ACR Appropriateness Criteria® Hernia

Approach to Acute Traumatic and Nontraumatic Diaphragmatic Abnormalities

Acute diaphragmatic abnormalities encompass a broad variety of relatively uncommon and underdiagnosed pathologic conditions, which can be subdivided into nontraumatic and traumatic entities. Nontraumatic abnormalities range from congenital hernia to spontaneous rupture, endometriosis-related disease, infection, paralysis, eventration, and thoracoabdominal fistula. Traumatic abnormalities comprise both blunt and penetrating injuries. Given the role of the diaphragm as the primary inspiratory muscle and the boundary dividing the thoracic and abdominal cavities, compromise to its integrity can yield devastating consequences. Yet, diagnosis can prove challenging, as symptoms may be vague and findings subtle. Imaging plays an essential role in investigation. Radiography is commonly used in emergency evaluation of a patient with a suspected thoracoabdominal process and may reveal evidence of diaphragmatic compromise, such as abdominal contents herniated into the thoracic cavity. CT is often superior, in particular when evaluating a trauma patient, as it allows rapid and more detailed evaluation and localization of pathologic conditions. Additional modalities including US, MRI, and scintigraphy may be required, depending on the clinical context. Developing a strong understanding of the acute pathologic conditions affecting the diaphragm and their characteristic imaging findings aids in efficient and accurate diagnosis. Additionally, understanding the appearance of diaphragmatic anatomy at imaging helps in differentiating acute pathologic conditions from normal variations. Ultimately, this knowledge guides management, which depends on the underlying cause, location, and severity of the abnormality, as well as patient factors. ©RSNA, 2024 Supplemental material is available for this article.

From inguinal to giant femoral hernia: An unusual postoperative twist - A rare case report

INTRODUCTION AND IMPORTANCE

Femoral hernias following inguinal hernia repairs are an unusual occurrence that presents diagnostic challenges for healthcare providers. Surgical repair of inguinal hernias is generally successful, but complications and recurrence can arise. The coexistence of femoral hernias following inguinal hernia repairs is rare, requiring careful evaluation and management.

CASE PRESENTATION

A middle-aged patient sought medical attention with complaints of recurrent groin pain and a palpable bulge in the inguinal region. Initial imaging studies, including ultrasonography and contrast-enhanced computed tomography (CT), pointed towards an inguinal hernia, leading to the scheduling of surgical repair. However, during the operation, the surgeon discovered a femoral hernia, highlighting the limitations of imaging techniques in accurately diagnosing these hernia types.

CLINICAL DISCUSSION

Due to anatomical variations and overlapping signs and symptoms, distinguishing between femoral and inguinal hernias can be challenging. Scar tissue from previous inguinal hernia repairs can further complicate imaging interpretations. Intraoperative exploration becomes crucial to confirm the diagnosis and facilitate proper surgical repair.

CONCLUSION

The reported case emphasizes the importance of maintaining vigilance in evaluating patients with suspected hernias, particularly those with prior inguinal hernia repairs. Relying solely on imaging studies can lead to misdiagnosis, as illustrated by the discovery of a femoral hernia during surgery. Healthcare providers should be aware of the possibility of femoral hernias and conduct comprehensive evaluations to ensure timely intervention and improve patient outcomes. Further research and awareness are essential to optimize the care of such uncommon clinical scenarios.