Occult Groin Hernias Research Articles

Diagnostic Accuracy of Imaging Modalities on Occult Groin Hernias According to Hernia type and a Surgeon-centered Individualized Groin Hernia Management Algorithm

The purpose of this study is to evaluate the diagnostic performance of imaging techniques for the identification of groin hernias based on the type of hernia and to demonstrate the efficacy of an algorithm based on the surgeon and surgical technique. Medical records of 561 patients who were operated on for groin hernia were retrospectively analyzed. A total of 102 patients who had both pelvic computed tomography (CT) and ultrasonography (USG) recordings preoperatively and underwent transabdominal preperitoneal repair were included in the study. A contralateral asymptomatic occult groin hernia was detected in 25.5% of all patients. The overall sensitivity of USG and CT on contralateral asymptomatic occult hernia was 42.3% and 65.4%, respectively. The sensitivity of USG according to the contralateral occult hernia type was 66.7%, 35.7%, 33.3%, and 50% for direct, indirect, femoral, and pantaloon hernias, respectively. The sensitivity of CT according to the contralateral occult hernia type was 0%, 57.1%, 100%, and 100% for direct, indirect, femoral, and pantaloon hernias, respectively. The handicap created by the variability in the diagnostic sensitivity of imaging modalities can be overcome with the choice of transabdominal preperitoneal repair in the surgical technique.

Accuracy of Ultrasound as a Diagnostic Tool for the Assessment of Occult Groin Hernias

Groin hernias are a common reason to attend general surgical clinic with over 71,000 groin hernia repairs carried out in England in 2014/15. Diagnosis of groin hernias is primarily a clinical one, but a significant proportion of them are symptomatic and are not clinically palpable. There are a number of investigative options available which includes herniography, ultrasound, CT and MRI. Herniography is invasive and less sensitive to diagnose occult hernias and some radiologist would consider it, unethical & obsolete. MRI and CT scan are expensive and not always available. We evaluated the role of ultrasound in the surgical management of a cohort of patients with clinically occult groin hernia in a district general hospital. A retrospective list of patients having ultrasound examination for symptomatic groin collected from radiology department. Ultrasound which confirmed presence of hernias were identified. Ultrasound findings and clinical assessment were analyzed. In patients who underwent surgery, intra-operative findings were taken as gold standard and compared with ultrasound results. Total number of hernias included in the study was 68. Male to female distribution of patients was 3.3; 1. The mean age of participants was 42 years. In 93%, the presenting symptoms were pain, lump or combination of both. 40 patients (59%) were operated from which there was PPV of 0.90 with intraoperative findings congruent with intraoperative findings. Ultrasound is non-invasive and non-ionizing radiation imaging modality for diagnosis of impalpable groin hernias with a PPV of 90%. Morbidity associated with this modality is low. It is readily available and cheaper than MRI and CT scan with no harmful ionization radiation thereby conferring a cost benefit as well. We have shown ultrasound is a suitable tool for the initial imaging investigation of occult clinically non-palpable hernia. Our review of current literature has shown wide variance of the choice of imaging technique and the accuracy of their published report.

Ultrasonography in diagnosing clinically occult groin hernia: systematic review and meta-analysis.

To provide an updated systematic review on the performance of ultrasonography (US) in diagnosing clinically occult groin hernia. A systematic search was performed in MEDLINE and Embase. Methodological quality of included studies was assessed. Accuracy data of US in detecting clinically occult groin hernia were extracted. Positive predictive value (PPV) was pooled with a random effects model. For studies investigating the performance of US in hernia type classification (inguinal vs femoral), correctly classified proportion was assessed. Sixteen studies were included. In the two studies without verification bias, sensitivities were 29.4% [95% confidence interval (CI), 15.1-47.5%] and 90.9% (95% CI, 70.8-98.9%); specificities were 90.0% (95% CI, 80.5-95.9%) and 90.6% (95% CI, 83.0-95.6%). Verification bias or a variation of it (i.e. study limited to only subjects with definitive proof of disease status) was present in all other studies. Sensitivity, specificity, and negative predictive value (NPV) were not pooled. PPV ranged from 58.8 to 100%. Pooled PPV, based on data from ten studies with low risk of bias and no applicability concerns with respect to patient selection, was 85.6% (95% CI, 76.5-92.7%). Proportion of correctly classified hernias, based on data from four studies, ranged between 94.4% and 99.1%. Sensitivity, specificity and NPV of US in detecting clinically occult groin hernia cannot reliably be determined based on current evidence. Further studies are necessary. Accuracy may strongly depend on the examiner's skills. PPV is high. Inguinal and femoral hernias can reliably be differentiated by US. • Sensitivity, specificity and NPV of ultrasound in detecting clinically occult groin hernia cannot reliably be determined based on current evidence. • Accuracy may strongly depend on the examiner's skills. • PPV of US in detection of clinically occult groin hernia is high [pooled PPV of 85.6% (95% confidence interval, 76.5-92.7%)]. • US has very high performance in correctly differentiating between clinically occult inguinal and femoral hernia (correctness of 94.4- 99.1%).

