No exact pathophysiological mechanism for chronic pain has so far been identified in SH or AP. The most common theories include adductor and/or rectus abdominis muscle tendinopathies, hip hyperextension injuries, or disruption of the posterior wall of inguinal canal [6, 7, 9, 10]. A tear of the abdominal wall in the posterior inguinal canal or conjoined tendon (tendinopathy), with or without bulging like a hernia, was originally suggested to be typical for a SH [4, 7, 9]. The tissue damage or disruption of the posterior wall is analogous to an incipient direct inguinal hernia (with or without bulge). To date, there are no histological, imaging, or operative studies which confirm the causal relationship between microscopic and/or macroscopic tissue injury to chronic pain in SH.

The combination of complex anatomy in the groin area, variability of presentation, and the nonspecific nature of the signs and symptoms make sometimes the differential diagnostic process problematic [11].

Treatment of SH and/or AP aims toward its specific pathology. First line management includes rest, muscle strengthening and stretching exercises, physiotherapy, anti-inflammatory analgesics, local anesthetic, and/or corticosteroid injections and, in resistant cases, operative management [1, 2].

Surgery should be undertaken by surgeons with vast experience in this field. A recommendation is to evaluate these patients in a “multi-specialist sports team” including a general surgeon, an orthopedic surgeon, and a physiotherapist. Educational programs are encouraged including mentorship followed by a certification. Competence has become a major concern and an essential requirement in the surgical community.

There is no evidence-based consensus available on indications for operative treatment of AP [1]. Both open and laparoscopic repairs are good and seem to result in equivalent results. The latter may allow earlier return to full sport [5, 8, 10]. Comparative or randomized studies between open and laparoscopic procedures are lacking. Endoscopic repair of SH, particularly in athletes, has many theoretical advantages. The posterior position of the mesh, that will include the conjoint tendon and pubic bone, creates theoretically a stronger support than a conventional anterior hernioplasty (Fig. 12.3).

Generally, postoperative pain and wound complications are less frequent after laparoscopic surgery than in open surgery. There is a huge experience in inguinal hernia surgery on advantages and disadvantages of different techniques. The endoscopic techniques seem superior when it comes to the sensation of a foreign body in the groin or chronic pain in mesh repairs [20, 21]. The open techniques include dissection in an area where the three inguinal nerves are found (the ilio-inguinal, the iliohypogastric, and the genital branch of the genitofemoral nerve) and the surgeon has to take notice of them. Harm of these nerves might result in restrictions and chronic pain frequently reported on after inguinal hernia surgery [22]. The consideration for nerve problems is less in the endoscopic techniques, especially when following the right planes for dissection and avoiding fixation [23].

The TEP technique has the advantage of being performed totally pre-peritoneal, thereby not entering the abdominal cavity. In TAPP you enter the cavity, which is a potential risk of harming intra-abdominal structures. However, the TAPP approach does allow the possibility to perform a diagnostic laparoscopy which might be indicated especially in female where differential diagnosis intra-abdominally might be considered. In the TEP approach, a pocket is dissected where a mesh can be placed without fixation or by the use of atraumatic glue [23]. In TAPP, some type of fixation of the mesh, usually by spiral tacks, is common and sometimes tacks are also used to cover the mesh with peritoneum. The pre-peritoneal endoscopic technique results in less dominant scars than the open techniques.

A novel, open, minimal suture repair technique, restoring the transverse fascia, may be a promising technique to repair sportsman’s groin [6]. Whether the endoscopic or the open technique is better than the other (concerning relief of pain) is now tested in a randomized controlled trial incorporating an international specialized team of surgeons experienced in both techniques (Clinical Trials NCT01876342).

All endoscopic SH operations are performed under general anesthesia [21]. Patients are placed in a supine position. The patient is catheterized after induction of anesthesia. In TAPP technique, pneumoperitoneum is established, preferably using an open access technique below the umbilicus to minimize the risk of blind puncture of intra-abdominal structures. A 10-mm port is placed with 30° camera used for initial visualization of the peritoneal cavity. Two 5-mm working ports are introduced for dissection. The peritoneum is incised well above the internal ring and the peritoneum is dissected 5 cm beyond the margin of the groin defect medially exposing the Cooper’s ligament and laterally/dorsally well exposing the triangle of doom (Fig. 12.4). An appropriate-sized (usually 10 cm × 15 cm) polypropylene mesh is chosen, allowing at least 5-cm overlap on the injury of the posterior wall. The mesh is unrolled in the pre-peritoneal space and fixed onto the abdominal wall with helical tacks, sutures or tissue glue including the posterior pubis and Cooper’s ligament [23]. Re-peritonealization is usually performed by continuous intra-corporeal suturing of the peritoneal flaps with 3–0 polyglactin suture or using tissue glue or tacks. Conventional non-steroidal anti-inflammatory drugs (NSAID) or paracetamol are used for postoperative pain relief. The operation is performed as day case surgery and follow-up is performed according to local protocol.

Laparoscopic mesh implantation in TAPP usually follows the current principle of inguinal hernia surgery and is based on the physiological principle of diffusing the intra-abdominal pressure on the whole area of the implanted mesh in the disrupted groin area (Fig. 12.4). This ensures immediate firm fixation of the mesh to the abdominal wall [21]. The pre-peritoneal mesh covers the most vulnerable and injured areas at the pubic symphysis complex, and also supports firmly the posterior wall of the inguinal canal. The tissue ingrowth is expected to be more extensive than a mesh placed directly on the peritoneal surface.

TAPP technique was the initial endoscopic treatment of SH reported by UK surgeons [24]. According to original reports this technique “appeared as effective as conventional repair for sporting injuries and merits further evaluation as a technique to permit early return to activity” [24]. Soon after that, many more athletes were operated using TAPP technique [8, 10, 25–29].

Area of maximal pain can preferably be marked preoperatively on the groin skin which helps to place the retro-pubic mesh in an optimal position (Fig. 12.5). In TEP, the retro-pubic pre-peritoneal space is approached through a small sub-umbilical skin incision, followed by the entrance through the anterior rectus fascia and a muscle split, entering the pre-peritoneal facial space using a blunt 10 mm port on the affected side. The use of balloon dilatation is optional. The surgeon can also open the pre-peritoneal space by using the camera together with gas insufflation which is convenient and cheap (Fig. 12.5). After dissection described above, the retro-pubic area is covered with a 10 cm × 15 cm low weight polypropylene mesh, preferably using no-fixation or tissue glue [23, 30]. Meshes are sometimes placed bilaterally even if the symptoms are unilateral, because scarring of the pre-peritoneal space would most likely prevent a later operation of the non-affected side. There is, however, no consensus presented in the literature for bilateral operation.