The rectus abdominis and adductor longus pull against the “pubic joint” with consequent weakness of posterior wall of the inguinal canal caused by force impairment (adductor’s strength overcomes rectus), without any nerve entrapment [4, 5]. Sports hernia is treated as a muscular problem with a reinforcement of distal insertion of rectus abdominis and inguinal canal posterior wall, broadening the insertional surface area (including the rectus, internal oblique, and transversus abdominis via the conjoint tendon) [6].

The procedure is like a standard open inguinal hernia repair from skin incision to spermatic cord isolation and dissection exposing the posterior wall of inguinal canal.

The exploration of conjoint tendon, rectus abdominis insertion, and transversalis fascia is crucial to identify any defect (injury or medial/cranial retraction of rectus abdominis tendinous portion, conjoint tendon’s tears, bulging of transversalis fascia).

Exposition of pubic tubercle and Cooper’s ligament is necessary to provide a good reconstruction in which the first two stitches are crucial:

The next stitch bites Cooper’s ligament, lateral edge of the pubic tubercle, and reflected part of the ilioinguinal ligament. Additional sutures are placed as a Bassini repair to bring the conjoined tendon down to the ilioinguinal ligament (reflected part).

The rest of the procedure is, again, like a standard inguinal hernia repair.

In selected cases, an adductor tendon release is combined (contracted or overdeveloped adductor musculature).

Litwin et al. reported good efficacy of the open, all-suture repair technique after evaluating 153 patients over a 6-year period from 2007 through January 2013.

Patient-reported outcome measure was used and showed positive results: physical health scores were improved by 15.5%, mental health scores were improved by 7.8%, and Tegner activity level scores were improved by 37.8%. A low rate of ipsilateral revision surgery and/or hip arthroscopy was reported [6].

Muscles and aponeurosis of groin region interact as sliding planes [7].

Transversalis fascia weakness in the inguinal canal posterior wall with “bulging” creates a compression of genital branch of the genitofemoral nerve. The nerve distribution to the inner thigh or scrotum explains the irritation symptoms in such area [7].

Impaired force interaction between the rectus abdominis and adductor (due to overuse, typical of pro sport athletes) causes a chronic pro-inflammatory state in the pubic area, acting directly and mechanically on sensory nerves.

Realignment of muscles, inguinal canal posterior wall reinforcement, and simultaneous nerve decompression are the three main steps of the procedure.

The minimal repair technique was developed by Dr. Ulrike Muschaweck, and it was first presented 14 years ago.

A 4-cm incision is made parallel to the inguinal ligament, more medial than for a standard inguinal hernia repair. A sharp incision is performed, and electrocautery dissects through the subcutaneous tissue and Scarpa’s fascia. The external inguinal ring is identified and evaluated (looking for edema or fiber enlargement/attenuation). After the division of external oblique fibers, the ilioinguinal nerve is identified and preserved. The spermatic cord is retracted to expose the floor of the inguinal canal and transversalis fascia (an eventual hernia sac should be identified and treated).

It’s important to use a Valsalva maneuver (direct or indirect) to clearly define a “bulging” in the floor. Careful evaluation of the genital branch of the genitofemoral nerve in this area can then be performed.

A lateral to medial incision of the transversalis is carried out, and a running suture (2/0 polypropylene) medial to lateral is performed between the iliopubic tract and the edge of the upper transversalis fascia; this first suture leaves a flap for the return suture. The running suture is continued to the lateral edge of the rectus muscle and anchored to it; then the flap is incorporated in the running suture laterally to the initial knot (imbricated suture line).

The final result is a complete obliteration of the bulging area.

The evaluation of the genital branch of the genitofemoral nerve in this area is mandatory; in case of inflammation or any other sign of involvement, it is excised.

To protect the ilioinguinal nerve from mechanical irritation, a collar made with internal oblique muscle fibers is prepared and placed around the nerve.

The rest of the procedure is, again, like a standard inguinal hernia repair.

Both open techniques without mesh positioning were associated with equivalent results. The minimal repair technique has a short postoperative rehabilitation time which allows athletes to return to play very quickly (4.5 vs. 16.5 weeks) [7].

Inguinal floor repair and stabilization with mesh (tension-free repair) avoid excessive tension (as in suture repair along the suture line) and its sequelae (postoperative chronic pain, recurrence) [8]. Alternative strategies are necessary in particular cases: young not completely grown male athletes, young female athletes (open primary tissue repair), and prior sports hernia or inguinal hernia open repair (laparoscopic approach) [9].

The choice to combine an adductor release procedure is related to tension reduction at its proximal insertion.

A standard incision and dissection through the subcutaneous tissue and Scarpa’s fascia as for an inguinal hernia repair are performed. The external inguinal ring is identified, and the two pillars are evaluated (tension, dilation, fiber attenuation). After the division of external oblique fibers, the ilioinguinal nerve is identified and preserved. The spermatic cord is retracted to expose the floor of the inguinal canal and transversalis fascia (an eventual hernia sac should be identified and treated).

The floor is reconstructed by suturing a lightweight polypropylene mesh to the transversalis fascia and rectus sheath with single nonabsorbable stitches. The lateral edge is sutured to the inguinal ligament with a running polypropylene suture, the mesh is split, and the two ends are sutured together to the inguinal ligament. As in Lichtenstein repair, a deep inguinal ring reconstruction with the two tails of the mesh is performed: the goal is not the ring reconstruction itself but to allow a linear and clear adhesion of the mesh to the floor.