hernia repair patients in primary care, in areas such as diagnosis, referral and advice on recuperation. OBJECTIVE: The purpose of the present study was to determine best practice in primary care aspects of managing groin hernia in adults, by examination of the evidence base. METHOD: A systematic review of the available evidence was carried out, searching the major electronic databases: Medline, the Cochrane Library, Embase, Assia, Helmis, Cinahl and Psyclit. Key search terms were hern$, inguinal, femoral, groin, truss$, with searches limited to human adult subjects and the English language. RESULTS: Robust research on groin hernia is concerned almost exclusively with the in-patient surgical management of patients undergoing primary elective hernia repair. The areas with which this review was concerned, principally diagnosis, referral and advice about return to work, are areas in which it is more difficult to conduct robustly designed studies. Perhaps because of this, the evidence base on the non-surgical aspects of management is of poor methodological quality, being based primarily on expert opinion, reviews of clinical practice and experience, surveys, descriptive case studies and clinical audits. CONCLUSIONS: As the research in this area is generally of poor quality, strong conclusions are precluded, but it is possible to define best practice in some areas of care. In relation to diagnosis, GPs should distinguish correctly between a femoral and inguinal hernia because of the increased risks of strangulation and incarceration associated with the former. Due to clinical inaccuracy, the identification of whether a hernia is direct or indirect is not a good basis on which to base decision making regarding referral for elective repair. The risks associated with surgical repair are those of the normal range found for any procedure. Decisions about the fitness of patients for surgery in this instance are not procedure specific, and therefore the decisions about elective repair especially in older patients should be considered in terms of quality of life and patient choice rather than increased risks with surgical repair. Further research is required to address the gap in the evidence for the management of groin hernia within the primary care sector.

Adult↗

PubMed1983

Therapeutic groin dissection in malignant melanoma.

In a retrospective review of therapeutic dissections of the groin, 22 patients underwent radical groin dissection and seven were alive at five years, whereas 26 patients underwent a superficial groin dissection and two were alive at five years, p less than 0.05. Involvement of the deep nodes is not always equivalent with systemic disease. A radical groin dissection should be used to eradicate the disease locally. The survival rate for the patients following groin dissection correlated significantly with the disease-free interval prior to occurrence of inguinal lymphadenopathy.

Female↗

PubMed1996

Laparoscopic exploration of the contralateral groin in children: an improved technique.

Repair of inguinal hernias are among the most frequently performed operative procedures in children. Bilateral inguinal hernias (BIH) are common, especially in patients under the age of 2 years, and present both synchronously and metachronously. Most pediatric surgeons perform open exploration of the contralateral groin in infants and young children with symptomatic unilateral inguinal hernias to avoid missing the potential metachronous presentation of BIH. The practice of contralateral groin exploration is controversial because of the increased cost, morbidity, and potentially serious complications associated with open groin exploration. We have developed a technique for laparoscopic exploration of the contralateral groin (LECG) to assess the internal inguinal ring in the asymptomatic groin and to measure the depth of a patent processus vaginalis. A pneumoperitoneum is produced by insufflation through a 14-gauge intravenous catheter placed into the hernia sac of the operated side. A 1.2-mm laparoscope is then passed through another 14-gauge intravenous catheter inserted through the abdominal wall of the contralateral side providing a direct, "in line" view of the internal ring. Depth of patency of >1.5 cm was considered positive and a standard operative repair was performed. In 110 children who underwent LECG the incidence of bilaterality was 21%. This technique is rapid, accurate and was associated with no complications.

Female↗

PubMed2006

Surgical management of the groin lymph nodes in melanoma in the era of sentinel lymph node dissection.

