Diagnostic Considerations in Inguinal Hernia Repair
The diagnosis of inguinal hernias is typically confirmed by physical examination. In some cases, the examination is non-diagnostic and so imaging may help confirm the presence of an inguinal hernia. In other cases, the patient may have a more complex situ
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Diagnostic Considerations in Inguinal Hernia Repair Shirin Towfigh and Yasmine Shafik
6.1
Introduction
The diagnosis of an inguinal hernia largely depends upon (a) a suggestive history and (b) the presence of a bulge during physical examination. However, physical examination for an inguinal hernia is at most 74.5 % sensitive and 96.3 % specific. Thus, imaging is a necessary tool to help confirm the diagnosis of inguinal hernia. In addition, imaging may help diagnosis alternative causes for inguinodynia and pelvic symptoms. Lastly, in the postoperative patient, imaging plays a vital role in the algorithm for working up post-herniorrhaphy chronic pain. There are a limited number of imaging modalities for evaluation of an inguinal hernia. Each has its indications, risks, and benefits. These include herniography, ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). Understanding how and when to order these studies will improve the diagnosis and treatment plan for patients with possible inguinal hernia.
6.2
maneuvers and lies in a series of positions to promote the contrast material to fill the myopectineal orifices. Herniography is now more commonly applied to adults. It is most useful to help evaluate inguinodynia of undetermined etiology among athletes, females, and obese patients. It was reported to have a sensitivity of at least 81 % and specificity of at least 92 %. Low false positive rates (0–18.7 %) and low false negative rates (2–7.9 %) are also noted in the literature. False negative studies occur in those with preperitoneal fat occluding a hernia orifice. One study that claims that herniography successfully detects more than 67 % of missed inguinal hernias from ultrasonography. Another has supported its superiority over the MRI. Despite these values, herniography has slowly falled out of favor in the USA. All but a few specialized centers have stopped offering this technique, as it is widely accepted that multi-planar imaging is superior and less invasive than herniography. The risks of the procedure include colonic perforation, peritonitis, anaphylactic reactions, and hemorrhage in 0.19 % of patients. Minor complications can be seen in up to 80 % of patients, which is mostly a deep pain during the injection of contrast material.
Herniography
Herniography, also referred to as focused peritoneography, was first introduced in the 1960s as a technique for diagnosing contralateral inguinal hernias in the pediatric population. It involves percutaneous injection of non-ionic iodinated contrast into the peritoneal space. The patient then performs
S. Towfigh, M.D., F.A.C.S. (*) Department of Surgery, Beverly Hills Hernia Center, 450 North Roxbury Drive #224, Beverly Hills, CA 90210, USA Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA e-mail: [email protected] Y. Shafik, M.B.B.S. Ministry of the National Guard-Health Affairs, King Abdulaziz Medical City, Jeddah, Saudi Arabia e-mail: [email protected]
6.3
Ultrasonogra
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