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Groin Exam
for the general surgeon:
chief complaint – groin pain
Brian Jacob, MD
Big Sky, MT 2018
Dr. Brian Jacob Disclosures
• Equity
• International Hernia Collaboration, INC
• LifeBond™
• ViaSurgical
• Consultant
• Me...
Chief complaint:
•Groin pain
Inguinal Hernia No Inguinal Hernia
Brian Jacob 2018
Chief complaint: History
•Groin pain
Inguinal Hernia
No Inguinal Hernia
•Where is it located, exactly?
•When did it start?...
Chief complaint: History
•Groin pain
Inguinal Hernia
No Inguinal Hernia
•When did it start?
•Why did it start?
•Constant o...
Injury or athletic pubalgia:
History documentation – let’s be consistent
• Sport
• S (starting event)
• P (pain descriptio...
Chief complaint: Exam
•Groin pain
Inguinal Hernia
No Inguinal Hernia
•Back
•Hip
•Abdomen
•Groin/ hernias / pubic tubercle
...
Exam: Back
• Palpate
• Flexion
• Extension
• Rule out obvious disc disease
•SI dysfunction
•TLS ?
• Thoraco-lumbar syndrom...
Exam: Back
SI dysfunction (lower back and groin)
http://www.hughston.com/
Brian Jacob 2018
Exam: Back
TLS (T12-L1) syndrome
Brian Jacob 2018
Exam: Hip
(for the hernia surgeon)
•Flexion
•Extension
•Rotation
•C-sign
•FABER exam
• Flexion/external
rotation/abduction...
Flexion, Abduction, External Rotation
Thank you Eduardo Parra-Davila
Brian Jacob 2018
Brian Jacob 2018
Brian Jacob 2018
Labral Tear
Brian Jacob 2018
Femoral Acetabular Impingement
Brian Jacob 2018
MRI : hip
arthrogram
Brian Jacob 2018
Exam: Intra-Abdominal
• Right side
• Appendicitis (chronic relapsing)
• Epiploica Appendigitis
• Adhesions
• Hidden hernia...
Exam: Groins / legs
(inguinal canals and pubic tubercles)
• Internal rings (inguinal hernia exam)
• Standing with Valsalva...
“conjoint tendinopathy”
• Lower part of the tranversus abdominis as it inserts into the crest of the pubis
and pectineal l...
Rectus sheeth avulsion or tear
• Lower part of the rectus tears or avulses off the pubic
tubercle
• Pain at insertion site...
Pubic Tubercle: the most underappreciated joint
drandyfranklynmiller.com Brian Jacob 2018
Rectus, AdductorsMuscles
Brian Jacob 2018
Bones Pubic tubercles, symphysis, acetabulum
Brian Jacob 2018
Groin pain is not so simple: need MRI to help
• Iliopsoas
• Rectus
• Pubic bone
• Adductors
http://www.clinicalsportsmedic...
Exam:
Rectus insertions, iliopsoas, and adductors
Brian Jacob 2018
Thank you Eduardo Parra-Davila
MRI: What can be the problem?
•Main buckets : athletic pubalgia
• Osteitis
• Rectus sheeth insertion
• Aponeurotic plate
•...
Osteitis
• MRI axial
Brian Jacob 2018
MRI: No osteitis
Brian Jacob 2018
MRI: confirmed osteitis
Brian Jacob 2018
Osteitis: which is yes vs no?
Brian Jacob 2018
MRI: Aponeurotic plate avulsion
Saggital mri view of left pubic tubercle
Brian Jacob 2018
MRI: coronal view
left adductor longus tear
• Look for the fluid
• (white on these images)
Brian Jacob 2018
Positive MRI Management options
•Acute injury: to surgery
•Chronic injury: to physical therapy first
•6 to 12 weeks of gra...
Repair options for acute injuries: surgery
•Prefer no mesh
•Rectus sheeth avulsion
•Reattach with 0 ethibonds
•Aponeurotic...
http://ernestschilders.com/
“sportsman groin”
(by exclusion of any other disruption sprain, injury,
or hernia)
Brian Jacob...
