1. ANATOMY AND RELATED ETIOLOGY OF GROIN PAIN George S. Ferzli MD, FACS Anne Erickson, CMI Tabulae Sceletie Musculorum Corporis HumaniBarnhard S. Albinus, London, 1747.Jan Wanderlaar, artist.

2.

A 28 year old woman with

right-sided groin pain

approaches a surgeon :

Albrecht Durer, Vier Bucher von menschlicher Proportion, Nurenberg, 1528.

She has already been seen by:

• Primary Care

• Gynecologist (vaginal ultrasound)

• Gastroenterologist (EGD and

• colonoscopy)

• Neurologist (MRI)

• Orthopedic (hip X-ray)

• Urologist (pelvic ultrasound)

3. DIFFERENTIAL DIAGNOSIS

INFECTIOUS DISEASE

Herpes zoster

HIV / tuberculosis

Lyme disease

Psoas abscess

DERMATOLOGY

Lymphadenitis

Psoriasis / burn

Sebaceous cyst /

hioradenitis

Thrombophlebitis /

cellulitis

VASCULAR

Abscess hematoma

Post vein stripping

Pseudoaneurysm

Vascular graft

RHEUMATOLOGY

Connective tissue disease

Iliopsoas bursitis

Osteitis pubis

SLE

ORTHOPEDIC

hip disorders:

Acetabular labral tears

Avascular necrosis

Chondritisdissecans

Legge-Calve Perthes dis.

Osteoarthritis

Pelvic stress fractures

Slipped fem. cap.epiphysis

Snapping hip syndrome

Synovitis

NEUROLOGY

Lumbosacral

disorders

Neurofibromatosis

GYNECOLOGY

C-section

Cervical cancer

Endometriosis

Tubal / ovarian

disorders

UROLOGY

Cystitis

Epididymitis

Nephrolithiasis

Prostatitis

Torsion of testes

Urethral extravasation

Urinary tract infection

Vas granuloma / fibrosis

SURGERY

Compensation (workmans)

Hernia

Recurrent hernia

Post hernia

• Open

• • neuropathic

• • non-neuropathic

• Laparoscopic

• • neuropathic

• • non-neuropathic

NEUROSURGERY

Disc disease

Spinal injuries,

inflammation, tumors

Spondylolisthesis

Spondylolysis

SPORTS MEDICINE

Sports hernia

(adductor strains)

Gilmores groin

GASTRO-ENTEROLOGY

Appendicitis / adhesions

Diverticulitis

Inflammatory

retroperitoneal

phlegmon (pancreatitis)

Meckel diverticulitis

Granulomatous colitis

4.

Running and kicking sports injuries (football, soccer, hockey, hurdling, skiing etc)

Could groin pain be due to a sports injury? 5. Gilmores Groin (sportsmans hernia)

Mechanism: hyper abduction of the thigh

and hyper extension of the hip with truncal

rotational movement result in:

Attenuation or laddering of the ext. oblique

Separation of the conjoin tendon from the

inguinal lig.

Laxity of the transversalis fascia

Strain on pubic symphysis

Tears in adductor muscles near pubic origins

Treatment involves repair of the floor and

adductor longus tenotomy.

6. Differential diagnosis

Has ruled everything out except:

Hernia

Open right hernia repair is

recommended.

All risks, complications and

recurrences are discussed at length.

De humani corpus fabrica libri septem. Andreas Vesalius, Basel, 1543. 7.

Patient requests surgery concommittant with laparoscopic tubal ligation.

Hernia operation is performed through the lateral aspect of the Pfannenstiel Cesarean section scar.

During the operation, a right indirect hernia is found -

the sac and round ligament are submitted to pathology.

8.

Litigation

Albrecht Durer, Vier Bucher von menschlicher Proportion, Nurenberg, 1528.

Right groin pain

Bladder frequency

Pain on right lateral side

extending from buttock to foot

One year later, she files alawsuit based on these symptoms:

Numbness in right labia majora,

clitoris and mons causing sexual

distress

9. The charge:

Deviation from

Standard of Care for

severing the

iliohypogastric and

ilioinguinal nerves.

