The use of ultrasound in the diagnosis of abdominal wall hernias

Comparison of the Effectiveness of Ultrasound Imaging and Perioperative Measurement in the Diagnosis and Characterization of Incisional Hernia

Background

Incisional hernia (IH) is a common complication after abdominal surgery, and there is no gold standard imaging modality for its diagnosis. Although computed tomography is frequently used in clinical practice, it has limitations such as radiation exposure and relatively high cost. The aim of this study is to establish standardization and hernia typing by comparing preoperative ultrasound (US) measurements and perioperative measurements in IH cases.

Methods

The patients who were operated for IH in our institution between January 2020 and March 2021 were reviewed, retrospectively. In result, 120 patients were included in the study, and the cases had preoperative US images and perioperative hernia measurements. IH was divided into three subtypes as omentum (Type I), intestinal (Type II), and mixed (Type III) according to the defect content.

Results

Type I IH was detected in 91 cases, Type II IH in 14 cases, and Type III IH in 15 cases. When the diameters of IH types were compared for preoperative US and perioperative measurements, respectively, there was no statistical significance (P = 0.185 and P = 0.262). According to Spearman correlation, there was a positive very strong correlation between preoperative US measurements and perioperative measurements (ρ = 0.861 and P < 0.001).

Conclusion

As stated by our results, US imaging can be performed easily and quickly, providing a reliable way to accurately detect and characterize an IH. It can also facilitate the planning of surgical intervention in IH by providing anatomical information.

High-resolution ultrasound of spigelian and groin hernias: a closer look at fascial architecture and aponeurotic passageways

From the clinical point of view, a proper diagnosis of spigelian, inguinal and femoral hernias may be relevant for orienting the patient's management, as these conditions carry a different risk of complications and require specific approaches and treatments. Imaging may play a significant role in the diagnostic work-up of patients with suspected abdominal hernias, as the identification and categorization of these conditions is often unfeasible on clinical ground. Ultrasound imaging is particularly suited for this purpose, owing to its dynamic capabilities, high accuracy, low cost and wide availability. The main limitation of this technique consists of its intrinsic operator dependency, which tends to be higher in difficult-to-scan areas such as the groin because of its intrinsic anatomic complexity. An in-depth knowledge of the anatomy of the lower abdominal wall is, therefore, an essential prerequisite to perform a targeted ultrasound examination and discriminate among different types of regional hernias. The aim of this review is to provide a detailed analysis of the fascial architecture and aponeurotic passageways of the abdominal wall through which spigelian, inguinal and femoral hernias extrude, by means of schematic drawings, ultrasound images and video clips. A reasoned landmark-based ultrasound scanning technique is described to allow a prompt and reliable identification of these pathologic conditions.

Inguinal Hernias in Cirrhotic Patients: From Diagnosis to Treatment

Cirrhosis has a strong association with abdominal wall hernias, especially in the presence of concomitant ascites. Major predisposing factors for hernia formation in this particular group of patients include increased intra-abdominal pressure and decreased muscle mass due to poor nutrition. Management of these patients is highly challenging and requires an experienced multidisciplinary surgical and medical approach. The aim of our review is to clarify crucial diagnostic and management approaches. Crucial medical and technical issues on this topic are widely discussed with special focus on indication, timing, and type of surgical repair, with an additional reference to the actual role of laparoscopy.

Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society

BACKGROUND

Umbilical and epigastric hernia repairs are frequently performed surgical procedures with an expected low complication rate. Nevertheless, the optimal method of repair with best short- and long-term outcomes remains debatable. The aim was to develop guidelines for the treatment of umbilical and epigastric hernias.

METHODS

The guideline group consisted of surgeons from Europe and North America including members from the European Hernia Society and the Americas Hernia Society. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, the Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done on 1 May 2018, and updated on 1 February 2019.

RESULTS

Literature reporting specifically on umbilical and epigastric hernias was limited in quantity and quality, resulting in a majority of the recommendations being graded as weak, based on low-quality evidence. The main recommendation was to use mesh for repair of umbilical and epigastric hernias to reduce the recurrence rate. Most umbilical and epigastric hernias may be repaired by an open approach with a preperitoneal flat mesh. A laparoscopic approach may be considered if the hernia defect is large, or if the patient has an increased risk of wound morbidity.

CONCLUSION

This is the first European and American guideline on the treatment of umbilical and epigastric hernias. It is recommended that symptomatic umbilical and epigastric hernias are repaired by an open approach with a preperitoneal flat mesh.

Recurrence after totally extraperitoneal (TEP) inguinal hernia repair: the role of physical examination and ultrasound

PURPOSE

Physical examination (PE) combined with ultrasound (US) is recommended to confirm a recurrent hernia. However, the evidence is rather weak. The aim of this study was to evaluate PE and appraise the added value of US in alleged recurrent inguinal hernias after totally extraperitoneal (TEP) inguinal hernia repair.

