BACKGROUND: Post-inguinal pain after a hernia surgery is prevalent and can be quite frustrating for the surgeon and patient alike. There are several sources for possible post-operative inguinal pain after a successful hernia repair; however, in the setting where a recurrent inguinal hernia is not present, it is likely related to the nerves in the inguinal canal or pelvis. Chronic inguinal groin pain after hernia repairs have been reported in a high percentage of patients following inguinal hernia surgery despite being one of the most common procedures performed annually in the USA and worldwide.
METHODS: We present ten of the basic concepts utilized by peripheral nerve surgeons to limit nerve injury, which can easily be applied to open inguinal hernia surgery with or without mesh, starting with the firm understanding of the inguinal anatomy to addressing the nerves, meticulous placement of the mesh and the active revision of the surrounding structures and nerve position before closure.
CONCLUSIONS: Understanding the proper handling of the inguinal nerves during hernia surgery can decrease the incidence of post-operative chronic pain by employing microsurgical concepts to day-to-day surgical procedures and prevent complications in an extensive set of patients.

Controversies remain regarding the diagnosis, imaging, and treatment of acute adductor injuries in athletes.
To investigate the diagnostic imaging, treatment, and prevention of acute adductor injuries based on the most recent and relevant scientific evidence.
Systematic review; Level of evidence, 4.
The PubMed and Web of Science databases were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify articles studying acute adductor injury in athletes. Inclusion criteria were original publication on acute adductor injury in amateur or professional athletes, level 1 to 4 evidence, mean patient age >15 years, and results presented as return-to-sport, pain, or functional outcomes. Quality assessment was performed with the CONSORT (Consolidated Standards of Reporting Trials) statement or the methodological index for non-randomized studies criteria. Articles were grouped as imaging, treatment, prevention focused, or mixed.
A total of 30 studies published between 2001 and 2021 were selected, involving 594 male patients with a mean age 26.2 years (range, 16-68 years). The most frequent sports were soccer (62%), basketball (14%), futsal (6%), American football (3%), and ice hockey and handball (2%). Risk factors for acute adductor injury were previous acute groin injury, adductor weakness compared with the uninjured side, any injury in the previous season, and reduced rotational hip range of motion. The frequency of complete adductor muscle tears on magnetic resonance imaging was 21% to 25%. For complete adductor tears, the average time to return to play was 8.9 weeks in patients treated nonoperatively and 14.2 weeks for patients treated surgically. Greater stump retraction was observed in individuals treated surgically. Partial acute adductor tears were treated nonoperatively with physical therapy in all studies in the present systematic review. The average time to return to play was 1 to 6.9 weeks depending on the injury grade. The efficacy of adductor strengthening on preventing acute adductor tears has controversial results in the literature.
Athletes with partial adductor injuries returned to play 1 to 7 weeks after injury with physical therapy treatment. Nonoperative or surgical treatment is an acceptable option for complete adductor longus tendon tear.