HYPOTHESIS: Intraoperative lymphatic mapping and sentinel lymphadenectomy (LM/SL) has become an increasingly popular surgical technique for staging the regional lymph nodes in early-stage melanoma. The technique of LM/SL has potentially great advantage for the groin, where the morbidity of superficial groin dissection or iliac dissection can be high. The surgical management of these basins is unknown for patients with tumor-positive sentinel lymph nodes (SNs). DESIGN: Cohort of successive patients undergoing LM/SL over 18 years. Those patients found to have tumor-positive SNs underwent sentinel complete lymph node dissection. Postoperatively, patients were followed up on a routine basis with serial examinations and chest radiography. The median follow-up was 50 months. SETTING: Tertiary cancer center. PATIENTS: The technique of LM/SL was performed for 431 consecutive patients. Sentinal lymph nodes were identified in each case. Patients with tumor-positive SNs underwent sentinel complete lymph node dissection. INTERVENTION: Cutaneous lymphoscintigraphy and blue dye with or without use of the gamma probe-directed LM/SL. Sentinel lymph nodes were examined by hematoxylin-eosin staining and immunohistochemistry staining with HMB-45 and S100 protein. Only patients with tumor-positive SNs had sentinel complete lymph node dissection. Main Outcome Measure Computer-assisted database with statistical analyses using log-rank tests and Cox regression models. RESULTS: Of the 431 patients, 264 (61%) were women and the median age was 50 years (age range, 15-89 years). A majority (86%) of the primary tumors were on the lower extremities, 54% were of Clark level IV or V, and there was a mean +/- SD thickness of 1.89 +/- 1.59 mm (range, 0.30-14.00 mm). Ninety-three patients (21%) were found to have tumor-positive SNs. After LM/SL and sentinel complete lymph node dissection, 62 patients (67%) were found to have a single tumor-positive lymph node, 25 (27%) had 2 tumor-positive lymph nodes, and 6 (6%) had 3 or more tumor-positive lymph nodes. Only 12 patients (4%) with tumor-negative SNs have had recurrence in the dissected basin. The 5-year overall survival was significantly better for patients with tumor-negative lymph nodes (mean +/- SD 5-year overall survival, 94% +/- 5%) than for patients with tumor-positive lymph nodes (mean +/- SD 5-year overall survival, 75% +/- 4%) (P < .01). The tumor status of the Cloquet lymph node was predictive of the tumor status of the iliac lymph nodes. Multivariate analyses with a Cox regression model identified tumor-positive SN (P = .001), primary tumor thickness (P = .03), and ulceration (P = .001) as being predictive of survival. Sex, age, Clark level, and primary site were not significant (P > .05). CONCLUSIONS: Our results demonstrate the prognostic significance of LM/SL for early-stage melanoma draining to the groin basin. The accuracy of LM/SL measured by the rare recurrences suggests that this surgical procedure should become standard for patients with early-stage melanoma of the lower extremities and trunk. Sampling of the Cloquet node should be used to determine the need for iliac dissection when a tumor-positive SN is identified in the groin.

Adolescent↗

PubMed1990

The effect of femoral arteriography on the incidence of groin contamination and postoperative infections.

A prospective study is presented on the effects of preoperative femoral arteriography on bacterial contamination and postoperative wound complications from groin incisions. Forty-four femoral reconstructive procedures (88 groin incisions) for aortoiliac disease were performed. Positive cultures occurred in 43.2% of patients and in 30.7% of the 88 incisions. There was no correlation found between the site of arteriography and positive cultures (Spearman correlation coefficient, p greater than .10). No correlation was found between the presence of hematoma due to arteriography and subsequent positive groin culture (Spearman correlation coefficient, p greater than .10). A higher incidence of positive cultures did occur for patients who had a difficult arteriographic procedure (Fisher's exact test, p = .020) or whose reconstructive procedure was greater than four hours (Fischer's exact test, p = .047). Seven patients had postoperative groin wound complications (15.9%), including three lymph leaks (6.8%) and four confirmed or suspected infections (9%). There were no graft infections. No correlation was found between the site of arteriography and the site of wound complication (Spearman correlation coefficient, p greater than .10). Neither positive culture results nor difficult arteriography nor presence of hematoma were accurate predictors of postoperative wound complications. We conclude that transfemoral arteriography does not increase the risk of complications of arterial reconstruction involving a femoral anastomosis.

Adult↗

PubMed1992

The influence of groin sepsis on extraanatomic bypass patency in patients with prosthetic graft infection.

Twenty-seven vascular prosthetic graft infections in 25 patients were managed from 1981 through 1990 using the principles of extraanatomic bypass through uncontaminated fields and removal of the infected prosthesis. This experience included 18 aortic, three femoral-femoral, three femoral-popliteal, two axillofemoral grafts, and one popliteal endarterectomy patch. The predominant organism was Staphylococcus epidermidis (26%). Mean follow-up was 36 months. There was only one early and one late death, with two late amputations. Extraanatomic bypass grafts were placed in 21 of 25 patients including all 18 infected aortic grafts. Of these 21 patients, 11 (52%) experienced at least one extraanatomic bypass failure within 15 months, resulting directly in two major lower extremity amputations and two graft reinfections. Axillounifemoral bypass had a higher incidence of failure than axillobifemoral bypass (54% versus 29%). More importantly, however, extraanatomic graft failure was also associated with the presence of groin sepsis. The revision rate was 63% when the graft required circuitous tunneling to avoid groin sepsis, in contrast to a revision rate of only 17% when the graft could be anastomosed directly to the common femoral artery. Of extraanatomic bypass grafts that failed once, 63% had multiple failures. Graft removal and extraanatomic revascularization produced excellent overall results when not involving the groin. Late complications occurred more frequently when groin sepsis was present. These results suggest that, to reduce the incidence of late graft failure and amputation, more aggressive early direct reconstruction should be performed in lieu of atypical graft tunneling, especially if the extraanatomic graft has failed once and the causative organism is Staphylococcus epidermidis.