METHODS

All adult patients who were re-operated for suspicion of a recurrent hernia after a primary unilateral or bilateral TEP between 2006 and 2017 were identified and investigated retrospectively. Patient characteristics, PE, additional imaging and intra-operative findings were registered. PE outcomes were compared with intra-operative findings to calculate the positive predictive value (PPV) of PE. In case of clinical doubt, the added value of US was evaluated by comparing US findings with the intra-operative findings.

RESULTS

A total of 130 patients were re-operated for suspicion of 137 recurrent hernias. In 75 patients, US was performed. PE was positive for an inguinal hernia in 101 groins (73.7%), negative in 30 (21.9%) and inconclusive in 6 (4.4%). PE matched the operative findings in 75.2%. The PPV of diagnosing a recurrent hernia (or lipoma) on PE was 97%. In case of clinical doubt (n = 36), positive US matched the operative findings in 20 cases (87.0%).

CONCLUSION

US does not necessarily need to be incorporated in the standard diagnostic workup of a recurrent inguinal hernia. After PE alone, a recurrent hernia (or lipoma) can be diagnosed with a PPV of 97%. Only in case of clinical doubt, US has additional value.

Superficial swellings in sheep (Ovis aries) and goats (Capra hircus): Clinical and ultrasonographic findings

This study describes the clinical presentation of superficial swellings and evaluates the utility of ultrasonography in the diagnosis of such swellings in sheep and goats. Ninety-three sheep and 73 goats were included in this study on the basis of presence of superficial swellings on the head (n=56), neck (n=16), chest wall (n=3), abdominal wall (n=40), umbilicus (n=14), scrotum (n=16), testes (n=1), udder (n=7), limbs (n=2), gluteal region (n=5), tail (n=1), and penile urethra (n=5). Ultrasonographic evaluation of these superficial swellings allowed the diagnosis of abscesses (n=54; 32.52%), cysts (n=12; 7.23%), hernias (n=57; 34.33%), hematomas (n=14; 8.44%), tumors (n=24; 14.45%), and urethral diverticula (n=5; 3.03%). Each lesion type could be precisely discriminated (sensitivity, 88-100%; specificity, 80-100%; and P=0.001). Ultrasonography was found to have a specificity of 100% for the diagnosis of hernias, urethral diverticula, and tumors, and a lower specificity of 80% for hematomas and 93% for abscesses when used for evaluation of superficial swellings in sheep and goats. In conclusion, ultrasonography is a unique, non-invasive diagnostic imaging tool that allows the diagnosis, differential diagnosis, and subsequent surgical treatment of different types of superficial swellings in sheep and goats.

Clinical Application Value of Automated Breast Volume Scanner in the Diagnosis of Abdominal External Hernia

This study investigated the clinical application value of the automated breast volume scanner (ABVS) in patients with abdominal external hernias. A total of 121 abdominal external hernias from 103 inpatients were examined with both conventional handheld ultrasound (HHUS) and the ABVS before surgery. The rate of detection of abdominal external hernias and the diagnostic accuracy of classifying inguinal hernias using the two modalities were compared between junior and senior sonographers. Additionally, the sonographic appearance of abdominal external hernias with the ABVS system was evaluated. The results revealed that junior sonographers had a higher detection rate with the ABVS (92.6%) than with HHUS (83.5%). For the classification of inguinal hernias, the accuracy of junior sonographers using the ABVS was 89.2%, which was higher than that for the HHUS system (77.6%), but there was no significant difference between HHUS (92.7%) and the ABVS (93.1%) for senior sonographers. Measurement of the hernia orifice size with the ABVS was accurate. In addition, the ABVS could provide coronal images and visually revealed the contents of the hernia, the shape of the hernia orifice and the pathway of herniation, as well as the relationship with adjacent tissues. Therefore, the clinical application value of the ABVS for abdominal external hernias is excellent.