OBJECTIVE: To compare and statistically evaluate the severity of pain syndrome and quality of life depending on the method of fixation of the parietal peritoneum during laparoscopic hernia repair (suture fixation or the use of tack fixation).
METHODS: A randomized clinical trial was conducted from May to June 2021 at the Lomonosov Moscow State University Medical Center. It was planned to observe patients for a year. In the first group, the fixation of the parietal peritoneum was performed using suture fixation, in the second group, the peritoneal flap was fixed using a fixation device. In the course of statistical data processing, it was planned to study the dependence of the duration of the operation, the severity of the pain syndrome in the early postoperative period, the frequency of complications, the quality of life of patients in the postoperative period on the chosen method of the fixation of the parietal peritoneum.
RESULTS: At the initial stage of the study, 8 patients with inguinal hernias were selected in the first group during randomization, and 6 patients were selected in the second group. Each patient of the second group in the early postoperative period had a more pronounced local pain, protective muscle tension in the projection of fixation of the parietal peritoneum with tacks, which was accompanied by negative psychoemotional reactions, an increase in the dose of analgesic drugs. Due to the revealed features of the early postoperative period in patients of second group, it was considered unethical and inappropriate to continue the study within the protocol.
CONCLUSIONS: The results obtained do not allow us to draw statistically supported conclusions. The solution of the problem of the peritoneal flap fixation method is possible in two ways: abandoning stapler fixation in favor of suture or conducting additional clinical studies with an analysis of the impact of the choice of peritoneal fixation technique not only on acute and chronic postoperative pain, but on quality of life in the early and delayed postoperative periods.
UNASSIGNED: Провести сравнение и статистическую оценку выраженности болевого синдрома и качества жизни в зависимости от метода фиксации париетальной брюшины во время выполнения лапароскопической герниопластики (шовная фиксация или использование скобочной фиксации).
UNASSIGNED: Рандомизированное клиническое исследование, проводилось с мая по июнь 2021 г. на базе МНОЦ МГУ им. М.В. Ломоносова. Планировалось наблюдение за пациентами в течение года. В 1-й группе фиксацию париетальной брюшины выполняли с помощью шовной фиксации, во 2-й группе перитонеальный лоскут фиксировали с помощью герниостеплера. В ходе статистической обработки данных планировалось изучение зависимости продолжительность операции, выраженности болевого синдрома в раннем послеоперационном периоде, частоты развития осложнений, качества жизни пациентов в послеоперационном периоде от выбранной методики восстановления целостности париетальной брюшины.
UNASSIGNED: На начальном этапе исследования в ходе рандомизации в 1-ю группу отобраны 8 пациентов с паховой грыжей, во 2-ю — 6 пациентов. У всех пациентов 2-й группы в раннем послеоперационном периоде отмечены более выраженный локальный болевой синдром, защитное мышечное напряжение в проекции фиксации париетальной брюшины скобами, что сопровождалось негативными психоэмоциональными реакциями, увеличением потребности в анальгетических препаратах. В связи с выявленными особенностями течения раннего послеоперационного периода у пациентов 2-й группы признано неэтичным и нецелесообразным продолжение исследования в рамках протокола.
UNASSIGNED: Полученные результаты не позволяют сделать статистически обоснованные выводы. Решение проблемы выбора способа фиксации перитонеального лоскута выглядит возможным двумя путями: отказ от степлерной фиксации в пользу шовной или проведение дополнительных клинических исследований с тщательным анализом влияния выбора методики восстановления брюшины не только на острую и хроническую послеоперационную боль, но и на показатели качества жизни в ранний и отсроченный послеоперационные периоды.

The objective of this study was to analyze the role of dynamic magnetic resonance imaging (MRI) in patients who suffered from groin pain and whose physical examination and ultrasound returned inconclusive/indefinite results, as well as in patients receiving an ongoing assessment for a previous herniotomy.
For this study, 25 patients 14 women and 11 men were selected with a mean age of 41.6 years, including clinical complaints, such as groin pain and or a previous herniotomies. These patients underwent dynamic MRI. Reports were created by a radiology resident and a radiology consultant. Clinical and ultrasound documentation were compared to with imaging results from the MRI.
The results of the dynamic MRI were negative for 23 patients (92%) and positive for two patients (8%). One patient suffered from an indirect hernia and one from a femoral hernia. A repeated hernia was an excluding for the preoperated patients with pain and ongoing assessment.
Dynamic MRI shows substantially higher diagnostic performance in exclusion of inguinal hernia, when compared to a physical examination and ultrasound. The examination can also be used in assessments to analyze the operation\'s results.