Groin hernia diagnostics: dynamic inguinal ultrasound (DIUS).

Although clinical examination is the gold standard for the diagnosis of groin hernia, imaging procedures can improve the detection of femoral hernias, incipient hernias, and less-common types of hernias (e.g., an obturator hernia). The aim of this study is to evaluate the sensitivity and specificity of dynamic inguinal ultrasound (DIUS). Between July 2010 and June 2015, 4951 clinical and ultrasound examinations of the groin area were conducted at the Hanse-Hernienzentrum in Hamburg, Germany. The ultrasonographic findings were prospectively evaluated to determine the number of inguinal and femoral hernia diagnoses that were ultrasonically confirmed and also to consider cases in which clinical examination overlooked these diagnoses. The results were compared with the intraoperative findings. The results show that standardized ultrasound examination of the groin area with high-frequency, small-part linear transducers also serves to accurately display femoral and small or occult groin hernias. The high-level specificity (0.9980) and sensitivity (0.9758) are proof of the procedure's quality. To ensure high-quality hernia treatment, regular use of standardized ultrasound examinations is recommended.

The role of ultrasound in the management of patients with occult groin hernias

Introduction: Groin ultrasound scanning is commonly used to examine patients with obscure groin pain or swelling. A recent study has shown ultrasound has a poor positive predictive value (PPV) in diagnosing groin hernias although earlier studies reported PPV values as high as 100%. Our aims were to calculate ultrasound's accuracy in diagnosing occult groin hernias in symptomatic patients and assess how management of these patients is affected by ultrasound result. Methods: We retrospectively analysed 375 symptomatic adult patients, who between February 2008 and March 2010, had ultrasound to diagnose groin hernias when clinical examination was inconclusive. Patients were identified on a prospective radiology database and all groin ultrasounds were performed by either one consultant radiologist or one radiographer. Results: Ultrasound was positive in 199 patients, of which 118 underwent surgery. Using operative findings as the gold standard, ultrasound's PPV for groin hernias was 70% (95% CI: 62–78%). Ultrasound was equivocal in 42 patients of which hernias were diagnosed in 7 of the 10 who had surgery. Ultrasound was negative in 151 patients of which none were later diagnosed with hernias during 3 years' median follow-up. Conclusion: Ultrasound is poor in diagnosing occult groin hernias with a PPV of 70% suggesting a 30% chance of negative groin exploration. The equivocal ultrasound group requires careful follow-up as a considerable number were later diagnosed with hernia. The absence of subsequent hernia diagnosis in the negative ultrasound group suggests it may be a useful rule-out test to exclude occult groin hernias in symptomatic patients.

Opinion. The preoperative role of herniography: reappraising a forgotten technique?

The purpose of the Journal of the Belgian Society of Radiology is the publication of articles dealing with diagnostic and interventional radiology, related imaging techniques, allied sciences, and continuing education

Computed tomography scan diagnosis of occult groin hernia

The value of computed tomography (CT) for the diagnosis of clinically occult (hidden) groin hernia was assessed in a series of patients presenting with undiagnosed groin pain. A total of 158 consecutive patients presenting over a period of 5 years with undiagnosed groin pain or lower abdominal pain and negative or equivocal clinical findings were radiologically assessed with non-contrast CT. The decision to manage operatively or conservatively was then based on a combination of the clinical and CT findings. Outcomes were assessed at 10 years follow-up. The study cohort comprised 158 patients presenting with groin or lower abdominal pain and/or swelling, and was studied prospectively. Seven of these patients were re-investigated at a later date after developing new pain on either the ipsilateral or contralateral side, giving a total of 165 CT examinations. One-third of cases (54) had clinically occult groin hernias and most of the remaining cases had diagnoses that could be managed non-operatively. Of those who came to surgery, the pre-operative CT diagnosis of hernia had a positive predictive value (PPV) of 92% and a negative predictive value (NPV) of 96% (overall accuracy 94%). Lipoma of the spermatic cord was responsible for three of five false-positive CT results. The concept of sports hernia/groin disruption injury (GDI) was encountered, and this entity is discussed in this paper. In the group of patients without hernia findings on CT, the most common diagnoses were rectus abdominis and/or pyramidalis muscle injury which could be treated by physiotherapy (22%), GDI (16%), post-surgical problems (14%), miscellaneous (20%) and 'no abnormality' was identified in 15%. Overall, there were 111 patients with a 'non-hernia' CT diagnosis, of which urological, gynaecological, gastrointestinal and neuralgia contributed to the non-musculoskeletal diagnosis. This prospective non-contrast CT study of patients with undiagnosed chronic groin pain detected the majority of occult hernias requiring surgical intervention. These results suggest that CT can be a useful adjunct to the evaluation of patients presenting with chronic undiagnosed groin pain, but that experienced clinical judgment remains a critical element in the diagnostic pathway.