Abdominal hernias in camel (Camelus dromedaries): Clinical findings and treatment outcomes

The present study was designed to describe the clinical presentation of abdominal hernias and to evaluate the efficacy of polypropylene mesh in repair of such affection in camels. Twenty-six dromedary camels were included in this study on the basis of clinical and ultrasonographic evidence of abdominal hernia. Factors associated with prevalence and clinical findings of hernia were presented and hernioplasty using polypropylene mesh was evaluated as a surgical intervention. Out of 26 studied camels, abdominal hernia was prevalent in Wadeh camels than other breeds (17 vs. 9, P<0.01). Camels <6 years of age exhibited more hernias than other age groups (18 vs. 8, P<0.01). Moreover, females showed a significantly higher prevalence (19 vs. 7, P<0.01) of abdominal hernia compared to males (26.9%, n=7). The sensitivity (96.8%) and specificity (93.1%) of ultrasonography (US) for diagnosing hernia were higher in comparison to clinical examination (88.3%). At 3 weeks postoperatively, the clinical index score of 26 operated camels was significantly reduced in comparison with pretreated (22 vs. 4, P<0.005). However, only 2 cases had recurrence of the hernia and 2 camels had slight swelling in situ. By the 6th month post treatment, all treated camels were completely recovered. In conclusion, the polypropylene mesh is a viable and consistent alternative effective treatment for abdominal hernias in camels. In addition, the clinical index scores and US provide a precise paradigm for diagnosis and preoperative planning for abdominal hernias in dromedary camels.

An 11-year analysis of reoperated groins after endoscopic totally extraperitoneal (TEP) inguinal hernia repair in a high volume hernia center

BACKGROUND

Developments in inguinal hernia surgery have substantially lowered recurrence rates, yet recurrences remain an important outcome parameter of inguinal hernia repair. The aim of this study was to analyze the characteristics of all reoperated groins after endoscopic totally extraperitoneal (TEP) inguinal hernia repair in a high-volume hernia clinic in the Netherlands.

METHODS

All groins with recurrence-like symptoms reoperated after previous TEP inguinal hernia repair between January 2006 and December 2016 were analyzed. Patient characteristics, imaging findings, primary hernia type, time to recurrence and recurrence type were assessed.

RESULTS

A total of 137 groins were reoperated in 130 patients. The median age at the TEP procedure was 55 years [interquartile range (IQR) 45-64 years]. Fifty-seven groins were initially part of a bilateral procedure (42%). Median time until recurrence was 9 months (IQR 4-26 months). Reoperation findings were a hernia recurrence in 76%, an isolated lipoma in 18%, and no recurrence or lipoma in 6%. The majority of hernias recurred at their initial site (70%), of which the greatest part involved direct hernias. Isolated lipomas were more frequently seen after indirect hernia repair.

CONCLUSIONS

Inguinal hernia recurrences were still observed in this high-volume hernia clinic. Recurrences were most frequently seen at their initial hernia site, the majority involving direct hernias. Isolated lipomas presenting as a pseudorecurrence were most frequently seen after correction of indirect hernias. In accordance with the current guidelines, reducing recurrence rates can be achieved by mesh fixation in bilateral, large and direct defects and by thoroughly reducing lipomas.

Relationship Between Interrectus Distance and Symptom Severity in Women With Diastasis Recti Abdominis in the Early Postpartum Period

BACKGROUND

Diastasis recti abdominis (DrA) is associated with negative body image, musculoskeletal pain and dysfunction, and perhaps urogynecological complaints. The severity of DrA has traditionally been determined by measuring the interrectus distance (IRD); however, the relationship between IRD and symptoms in women with DrA is unclear.

OBJECTIVE

The objective of the study was to investigate the relationship between IRD and symptom severity in women with DrA in the early postpartum period.

DESIGN

This study used a cross-sectional design.

METHODS

Thirty-two women with DrA were assessed at 3 weeks postpartum. The IRD was measured using ultrasound imaging. Symptom severity was assessed using the Multidimensional Body-Self Relations Questionnaire subscales (body image), visual analog scales (abdominal, low back, and pelvic pain intensity), the Modified Oswestry Index (disability due to low back pain), and the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire (urogynecological dysfunction). Spearman correlation coefficients (ρ) between IRD and each outcome were calculated and tested using 1-tailed significance (adjusted α = .009).

RESULTS

The group median IRD was 2.97 cm (interquartile range = 1.65 cm), with the largest IRD in the sample being 7.97 cm. The IRD was significantly correlated with worst abdominal pain in the last 24 hours (ρ = 0.45, P = .005) and with overall body image (ρ = -0.44, P = .006) but not with the other outcomes.

LIMITATIONS

Women in the sample were primiparous, were in the early (3 weeks) postpartum period, had relatively low body mass indexes (mean = 25.0 kg/m2) considering that they had recently given birth, were all breast-feeding, and had a narrow age range (27-35 years old). These factors limited the generalizability of our results to all women with DrA.