Bacterial Infections↗

PubMed2003

A preliminary report on prevalence of acetabular labrum tears in sports patients with groin pain.

To the best of our knowledge, this prospective study is the first to investigate the prevalence of acetabular labrum tears in athletes presenting with groin pain. Eighteen athletes who presented to our sports clinic with groin pain, underwent clinical assessment and magnetic resonance arthrography (MRa) to detect presence or absence of acetabular labrum tears. Ethical committee approval and informed consent was obtained from each patient. In four out of these eighteen athletes (22%) the MRa demonstrated the presence of acetabular labrum tear. Three of them underwent arthroscopic debridement of their acetabular labrum tears and returned to their sporting activities within 8 months. Clicking sensation of the hip was a sensitive (100%) and specific (85%) clinical symptom to predict labral tears. The internal rotation-flexion-axial compression manoeuvre was sensitive (75%) but not specific (43%). The Thomas test was neither sensitive nor specific. The conclusion of the study is that acetabular labrum tears can be a common cause of groin pain in athletes. Sports clinicians managing athletes with groin pain have to be well aware of the condition.

Acetabulum↗

PubMed2005

Groin lymphadenectomy with preservation of femoral fascia: total inguinofemoral node dissection for treatment of vulvar carcinoma.

This article describes a new technique for groin lymphadenectomy with preservation of the femoral fascia based on correct embryologic and anatomic knowledge of inguinofemoral lymph node disposition and their exact relation with the fascial structures of Scarpa's triangle. Scarpa's triangle dissection follows a three-step procedure: development of the side starting from the inguinal ligament; development of the angles proceeding from the apex where the saphenous vein is resected; and dissection of the fossa ovalis by grasping and elevating the entire block of adipose tissue containing the superficial inguinofemoral nodes and the stump of the great saphenous vein. This surgical step allows us to expose and remove en bloc the deep femoral nodes lying medial to the portion of the femoral vein located within the fossa ovalis. The total number of inguinofemoral nodes removed from a series of 156 patients operated on during 1981-2002 ranged from 8 to 35 (mean 20) bilaterally and from 4 to 18 (mean 10) unilaterally. The 5-year survivals by stage were, respectively, 86.2% for stage Ib, 69.2% for stage II, 49.3% for stage III, and 13.3% for stage IVa; these figures are comparable to the survival rates reported by those performing the classic groin lymphadenectomy. Groin lymphadenectomy with preservation of the femoral fascia is thus an oncologically sound conservative procedure that can replace the classic Way's technique, which involves femoral vessel skeletonization, and can be useful for treating malignant diseases requiring groin dissection.

Adult↗

PubMed1998

Masses and pain in the groin: a review of imaging findings.

The inguinofemoral region is a crossroads of numerous vascular, nervous and muscular structures. As even the most astute clinician can have difficulty in correctly diagnosing the cause of complaints or a mass in the groin and thigh region, radiological investigation is frequently warranted. For the radiologist involved, knowledge of the anatomy and specific pathology of the groin is essential. This paper deals with the imaging characteristics of the various diseases in the inguinofemoral triangle. Furthermore, this article provides an overview of the role of the various imaging modalities in the evaluation of disease in the groin and upper thigh. A sound working knowledge of groin anatomy and pathology is mandatory. The various imaging modalities used should be considered complementary.

Groin↗

PubMed2006

Successful endoscopic treatment of chronic groin pain in athletes.