Dynamic Ultrasound
http://www.aspetar.com/
Brian Jacob 2018
Repair options for weak floor (sportsman groin):
•Diagnosis made with sonogram or MRI with Valsalva
•Repair can be open or...
Nerves: Neuroanatomy (open)
• Iliohypogastric nerve
• Ilioinguinal nerve
• Distal genital branch of the
genitofemoral nerv...
Brian Jacob 2018
Chief complaint: History
•Groin pain
No Inguinal Hernia
•When did it start?
•Why did it start?
•Constant or intermittent?
...
Groin Pain with History of an inguinal hernia or a repair:
Diagnostic Evaluation
• Review All Operative Reports
• Focused ...
• Nociceptive:
• inflammation, meshoma, in one spot
• Neuropathic:
• nerve injury, scarring, radiating
• Combination
• Ove...
A word about mapping with previous hernia history
• I always draw on patients in exam room, and right before surgery.
Nerve Injury: Pain Mapping
Brian Jacob 2018
Cases: Right groin pain for 6 years
Localized,
nonradiating,
constant
Brian Jacob 2017
Ct scan was normal
Intraoperative exploration:
(what did we find in OR??)
Hidden right inguinal hernia in a male
Brian Jac...
5 years of right groin pain. No previous surgery.
Exam, Ct, and MRI all negative
Brian Jacob 2017
Hidden right inguinal hernia in a female
Brian Jacob 2017
Colon resection 5 years ago. No hernias.
Chronic nociceptive pain.
Brian Jacob 2017
Suture granuloma
Brian Jacob 2017
2 years of nociceptive left groin pain
No previous surgery
Started after a work out
Brian Jacob 2017
2 years of nociceptive left groin pain
after open plug and patch
Brian Jacob 2017
14 years of both nociceptive and neuropathic
Brian Jacob 2017
Brian Jacob 2017
Scrotum and testicle NO Pain
Brian Jacob 2017
Open right groin
Staples and mesh found b/t external oblique + internal oblique
Staples seem to be from inside to out (loo...
Brian Jacob 2017
WWYD ?
Brian Jacob 2017
Neuropathic pain after open hernia repair
Pain management injections working
Holding off on surgery
Brian Jacob 2017
Hidden inguinal hernias can really be hidden
Brian Jacob 2017
Inguinodynia: tack
Brian Jacob 2017
Inguinodynia: old mesh
Brian Jacob 2017
Inguinodynia: recurrence
Brian Jacob 2017
Inguinodynia: missed femoral hernia
after open plug and patch
Brian Jacob 2017
Let’s Review
• History (work from back to hip to groin to leg)(then to abdomen and gyn)
• Review of previous Op reports
• ...
Thank you
Groin pain and hernia exam final by dr. brian jacob
Groin pain and hernia exam final by dr. brian jacob
Groin pain and hernia exam final by dr. brian jacob
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Groin pain and hernia exam final by dr. brian jacob

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groin pain and hernia history and exam : the best way to identify a diagnosis by Dr. Brian Jacob

Publicada em: Saúde e medicina
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Groin pain and hernia exam final by dr. brian jacob

  1. 1. Groin Exam for the general surgeon: chief complaint – groin pain Brian Jacob, MD Big Sky, MT 2018
  2. 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. 3. Chief complaint: •Groin pain Inguinal Hernia No Inguinal Hernia Brian Jacob 2018
  4. 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. 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. 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. 7. Chief complaint: Exam •Groin pain Inguinal Hernia No Inguinal Hernia •Back •Hip •Abdomen •Groin/ hernias / pubic tubercle •Legs •Photograph Brian Jacob 2018
  8. 8. Exam: Back • Palpate • Flexion • Extension • Rule out obvious disc disease •SI dysfunction •TLS ? • Thoraco-lumbar syndrome Brian Jacob 2018
  9. 9. Exam: Back SI dysfunction (lower back and groin) http://www.hughston.com/ Brian Jacob 2018
  10. 10. Exam: Back TLS (T12-L1) syndrome Brian Jacob 2018
  11. 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. 12. Flexion, Abduction, External Rotation Thank you Eduardo Parra-Davila Brian Jacob 2018