10. FRIDAY

Malpractice insurance company lawyers advise an

out-of court settlement or the surgeon would face a

multimillion dollar lawsuit (malpractice insurance covered

up to one million dollars) against a plaintiff-sympathetic

jury in Federal Court with no chance for appeal.

11.

During testimony and cross examination the surgeon explains that

chronic groin pain (CGP) after hernia repair is well described.*

Reported incidence is 10%, although different studies have placed it

between 0-60%.

Risk factors associated with CGP that have been identified include:

Recurrent hernia repair

Insurance status

Preoperative pain

Day surgery

MONDAY

Young age

Surgeons experience

Surgical technique

Severe early post-operative pain

* Kumar S, Wilson RG, Nixon SJ and Macintyre IMC. Chronic pain after groin hernia surgery. BJM 2002, 89, 1476-1479 12. Genitofemoral causalgia was first reported by Magee in 1942*.It is often debilitating and reflects chronic neuralgia including paresthesia, hypesthesia and dysesthesia. * Magee RK. Genitofemoral causalgia (a new syndrome). CMAJ 1942, 46: 326-9. 13. Related Dermatome Regions

T 11,12 (thoracic region)

ilioinguinal and iliohypogastric nerves

L 1,2,3,4,5 (lumbar plexus)

genitofemoral and lat. femoral cutaneous nerves

S 1,2,3 (sacral plexus)

pudendal nerve

Albrecht Durer, Vier Bucher von menschlicher Proportion, Nurenberg, 1528. 14. The ilioinguinal nerve (T12 and L1) supplies sensory innervation to the proximal and medial thigh.In the female innervation is supplied to abdominal skin of the mons pubis and labium majus. In the male, the ilioinguinal nerve innervates the root of the penis and upper scrotum.The iliohypogastric nerve supplies similar sensory innervation to that of the ilioinguinal nerve. Iliohypogastric n. Ilioinguinal n. Cross innervation 15. Surgeons testimony continues

Main innervation of external genitalia is

provided by the genitofemoral (L1,2) and

pudendal nerves (S2,3,4.)

16. Genitofemoral nerve innervation (L1,2) The genital branch of the genitofemoral nerve supplies sensation to the mons pubis and labium majus. In the male, sensation is supplied to the scrotum and motor fibers to the cremasteric muscle. Genital branch, genitofemoral nerve 17. Pudendal nerve innervationof female external genitalia (S2,3,4) 18. Surgeons testimony continues

He routinely identifies the nerves, protects them

(without stretching), doesnt use cautery in their

vicinity and does not incorporate them into suture

material.

Nerve entrapment, excessive scar formation or

mechanical pressure from mesh are possible

etiologies.

19.

Despite sound, anatomic-based and unwavering

testimony in front of a jury (6 women and 2 men),

the insurance company increases pressure on

the surgeon for an out-of-court settlement, offering

the plaintiff $450,000.

20. TUESDAY

During her testimony and cross examination, the patient

complains that quality and quantity of sex has diminished,

compromising marriage.

Her husband testifies that long walks and romance

are gone because of wifes groin pain.

21. TUESDAY

Expert witness *for the prosecution states that the surgeon:

Deviated from Standard of Care

Caused irreversible damage by severing the

ilioinguinal and iliohypogastric nerves

Definitely not a case of nerve entrapment

Should have performed the operation laparoscopically

* Admitted to have never observed the patienthis conclusions were based on a 17 page diary that the plaintiff had prepared for him. 22.

Insurance company faxes

consent form and demands

surgeon settle out-of-court.

They propose a settlement

of $750,000.