BACKGROUND: Chronic groin pain, especially in professional sportsmen, is a difficult clinical problem. METHODS: From January 1999 to August 2005, 55 professional and semiprofessional sportsmen (53 males; mean age, 25 +/- 4.5 years; range, 17-36 years) with undiagnosed chronic groin pain were followed prospectively. All the patients underwent an endoscopic total extraperitoneal (TEP) mesh placement. RESULTS: Incipient hernia was diagnosed in the study athletes: 15 on the right side (27%), 12 on the left side (22%), and 9 bilaterally (16%). In 20 patients (36%), an inguinal hernia was found: 3 direct inguinal hernias (5%) and 17 indirect hernias (31%). All the athletes returned to their normal sports level within 3 months after the operation. CONCLUSIONS: A TEP repair must be proposed to patients with prolonged groin pain unresponsive to conservative treatment. If no clear pathology is identified, reinforcement of the wall using a mesh offers good clinical results for athletes with idiopathic groin pain.

Adolescent↗

PubMed2000

The value of the oblique groin incision for femoral artery access during endovascular procedures.

Groin incisions for access to femoral vessels are typically made in a vertical fashion extending across the groin crease. Significant morbidity can be associated with these incisions, including lymphoceles, lymph fistulae and infections, as documented in the infrainguinal revascularization literature. We have adopted an oblique groin incision for femoral artery access during endovascular graft reconstruction of the aorta because of the potential for reduced wound morbidity. In this study we report our experience with this technique and compare it with the existing literature to determine its usefulness. From June 1998 to May 1999, 98 consecutive patients received endovascular exclusion of aortic aneurysms at The Mount Sinai Medical Center, New York. Patients were treated with aortoaortic (24), aortouniiliac with femorofemoral crossover bypass (41), or bifurcated endografts (33) and were prospectively studied for wound complications. Aortoaortic procedures required one inguinal incision whereas aortouniiliac with femorofemoral crossover bypass and bifurcated procedures employed bilateral inguinal wounds. Wound complications were defined as cellulitis, subcutaneous purulence, femorofemoral graft infection, lymphocele, or lymphocutaneous fistulae. The oblique groin incision allows adequate exposure to the femoral arteries and is associated with low wound morbidity. We suggest that this approach may be the preferred technique for access to femoral arteries during endovascular procedures, and should be considered for infrainguinal arterial reconstructions.

Aged↗

PubMed2002

Groin pain in the absence of hernia: a new syndrome.

Groin pain may be produced by a true hernia, trauma to the groin structures or peripheral nerve, or root compression at various levels. Approximately 4,000 patients underwent inguinal herniorrhaphy (group A). An additional 134 patients complaining of groin pain and exhibiting no evidence of primary or recurrent hernia fell into two categories: 30 patients who had a previous herniorrhaphy (group B) and 104 patients without previous surgery (group C). Group B patients underwent a diagnostic nerve block which, when positive, suggested ilioinguinal nerve compromise at the wound. Those who failed conservative measures underwent nerve division. Group C patients were advised to decrease recreational and occupational activities; if that failed, they underwent lumbosacral spine imaging. There were no neuralgias in group A. Eight group B patients responded to conservative measures; the 22 others required ilioinguinal nerve division which relieved their pain. In group C, 42 patients responded to physical activity restriction plus NSAIDs; the remaining 62 underwent imaging which revealed lumbosacral bone pathology producing root compression and were referred to orthopedists. Lumbosacral spine pathology should be suspected in patients who complain of groin pain in the absence of hernia or previous herniorrhaphy. Recognition of this syndrome may avoid negative exploratory herniorrhaphies.

Algorithms↗

PubMedDate not supplied

Experience of 73 free groin flaps.

The free groin flap has gradually lost its popularity due to the disadvantages relating to the pedicle and the plethora of new donor sites. The purpose of this article is to re-evaluate this time-honoured free flap and to demonstrate its reliability and versatility through a review of 73 free groin flaps performed between 1985 and 1990. 7% of free transfers (total 1096 cases) in our institution were free groin flaps. The complication rate was 8% (three complete failures and three partial failures). This result is acceptable and not so high as other reports have described. The artery discrepancy is the main cause of the complication rate. Two special techniques to gain additional diameter of vessel size to overcome the pedicle disadvantages are stressed. The groin flap has proved to be useful and still deserves consideration in reconstructive procedures.

Adolescent↗

PubMed2005

Differences in the outcome of surgically placed long-term central venous catheters in neonates: neck vs groin placement.

