Hernia treatment influenced by Gilmore's Groin repair techniques

In his previous articles in this series on Gilmore's Groin, esteemed consultant surgeon Mr Simon Marsh clearly explained what Gilmore's Groin is and how it is diagnosed and treated. Although commonly thought of like a hernia, Mr Marsh has explained how the two injuries differ. Nevertheless, in his latest articles with Top Doctors, the surgical director of the Gilmore Groin and Hernia Clinic in London explains how the treatment of Gilmore’s Groin has influenced the treatment of hernias.  

Gilmore's Groin: not just any groin pain

Diagnosing and treating Gilmore’s Groin

Is Gilmore's Groin a type of hernia?

Hernias and Gilmore's Groin are different things, although Gilmore’s Groin is sometimes described incorrectly as a sportsman's hernia. In a hernia, to use a formal medial definition, there is the “protrusion of a viscus through the wall of the cavity that normally contains that viscus”. In other words, something inside the tummy pokes through the muscles and you get a lump in the groin. Most people, I think, are familiar with an inguinal hernia; there is a squishy lump that tends to disappear (reduce) if you lie down.

It’s very common in men and 98% of inguinal hernias occur in men and only 2% in women. It is different from Gilmore’s Groin which is a musculotendinous injury. Our experience with Gilmore’s Groin and the anatomical repair that we do now, however, has implications for how hernias are fixed in the groin.

Are hernias and Gilmore’s Groin treated in the same way?

To repair Gilmore’s Groin, you have to understand the anatomy, and that understanding is really useful when a hernia needs to be repaired. Although we have known about hernias since ancient Egyptian and Roman times, they couldn’t be treated safely until general anaesthesia was available, so until the second half of the 19th century.

The pioneer of hernia surgery was an Italian surgeon called Edoardo Bassini, who in the late 1800s performed several hundred hernia operations under general anaesthetic. He repaired them by learning thoroughly about the anatomy of the groin. He worked out where the hernias were coming through the muscles, and operated on them to put the hernia back (reduce it), before repairing the muscles over the top to stop the hernia from coming back.

This is how hernias were treated until the 1990s, and to anyone aware of the procedure to treat Gilmore’s Groin, it will sound familiar. There’s a very famous Canadian clinic, the Shouldice Clinic, that’s also called the “hernia factory”, which performs thousands of hernia procedures using this exact suture technique to repair them anatomically. This is also the way I learned to repair hernias.

How are hernias usually treated today?

In the mid-1990s, the Lichtenstein technique became the most common way to repair hernias. Lichtenstein was an American surgeon who, instead of putting the hernia back and repairing the muscles, just put a plastic patch over the weakened muscles to stop the hernia from coming through. This technique became popular, as it was felt to be an easier technique for inexperienced surgeons to do. At the time, particularly in the NHS in this country, most hernias were repaired by surgical registrars or trainee surgeons and it was seen as a good technique for them to use. It was also sold as having a lower recurrence rate and complication rate. Even though studies have shown that none of that is true, it is still the way most hernias are treated now.

They’re treated either from the front, what we call an open approach, or with a “telescope”, the so-called laparoscopic technique when an even bigger mesh is put on the inside of the tummy. In the vast majority of people who have hernias repaired by either of these techniques, there will be no problems. Recently, however, the issue has been raised as to whether these meshes cause chronic pain in a small number of people, which is really difficult to treat. If a big mesh is put inside the tummy using a laparoscopic technique, it’s almost impossible to get out. If you’re suffering from chronic pain as a result, it is almost impossible to cure. In the case of an open mesh technique, the mesh can be taken out as a last resort. It’s not an easy operation, although, in a small number of patients that I have seen the results have been quite good, but it’s only performed when you have exhausted everything else.

What other hernia treatments are available?

If there is a potential problem with the mesh, why use it in the first place? If you've developed a thorough understanding of the anatomy and function of the groin muscles by treating elite sportsmen for Gilmore's Groin and you learn to fix hernias without meshes, why don't we do it that way? The answer is; I do! I see more and more people now, coming to see me saying that they would like a hernia repair without a mesh. Any hernia operation is a compromise between stopping it from coming back and keeping the complication rate as low as possible. I'm now performing quite a few hernia repairs every week, dare I say it, as we used to in the old days, because we have a thorough understanding of the anatomy of the groin that allows us to treat hernias anatomically, without mesh.

If you are interested in booking a consultation with Mr Simon Marsh, you can do so directly from his Top Doctors profile.