23. WEDNESDAY

Expert witness for the defense (surgeon) testifies:

24. Groin pain could be neuropathic:

Neuroma formation

Perineural fibrosis

Partial or complete nerve

severance

Nerve entrapment by

staple or suture

Nerve entrapment

by mesh (meshalgia)

25. Nerves prone toinjury duringlaparoscopic repair:

Lateral femoral

cutaneous nerve

Femoral branch of

the genitofemoral

nerve

Femoral nerve

26. Lateral femoral cutaneous nerve innervation (L2,3)

Sensory innervation

to anterolateral thigh

Injury may result in

a severe burning

sensation along the

anterolateral aspect

of the thigh

27. Femoral branchof genitofemoral nerve-innervation (L1,2) The femoral branch supplies sensory innervation to the anterolateral thigh. 28. Femoral nerve innervation (L2,3)

Sensory innervation

to anterolateral thigh

Injury may result in

atrophy of the

quadriceps muscle

29. Pain could be non-neuropathic and related to:

Excessive scar formation

Mesh pressure or bulk-

forming mesh material

Mesh(algia)

Staple(algia)

30.

Pressure on surgeon increases to settle out of court (legal settlement consent forms arrive via FEDEX at the surgeons home.)

Trial counsel is convinced surgeon cannot prevail against lay jury.

31. THURSDAY

Jury asks to review all the previous visual

information for a second time and deliberates

From 9am until 4:10pm.

32. The ilioinguinal nerve (T12 and L1) supplies sensory innervation to the proximal and medial thigh.In the female innervation is supplied to abdominal skin of the mons pubis and labium majus. In the male, the ilioinguinal nerve innervates the root of the penis and upper scrotum. The iliohypogastric nerve supplies similar sensory innervation to that of the ilioinguinal nerve. Iliohypogastric n. Ilioinguinal n. Cross innervation 33. Pudendal nerve innervationof female external genitalia (S2,3,4) 34. Genitofemoral nerve innervation (L1,2) The genital branch of the genitofemoral nerve supplies sensation to the mons pubis and labium majus. In the male, sensation is supplied to the scrotum and motor fibers to the cremasteric muscle. Genital branch, genitofemoral nerve 35. Groin pain couldbe neuropathic:

Neuroma formation

Perineural fibrosis

Partial or complete nerve

severance

Nerve entrapment by

staple or suture

Nerve entrapment

by mesh (meshalgia)

36. Pain could be non-neuropathic and related to:

Excessive scar formation

Mesh pressure or bulk-

forming mesh material

Mesh(algia)

Staple(algia)

37. THURSDAY Jury Verdict 4:10pm

Reasonable doubt as to the cause of

the womans symptoms was raised

by the issue of nerve entrapment

from accumulating scar tissue.

Standard of Care was not violated

and the surgeon was exonerated.

William Cheselden, Osteographia, London 1733. 38.

groin pain can cause litigation

and litigation can cause groin pain.

William Cheselden, Osteographia, London 1733. 39. An indepth knowledge of anatomy and the multiple etiologies of groin pain is essential. De humani corpus fabrica libri septem.Andreas Vesalius, Basel, 1543. 40. References

Elementi di anatomias

fisiologica applicata

alle belle arti

figurative.Francesco

Bertinatti,Turin, 1837.

Mecco Leone, artist.

Gilmore's groin repair in athletes. Brannigan AE;Kerin MJ;McEntee GPJ Ortho. and Sports PT 2000Jun;30:329-32

A1-stage surgical treatment for postherniorrhaphy neuropathic pain. Parviz K. Amid,MD,FACSArch Surg 2002; 137:100-104

Diagnosis and treatment of genitofemoral and ilioinguinal neuralgia Starling JR, Harms BA.World J Surg 1989 ;13:586-591

Managment of severe lower abdominal or inguinal pain in high performance athletes Meyers WC, Foley DP , Garret WE,Lohnes JH, Mandelebaum BRAm J Sports Med. 2000 ; 28(4):616-7

Groin pain in Athletes Jeblanc KE, Leblanc KAHernia.2003Jun;7(2):68-71

Chronic pain and quality of life following open inguinal hernia repair. Poobalan AS,Bruce J, King PM, Chambers WA, Krukowski ZH, Smith WC.BR J Surg. 2001Aug;88(8);1122-6

Outcome of patients with severe chronic pain following repair of groin hernia. Courtney CA, Duffy K, Serpell MG, O'Dwyer PJ.BR J Surg.2002Oct;89(10):1310-4

Surgical management of groin pain of neural origin. Lee CH, Dellon, AL.J Am Coll Surg. 2000Aug; 191 (2): 137-42.