BACKGROUND/PURPOSE: Long-term tunneled central venous catheters (CVC) are frequently used in the neonatal intensive care unit (NICU) babies. They are placed either in the neck or groin based primarily upon the surgeon's preference. There is meager published information available about the relative risks of these lines. METHODS: This is a retrospective analysis of all the tunneled central venous catheters placed in NICU babies at a children's hospital over a nearly 5-year period. Single lumen Broviac catheters were used in all cases. RESULTS: A total of 137 catheters were placed in 126 patients. There were 88 neck lines and 49 groin lines. Age, gestational maturity, and body weight were significantly lower for babies who underwent groin line placement. There was no significant difference in the number of days the catheters were live between the 2 groups. Total complication rates and catheter infection rates were significantly higher with neck lines. The accidental removal rate was higher with neck lines but did not reach statistical significance. CONCLUSIONS: Broviac catheters placed in the groin of NICU babies are associated with significantly fewer complications compared with those placed in the neck.

Catheterization, Central Venous↗

PubMed1998

Groin pain in the soccer athlete: fact, fiction, and treatment.

Groin pain in the soccer athlete is a common problem accounting for 5% of soccer injuries. Groin distribution has proved to be the most common cause of groin pain. Other causes are direct trauma, ostetis pubis, muscle injuries, fractures, bursitis, hip problems, and hernia and referred pain. Soccer players with groin pain present a complex management problem that is discussed.

Athletic Injuries↗

PubMed1994

Groin lymphatic complications after arterial reconstruction.

PURPOSE: The purpose of this study was to better define the associated risks and optimal management of groin lymphatic complications (GLC) after femoral artery reconstructive operations. METHODS: Retrospective review of a vascular surgery registry for the last 15 years identified 2679 arterial operations requiring a groin incision. Forty-one GLC were recognized, 28 lymphocutaneous fistulas (LF) and 13 lymphoceles. RESULTS: The incidence of GLC was 1.5% per patient or 1.2% per incision. The highest incidence of GLC was in patients having an aortobifemoral bypass for aneurysmal disease in a previously operated groin (8.1% per patient) and in those undergoing an isolated femoral procedure in a previously operated groin (5.3%). The lowest frequency of GLC was after femoropopliteal/tibial bypasses (0.5%). Twenty-nine patients (71%) were treated without operation with bedrest, intravenous antibiotics, and aggressive local wound care. Operative therapy with wound reexploration attempted identification and control of the leak site, and meticulous wound closure was used in 12 patients (29%). Lymph fistulas in patients undergoing reoperation (10/28) resolved sooner than in patients treated without operation (18/28) (9 +/- 3 days vs 24 +/- 3 days). Infectious wound complications with one resultant graft infection developed in five of 18 patients with LF who did not undergo reoperation. There were no wound or graft infections in the patients in the LF group treated with operation. Operative exploration of lymphoceles did not reduce hospital stay or infectious wound complications. Repetitive lymphocele aspiration did not affect rapidity of resolution or increase the infectious complications. CONCLUSION: GLC remain a troublesome complication of femoral arterial reconstruction. Early reoperation should be performed once a LF is diagnosed. Treatment for lymphoceles should be individualized, with neither operative nor nonoperative management showing clear superiority.

Aged↗

PubMed2003

Dermatofibrosarcoma protuberans of the vulva and groin: detection of COL1A1-PDGFB fusion transcripts by RT-PCR.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is an uncommon infiltrative tumor of the dermis with characteristic cytogenetic features, specifically the translocation t(17;22)(q22;q13) which often manifests as a supernumerary ring chromosome r(17;22). The translocation results in the fusion of two genes, collagen type I alpha 1(COL1A1) and platelet-derived growth factor B-chain (PDGFB). The trunk and extremities are the anatomic sites of predilection for DFSP, whereas the vulva and groin are quite uncommon sites of involvement. METHODS: This investigation evaluated seven DFSPs (four vulvar and three groin) for the presence of COL1A1-PDGFB fusion transcripts by reverse transcriptase-polymerase chain reaction (RT-PCR), using archival formalin-fixed, paraffin-embedded tissue. RESULTS: Six of seven cases (three vulvar, three groin) contained a COL1A1-PDGFB fusion transcript. Sequence analysis of the PCR products revealed that the break-point of the COL1A1 gene was located after exon 40 in two patients, after exon 42 in one patient, after exon 44 in one patient, and after exon 47 in two patients; the break-point in the PDGFB gene was before exon 2 in all cases. No fusion transcript could be amplified in one case. CONCLUSIONS: As in DFSP at other sites, COL1A1- PDGFB chimeric fusion transcripts are present in vulvar and groin DFSP. The transcripts can be detected in formalin-fixed, paraffin-embedded tumor tissues, and have the same general pattern of exon boundaries as in DFSP at other sites.

Adolescent↗