Pre-operative diagnosis of obturator hernia: a report of two cases

Obturator hernias are rare, accounting for less than 1.5% of all hernias, and usually present with acute intestinal obstruction requiring emergency surgery. They are rarely diagnosed in the elective setting. We discuss two cases, a 52-year-old man and a 71-year-old woman, both presenting electively with a history suggestive of occult groin hernia; neither had a palpable lump. They both underwent out-patient herniography which demonstrated obturator hernia and both patients subsequently had elective laparoscopic repair, with good results. A high index of suspicion along with appropriate use of imaging modality allows for early identification of this rare condition. Early intervention can prevent the morbidity and mortality associated with complicated obturator hernia.

Herniography: a reliable investigation avoiding needless groin exploration—a retrospective study

Herniography has been shown to be useful in the detection of occult groin hernias in patients with a history of groin pain. We performed a retrospective review to assess our experience of this investigation. The notes of 170 patients who underwent herniography between 1995 and 2004 were reviewed. The results of herniography and subsequent treatment and follow-up were investigated. Of the 170 patients who underwent herniography, 84 patients (49%) had positive herniograms, indicating the presence of hernia. Twelve of these were patients with chronic groin pain post hernia repair. All patients reported as having a positive herniogram underwent surgical exploration, which confirmed the presence of herniae, which were repaired and patients reported symptomatic benefit on further follow-up. The remaining 86 patients (51%) had a normal herniogram; 20 patients presented with groin pain after hernia repair and were referred to a pain management team. There were two minor complications of the procedure and no major complications. Twenty patients were prevented from undergoing needless surgical re-exploration by the use of this technique. Herniography has great value in excluding inguinal hernia in patients with chronic symptoms in the groin. It is a useful diagnostic tool for the identification of clinically occult herniae and this investigation can prevent needless surgery and re-exploration in those cases with previous hernia repair.

The accuracy of ultrasound in the diagnosis of clinically occult groin hernias in adults

This prospective study examined the accuracy of ultrasound in diagnosing occult groin hernias in adults. The study included 52 consecutive patients reviewed in the surgical out-patient clinic with a history suggestive of groin hernia but with a normal or inconclusive clinical examination. Each patient underwent a preliminary ultrasound examination by an experienced consultant radiologist who was aware that the patient had a history suggestive of a hernia but was blinded to the side of the symptoms. The patient then proceeded to herniography, and some patients also had surgical exploration. The results of the ultrasound were assessed in relation to the herniography, and the patients who proceeded to surgical exploration had further correlation with surgery. Ultrasound had a sensitivity of 29% and specificity of 90% compared with the herniography. Correlation with surgical findings showed ultrasound to have a sensitivity of 33% and a specificity of 100%. The sensitivity of ultrasound in detecting clinically occult hernias in a non-acute presentation is poor, and patients with normal ultrasound should be considered for further investigation.

CT herniography in the diagnosis of occult groin hernias

To evaluate the role of computed tomography (CT) after herniography in the diagnosis and management of primary and recurrent groin hernias not detectable on clinical examination. Fifty-one patients underwent CT post-herniography over a 6-year period for suspected primary or recurrent inguinal hernia. The herniography and post-herniography CT findings were retrospectively compared with clinical and surgical follow-up. Statistical analysis was performed to assess the role of herniography and CT post-herniography in the primary and recurrent groups. Of the 51 patients investigated for occult inguinal hernia, 19 had previous hernia repair with possible recurrence. The most common symptom at presentation was groin pain or discomfort (84%). Seventy-five percent in the primary group and 84% in the recurrent group had no findings on herniography or CT. Nine percent in the primary group and 16% in the recurrent group had hernias diagnosed by herniography. CT did not enhance the detection of hernia. Sensitivity for herniography and CT herniography in the primary groin hernia group was 75% as against specificity, which was 100 and 90%, respectively. For the recurrent groin hernias, sensitivity was 60% for herniography and 40% for CT herniography and specificity 100% for both. CT performed post-herniography did not provide any benefit over performing herniography alone in the diagnosis of occult primary or recurrent inguinal hernias.

Unexplained groin pain: safety and reliability of herniography for the diagnosis of occult hernias

A retrospective study of our initial experience of herniography in a district general hospital is presented. A total of 43 herniograms were performed in 41 patients (median age 57, range...