  13. 13. Brian Jacob 2018
  14. 14. Brian Jacob 2018
  15. 15. Labral Tear Brian Jacob 2018
  16. 16. Femoral Acetabular Impingement Brian Jacob 2018
  17. 17. MRI : hip arthrogram Brian Jacob 2018
  18. 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. 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. 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. 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. 22. Pubic Tubercle: the most underappreciated joint drandyfranklynmiller.com Brian Jacob 2018
  23. 23. Rectus, AdductorsMuscles Brian Jacob 2018
  24. 24. Bones Pubic tubercles, symphysis, acetabulum Brian Jacob 2018
  25. 25. Groin pain is not so simple: need MRI to help • Iliopsoas • Rectus • Pubic bone • Adductors http://www.clinicalsportsmedicine.com/ Brian Jacob 2018
  26. 26. Exam: Rectus insertions, iliopsoas, and adductors Brian Jacob 2018 Thank you Eduardo Parra-Davila
  27. 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. 28. Osteitis • MRI axial Brian Jacob 2018
  29. 29. MRI: No osteitis Brian Jacob 2018
  30. 30. MRI: confirmed osteitis Brian Jacob 2018
  31. 31. Osteitis: which is yes vs no? Brian Jacob 2018
  32. 32. MRI: Aponeurotic plate avulsion Saggital mri view of left pubic tubercle Brian Jacob 2018
  33. 33. MRI: coronal view left adductor longus tear • Look for the fluid • (white on these images) Brian Jacob 2018
  34. 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. 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. 36. http://ernestschilders.com/ “sportsman groin” (by exclusion of any other disruption sprain, injury, or hernia) Brian Jacob 2018
  37. 37. Dynamic Ultrasound http://www.aspetar.com/ Brian Jacob 2018
  38. 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. 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. 40. Brian Jacob 2018
  41. 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. 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. 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. 44. A word about mapping with previous hernia history • I always draw on patients in exam room, and right before surgery.
  45. 45. Nerve Injury: Pain Mapping Brian Jacob 2018
  46. 46. Cases: Right groin pain for 6 years Localized, nonradiating, constant Brian Jacob 2017
  47. 47. Ct scan was normal Intraoperative exploration: (what did we find in OR??) Hidden right inguinal hernia in a male Brian Jacob 2017
  48. 48. 5 years of right groin pain. No previous surgery. Exam, Ct, and MRI all negative Brian Jacob 2017
  49. 49. Hidden right inguinal hernia in a female Brian Jacob 2017
  50. 50. Colon resection 5 years ago. No hernias. Chronic nociceptive pain. Brian Jacob 2017
  51. 51. Suture granuloma Brian Jacob 2017
  52. 52. 2 years of nociceptive left groin pain No previous surgery Started after a work out Brian Jacob 2017
  53. 53. 2 years of nociceptive left groin pain after open plug and patch Brian Jacob 2017
  54. 54. 14 years of both nociceptive and neuropathic Brian Jacob 2017
  55. 55. Brian Jacob 2017 Scrotum and testicle NO Pain
  56. 56. Brian Jacob 2017
  57. 57. 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)
  58. 58. Brian Jacob 2017 WWYD ?
  59. 59. Brian Jacob 2017 Neuropathic pain after open hernia repair Pain management injections working Holding off on surgery
  60. 60. Brian Jacob 2017
  61. 61. Hidden inguinal hernias can really be hidden Brian Jacob 2017
  62. 62. Inguinodynia: tack Brian Jacob 2017
  63. 63. Inguinodynia: old mesh Brian Jacob 2017
  64. 64. Inguinodynia: recurrence Brian Jacob 2017
  65. 65. Inguinodynia: missed femoral hernia after open plug and patch Brian Jacob 2017
  66. 66. 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
  67. 67. Thank you

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