UNASSIGNED: Controversies remain regarding the surgical treatment of inguinal-, pubic-, and adductor-related chronic groin pain (CGP) in athletes.
UNASSIGNED: To investigate the outcomes of surgery for CGP in athletes based on surgical technique and anatomic area addressed.
UNASSIGNED: Systematic review; Level of evidence, 4.
UNASSIGNED: The PubMed and Embase databases were searched for articles reporting surgical treatment of inguinal-, pubic-, or adductor-related CGP in athletes. Inclusion criteria were level 1 to 4 evidence, mean patient age >15 years, and results presented as return-to-sport, pain, or functional outcomes. Quality assessment was performed with the CONSORT (Consolidated Standards of Reporting Trials) statement or MINORS (Methodological Index for Non-randomized Studies) criteria. Techniques were grouped as inguinal, adductor origin, pubic symphysis, combined inguinal and adductor, combined pubic symphysis and adductor, or mixed.
UNASSIGNED: Overall, 47 studies published between 1991 and 2020 were included. There were 2737 patients (94% male) with a mean age at surgery of 27.8 years (range, 12-65 years). The mean duration of symptoms was 13.1 months (range, 0.3-144 months). The most frequent sport involved was soccer (71%), followed by rugby (7%), Australian football (5%), and ice hockey (4%). Of the 47 articles reviewed, 44 were classified as level 4 evidence, 1 study was classified as level 3, and 2 randomized controlled trials were classified as level 1b. The quality of the observational studies improved modestly with time, with a mean MINORS score of 6 for articles published between 1991 and 2000, 6.53 for articles published from 2001 to 2010, and 6.9 for articles published from 2011 to 2020. Return to play at preinjury or higher level was observed in 92% (95% CI, 88%-95%) of the athletes after surgery to the inguinal area, 75% (95% CI, 57%-89%) after surgery to the adductor origin, 84% (95% CI, 47%-100%) after surgery to the pubic symphysis, and 89% (95% CI, 70%-99%) after combined surgery in the inguinal and adductor origin.
UNASSIGNED: Return to play at preinjury or higher level was more likely after surgery for inguinal-related CGP (92%) versus adductor-related CGP (75%). However, the majority of studies reviewed were methodologically of low quality owing to the lack of comparison groups.

Van Neck-Odelberg disease or ischiopubic osteochondritis, is a rare cause of pain in the pediatric pelvis due to late closure in synchondrosis ischiopubic, whose main symptom is an asymmetric pain that can cause a limitation in movement or limp. The different characteristics by images from simple radiography, computed tomography, MRI and bone scintigraphy scan will increase certainty diagnosis and will allow the correct differential diagnosis with fractures, posttraumatic osteolysis, infections or tumors, that leads to unnecessary invasive procedures, this being a benign disease with an evolution and improvement that occurs in weeks or months with conservative treatment. A case of a 15-year-old boy who consulted our hospital with an extra-institutional diagnosis of right ischiopubic fracture. After being evaluated by different imaging methods, a diagnosis of Van Neck-Odelberg or ischiopubic osteochondritis was made.

OBJECTIVE: Persistent postoperative pain (PPP) is a prevalent complication after inguinal hernia repair. The aim of this study was to develop and validate a preoperative risk score for PPP.
METHODS: We developed the risk score based on a cohort of 2,508 Danish men, who answered a questionnaire six months after inguinal hernia repair performed 2015-2016. PPP was defined as a numerical rating scale score ≥ 2 during activity six months postoperatively. Logistic regression analyses were undertaken to determine statistically significant predictors of PPP. Univariable analysis selected potential predictors with a p value ≤ 0.20, and a subsequent multivariable model was built using backward elimination with a criterion of p value < 0.10. We created a risk score based on the β coefficients of the multivariable model. The risk score was validated internally using Hosmer-Lemeshow goodness of fit test, calibration belt test, and receiver operating characteristic curve analyses with 95% confidence intervals based on the bootstrap analysis. External validation was performed in a cohort of 293 men recruited preoperatively.
RESULTS: Predictors of PPP were age 18-49 and 50-59 (versus ≥ 60) years (p < 0.001), total load lifted > 1,000 kg/day (p = 0.001), working in a bent-over position > 1 h/day (p < 0.001), leisure-time physical activity < 2 h/week (p = 0.009), increasing body mass index (per unit) (p < 0.003), and repair of recurrent hernia (p = 0.001).The preoperative risk score predicted risks of 6-61% in the development population. The model showed good internal and external validity.
CONCLUSIONS: The results suggest that the risk of PPP after inguinal hernia repair can be predicted using a preoperative risk score.