CONCLUSIONS

This preliminary work suggests that, in the early postpartum period, IRD as a measure of DrA severity is meaningful for body image.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Utility of ultrasonography for diagnosis of superficial swellings in buffalo (Bubalus bubalis)

We studied 72 buffalo with superficial swellings in the head (n=4), neck (n=5), chest wall (n=4), abdominal wall (n=28), limbs (n=16), gluteal region (n=8), perineal region (n=6) and udder (n=1). Ultrasonographically, the swellings varied according to type, duration, content and location. The clinical use of ultrasound to assess these superficial swellings allowed diagnosis of abscesses (n=21), hematomas (n=11), hernias (n=17), bursitis (n=13), urethral diverticula (n=6) and tumors (n=4). Ultrasonography could precisely discriminate each lesion type (sensitivity, 71-100%; specificity, 75-100%; odds ratio, 1.0-8.4; Confidence Interval, 74.2-20; and P value 0.001). The specificity for ultrasonographic evaluation of superficial swellings was 100% for hernias, urethral diverticula and tumors, whilst the lowest specificity was recorded for hematomas (75%) and abscesses (92%). In conclusion, ultrasonography provides a precise, non-invasive and fast technique for the evaluation, classification and subsequent treatment of a variety of superficial swellings in buffalo.

Diagnostic value of an automated breast volume scanner for abdominal hernias

OBJECTIVES

This study explored the diagnostic values of an automated breast volume scanner (ABVS) for abdominal external hernias.

METHODS

Conventional sonograms and ABVS images from 128 abdominal external hernias in 104 patients (98 male and 6 female; age range, 41-79 years; mean age ± SD, 68.0 ± 14.6 years) were analyzed. The results were identified by surgical outcomes. The hernia type, hernial ring position, hernial sac size, hernia content, and hernia structure were evaluated by both sonographic modalities.

RESULTS

The sensitivity and accuracy differences between the ABVS and conventional sonography for diagnosis of abdominal hernias and hernia size measurements were compared. The hernia types, as confirmed by surgery, included 45 indirect inguinal hernias (30 reducible and 15 irreducible), 12 reducible direct inguinal hernias, 5 femoral hernias, 62 incisional hernias (42 isolated and 20 multiple), and 4 umbilical hernias. The sensitivity of the ABVS was higher than that of conventional sonography for incisional hernias (P < .01), whereas there were no statistical differences in sensitivity for other types of hernias. The ABVS hernial sac number detection rate for both isolated and multiple incisional hernias was significantly higher compared with that of conventional sonography (both P < .01). The ABVS measurements correlated well with surgical results (length, P = .47; width, P = .31).

CONCLUSIONS

Automated breast volume scanner images have the outstanding advantage of displaying the entire scope of the internal structure and the relationship with adjacent tissues of abdominal hernias. Therefore, an ABVS has good application prospects for diagnosis of abdominal external hernias and merits further research.

Computed tomography scan diagnosis of occult groin hernia

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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-, intra-, and postoperative sonography of the abdominal wall in patients with incisional hernias repaired via a three-layered operative suture method

We illustrate the various sonographic (US) appearances of the abdominal wall following this type of repair, including partial and complete recurrences. Correlation is made with CT imaging. The three-layered anatomical reconstruction of an incisional hernia is described.

Comparison of ultrasonography with computed tomography in the diagnosis of incisional hernias

BACKGROUND

The objective of this study is to determine the reliability and validity of ultrasonography (US) in diagnosing incisional hernias in comparison with computed tomography (CT). The CT scans were assessed by two radiologists in order to estimate the inter-observer variation and twice by one radiologist to estimate the intra-observer variation. Patients were evaluated after reconstruction for an abdominal aortic aneurysm or an aortoiliac occlusion.

METHODS

Patients with a midline incision after undergoing reconstruction of an abdominal aortic aneurysm or aortoiliac occlusion were examined by CT scanning and US. Two radiologists evaluated the CT scans independently. One radiologist examined the CT scans twice. Discrepancies between the CT observations were resolved in a common evaluation session between the two radiologists.

RESULTS

After a mean follow-up of 3.4 years, 40 patients were imaged after a reconstructed abdominal aortic aneurysm (80% of the patients) or aortoiliac occlusion. The prevalence of incisional hernias was 24/40 = 60.0% with CT scanning as the diagnostic modality and 17/40 = 42.5% with US. The measure of agreement between CT scanning and US expressed as a Kappa statistic was 0.66 (95% confidence interval [CI] 0.45-0.88). The sensitivity of US examination when using CT as a comparison was 70.8%, the specificity was 100%, the predictive value of a positive US was 100%, and the predictive value of a negative US was 69.6%. The likelihood ratio of a positive US was infinite and that of a negative US was 0.29. The inter- and intra-observer Kappa statistics were 0.74 (CI 0.54-0.95) and 0.80 (CI 0.62-0.99), respectively.

CONCLUSIONS

US imaging has a moderate sensitivity and negative predictive value, and a very good specificity and positive predictive value. Consistency of diagnosis, as determined by calculating the inter- and intra-observer Kappa statistics, was good. The incidence of incisional hernias is high after aortic reconstructions.