Anatomic basis of chronic groin pain with special reference to sports hernia. Akita K, Niga S, Yamato Y, Muneta T, Sato T.Surg Radiol Anat. 1999 ; 21 (1): 1-5.

Anatomic variability of the ilioinguinal and genitofemoral nerve: implications for the treatment of groin pain. Ebner, RM and Dellon ALPlast Reconstr Surg .2001Nov; 108 (6):1618-23

Ultrasound of the inguinal floor for evaluation of hernias. Lilly MC, Arregui ME.Surgical Endoscopy 200216:659-662.

Kumar S, Wilson RG, Nixon SJ and Macintyre IMC. Chronic pain after groin hernia surgery.BJM 2002,89, 1476-1479.

Magee, RK. Genitofemoral causalgia (a new syndrome).CMA J1942 , 46: 326-9

Images from: National Library of Medicine, Bethesda, MD online at:

historical anatomies@ nlm . nih .gov

41. Questions:

• 1. Which of the following statements about innervation of the

• groin is incorrect?

• • a. The ilioinguinal nerve arises from T12 and L1 and supplies sensory innervation

• • to the proximal and medial thigh, root of penis and upper scrotum or the mons

• • pubis and labium majus.

• • b. The genitofemoral nerve originates from L1 and L2 and it divides into the genital

• • and femoral branches. The genital branch supply motor fibers to the cremasteric

• • muscle and sensation to the scrotum (mons pubis and labium majus in women).

• • c. The iliohypogastric nerve originates from T12 and L1. The sensory innervation

• • field of this nerve is similar to that of the ilioinguinal nerve.

• • d. The lateral femoral cutaneous nerve arises from L2 and L3, and supplies sensory

• • innervation to the anterior and lateral aspects of the thigh.

• • e. The femoral branch of the genitofemoral nerve provides sensory innervation to

• • the posterolateral aspect of the upper thigh.

N.B.(e) is the correct answer

42. 2.Groin pain can result from all the following except: a.Vas deferens fibrosis post hernia b.Herpes zoster infection c.Reflex sympathetic dystrophy d.Rolled up, bulk forming mesh material e.Torsion of the appendix testes N.B. (e) is the correct answer

Questions:

43. 3.Chronic post herniorrhaphy neuropathic groin pain is the result of all the following except: a.Neuroma formation b. P perineural fibrosis c.Entrapment by staples, sutures or prosthetic material d.Nerve damage from stretching, contusion, crushing, electrical damage, partial or complete division e.Periosteal reaction N.B. e. is the correct answer

Questions:

44. 4.In comparison to open mesh (tension-free) hernia repair, the nerves prone to injury during laparoscopic hernia repair are: a.Ilioinguinal and iliohypogastric nerves b.Ilioinguinal and genital branch of the genitofemoral nerve c.Ilioinguinal and lateral femoral cutaneous nerves d.Femoral branch of the genitofemoral nerve and iliohypogastric nerve e.Femoral branch of the genitofemoral nerve and lateral femoral cutaneousnerve N.B. (e) is the correct answer

Questions:

45. 5.Which of the following statements is incorrect? a.Femoral nerve injury may result in atrophy of the quadriceps muscle b.Lateral femoral cutaneous nerve injury may result in severe burning sensation along the anterolateral aspect of the thigh c.Peripheral communication between the ilioinguinal, iliohypogastric and genital branch of genitofemoral nerve is very common and results in an overlap of their sensory innervation d.A mesh placed taut and fixed with too many staples during laparoscopic preperitoneal hernia repair may result in meshalgia or staplealgia e.Sport related groin pain may result from injury to the abductor muscles N.B.e. is the correct answer

Questions: