- 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.
Albrecht Durer, Vier Bucher von menschlicher Proportion,
Nurenberg, 1528.
- She has already been seen by:
-
- Gynecologist (vaginal ultrasound)
-
- Gastroenterologist (EGD and
-
- Urologist (pelvic ultrasound)
3. DIFFERENTIAL DIAGNOSIS
- Connective tissue disease
- Slipped fem. cap.epiphysis
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
- 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:
- Open right hernia repair is
- 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.
Albrecht Durer, Vier Bucher von menschlicher Proportion,
Nurenberg, 1528.
- 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
9. The charge:
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
- Risk factors associated with CGP that have been identified
include:
MONDAY
- 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
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
- Nerve entrapment, excessive scar formation or
- mechanical pressure from mesh are possible
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
20. TUESDAY
- During her testimony and cross examination, the patient
- complains that quality and quantity of sex has diminished,
- 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.
- surgeon settle out-of-court.
- They propose a settlement
23. WEDNESDAY
- Expert witness for the defense (surgeon) testifies:
24. Groin pain could be neuropathic:
- Partial or complete nerve
25. Nerves prone toinjury duringlaparoscopic repair:
26. Lateral femoral cutaneous nerve innervation (L2,3)
27. Femoral branchof genitofemoral nerve-innervation (L1,2) The
femoral branch supplies sensory innervation to the anterolateral
thigh. 28. Femoral nerve innervation (L2,3)
29. Pain could be non-neuropathic and related to:
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
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:
- Partial or complete nerve
36. Pain could be non-neuropathic and related to:
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
- 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
-
-
- 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
-
-
- 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
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
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
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