1. The Marsh Modification of the Gilmore Technique Simon Marsh MA MD FRCS Surgical Director

4. Challenges Maintain high success rate Single operation Get back and stay back Rapid return to full activity

6. Surgery

15. Surgical Technique Inguinal ligament tenolysis Plication of posterior wall Resuturing conjoint tendon to inguinal ligament 2/0 prolene darn (permanent) Closure of Scarpa’s fascia Skin closure

16. Groin Reconstruction Marsh Modification –Builds on traditional repair –Incorporates the best from around the world –Includes inguinal ligament tenolysis and less tissue trauma –Specific anaesthesia –Individualised rehabilitation Traditional repair –Based on established anatomical and physiological principles –30 years experience –Established success

17. Rehabilitation

18. Traditional 4 week program Week 1:walk 4 x day Week 2:jog --- running adductor exercises Week 3: start sprinting cycling Week 4: kicking twist & turn Week 5: play PLAY

19. Rehabilitation 4 Stages: Summary: Stage 1:Mobility Stage 2:Flexibility Stage 3:Strength Stage 4:Sport Specific Different requirements for amateurs and professionals

20. Stage 1: Mobility Straight line activities Avoid abdominal straining Treadmill jogging/running Front crawl swimming Cross training

21. Stage 2: Flexibility Body weight movements Lunges Side lunges Partial squats Hip flexion and extension

22. Stage 3: Strength Increase intensity of core stability work Change of direction at speed Box drills Cutting drills Figure of eight routines

23. Stage 4: Sport specific training

24. Rehabilitation Professional: 3-4 weeks Amateur: 6-8 weeks

26. The Team: Patient SurgeonAnaesthetist Sports and Exercise Physician Physiotherapist Specialist Nurses Orthopaedic Surgeon

29. Some Physiology

30. Wound without sutures Graph of wound strength against time

31. Wound without sutures Graph of wound strength against time Wound with Dissolvable sutures

32. Wound without sutures Graph of wound strength against time Wound with Dissolvable sutures Wound with Permanent sutures

33. Definitely NOT a hernia (and re-operations)

42. http://www.108harleystreet.co.uk/