BACKGROUND: The incidence of mucinous appendiceal adenocarcinomas (MAA) has increased over the past three decades. Advanced stage tumor diagnosis is likely attributable to non-specific findings. Here we describe advanced stage appendiceal MAA presenting as inguinal ulcers, scrotal abscesses, and other nonspecific symptoms. To our knowledge, this is the first report of MAA presenting as inguinal pain with inflamed phlegmonous tissue and scrotal abscess.
METHODS: A 67-year-old male presented to a rural facility complaining of weight-loss, fatigue, hematuria, dysuria, painful right inguinal ulceration, and right scrotal abscess drainage. Computed tomography of the abdomen and pelvis revealed a distended appendix (> 1.3 cm) and a fistula between the appendix, urinary bladder, right scrotum, and right groin. Laparoscopic appendectomy was performed and diagnosed as MAA. After a right hemicolectomy, the MAA was staged as pT3b pN0 M0 G2.
CONCLUSIONS: This case highlights a unique presentation of late stage appendiceal MAA. Due to the increased incidence of appendiceal MAAs, reports of unique clinical features are needed to facilitate early diagnosis and intervention, especially in rural settings with limited access to specialists.

BACKGROUND: Muscular and apophyseal injuries in the inguinal region are a common cause of groin pain in athletes.
OBJECTIVE: Frequently occurring muscular and apophyseal injuries in the groin region are described.
METHODS: Fundamental studies and expert recommendations are discussed. Examination protocols for routine clinical practice are presented.
RESULTS: The exact diagnosis and classification of muscular or apophyseal injuries in the inguinal region are the basic prerequisites for the initiation of a targeted treatment and thus crucial for the return to sport time. These injuries are occurring with increasing frequency in both professional and recreational sports.
CONCLUSIONS: In addition to the clinical examination and the history of the course of the injury, MRI plays an important role in the evaluation of muscular and apophyseal injuries in the inguinal region.

BACKGROUND: Athletic pubalgia is typically associated with male athletes participating in contact sports and less frequently with females. Endoscopic surgery may fully treat the patient with athletic pubalgia.
OBJECTIVE: To perform an outcomes analysis of magnetic resonance imaging (MRI) and endoscopic surgery in female patients with athletic pubalgia.
METHODS: Cohort study; Level of evidence, 3.
METHODS: Fifteen physically active female patients (mean age, 37 years) with athletic pubalgia were treated surgically via placement of total extraperitoneal endoscopic polypropylene mesh behind the injured groin area. The presence of preoperative bone marrow edema (BME) at the pubic symphysis seen on MRI was graded from 0 to 3 and correlated with pain scores after surgery. The outcome measures were pre- and postoperative pain scores and recovery to daily activity between 1 and 12 months after surgery. Results were compared with previously published scores from male athletes (n = 30).
RESULTS: With the exception of lower body mass index, the females with (n = 8) and without (n = 7) pubic BME had similar patient characteristics to the corresponding males. Mean inguinal pain scores (0-10) before surgical treatment were greater in females than males (during exercise, 7.8 ± 1.1 vs 6.9 ± 1.1; P = .0131). One month after surgery, mean pain scores for females were still greater compared with males (2.9 ± 1.7 vs 1.3 ± 1.6; P = .0034). Compared with female athletes with normal MRI, pubic BME was related to increased mean preoperative pain scores (8.13 ± 0.99 vs 6.43 ± 1.2; P = .0122). After 1 year, surgical outcomes were excellent or good in 47% of women.
CONCLUSIONS: Endoscopic surgery was helpful in half of the females with athletic pubalgia in this study. The presence of pubic BME may predict slightly prolonged recovery from surgery.