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Length

Width

nia

Length

Hernia

Width

defect

Multiple her

defects

Fig. 4.3 Hernia defect surface can be measured by com-

bining width and length in a formula for an oval, thus trying to make an estimation of the real surface in cm

• W1<4cm

• W2≥4–10cm

• W3≥10cm (Table4.3)

References

1. Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009;13:343–403. https://doi.org/10.1007/

s10029-009-0529-7

2. Miserez M, Alexandre JH, Campanelli G, etal. The European Hernia Society groin hernia classication: simple and easy to remember. Hernia. 2007;11(2):113–

6. https://doi.org/10.1007/s10029-007-0198-3

3. Campanelli G, Pettinari D, Nicolosi FM, Cavalli M, Avesani EC.Inguinal hernia recurrence: classication and approach. Hernia. 2006;10(2):159–61. https://doi.

org/10.1007/s10029-005-0053-3

4. Chowbey P, Khullar R, Mehrotra M, Sharma A, Soni V, Baijal M. Sir Ganga Ram Hospital classication of groin and ventral abdominal wall hernias.

D. Cuccurullo and S. Reggio

Table 4.3 EHS classication for incisional abdominal

wall hernias

EHS incisional hernia classication Midline Subxyphoidal M1

Epigastric M2 Umbilical M3 Infraumbilical M4 Suprapubic M5

Lateral Subcostal L1

Flank L2 Iliac L3

Lumbar L4 Recurrent incisional hernia Ye s O No O Length: cm Width: cm Width cm W1 W2 W3

<4cm

≥4–10cm ≥10cm

O O O

J Minim Access Surg. 2006;2(3):106. https://doi.

org/10.4103/0972-9941.27720

5. Holzheimer RG.Inguinal hernia: classication, diagnosis and treatment—classic, traumatic and sportsman’s hernia. Eur J Med Res. 2005;10(3):121–34.

6. Zollinger RM.An updated traditional classication of inguinal hernias. Hernia. 2004;8(4):318–22. https://

doi.org/10.1007/s10029-004-0245-2

7. Kingsnorth AN.A clinical classication for patients with inguinal hernia. Hernia. 2004;8(3):283–4.

https://doi.org/10.1007/s10029-004-0228-3

8. Nyhus LM.Classication of groin hernia: milestones. Hernia. 2004;8(2):87–8. https://doi.org/10.1007/

s10029-003-0173-6

9. Zollinger RM. Classication systems for groin hernias. Surg Clin North Am. 2003;83(5):1053–63.

https://doi.org/10.1016/S0039-6109(03)00126-9

10. Schumpelick V, Treutner KH, Arlt G.Classication of inguinal hernias. Chirurg. 1994;65:877–9.

11. Chevrel JP, Rath AM.Classication of incisional hernias of the abdominal wall. Hernia. 2000;4:7–11.

12. Korenkov M, Paul A, Sauerland S, Neugebauer E, Arndt M, Chevrel JP, Corcione F, Fingerhut A, Flament JB, Kux M, Matzinger A, Myrvold HE, Rath AM, Simmermacher RK. Classication and surgical treatment of incisional hernia. Results of an “experts” meeting. Langenbecks Arch Surg. 2011;386:65–73.

13. Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, Dietz UA, Eker HH, El Nahadi I, Hauters P, Hidalgo Pascual M, et al. Classication of primary and incisional abdominal wall hernias. Hernia. 2009;13:407–14.

14. Śmietański M, Szczepkowski M, Alexandre JA, Berger D, Bury K, Conze J, Hansson B, Janes A, Miserez M, Mandala V, Montgomery A, Morales Conde S, Muysoms F. European Hernia Society classication of parastomal hernias. Hernia. 2014;18(1):1–6.

Diagnostic Tools inHernia Disease

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

PaulTenzel, JordanBilezikian, andWilliamW.Hope

5.1 Introduction

Most inguinal and ventral hernias can be diagnosed using a thorough history and physical examination. Patients are usually referred to a surgeon for diagnosis conrmation and a discussion of treatment options. However, additional diagnostic imaging may be necessary to identify an occult hernia or to plan the operation. In this case, the surgeon has many choices depending on the hernia type or clinical problem and the information that is needed. In general, additional diagnostic tools include ultrasound, computed tomography (CT) scanning, and magnetic resonance imaging (MRI) with other adjuncts for inguinal hernias including herniography. Each imaging modality has strengths and weaknesses. Imaging choice is impacted by the local hospital environment and radiology department.

5.2 History andPhysical

Patients with a hernia often complain of feeling a bulge. In this case, the surgeon should conrm hernia presence with a physical examination (Fig.5.1). In some cases, an occult hernia (one that is difcult to detect) is present. This can be

P. Tenzel, M.D. · J. Bilezikian, M.D. W. W. Hope, M.D. (*) Department of Surgery, New Hanover Regional Medical Center, Wilmington, NC, USA e-mail: William.hope@nhrmc.org

Fig. 5.1 Ventral hernia shown on physical exam

due to the small hernia size or other patient characteristics such as obesity. In this case, additional diagnostic imaging should be obtained.

P. Tenzel et al.

5.3 Diagnostic Tools forInguinal Hernia

5.3.1 Imaging inInguinal Hernias

In most cases, a history of groin pain and an obvious inguinal bulge are all that are required to diagnose an inguinal hernia. In this case, the next step is operative repair. Diagnosis is less clear when there are no physical exam observations consistent with inguinal hernia. An occult inguinal hernia can be too small to detect on physical exam but can produce symptoms consistent with a groin hernia such as a feeling of a bulge or pain. Without physical exam evidence, imaging is crucial in diagnosis, because there are many causes of pain that should not be treated using surgery.

5.3.2 Ultrasound

Ultrasound is usually the rst modality used to diagnose occult inguinal hernias because it is easily accessible and relatively inexpensive. An ingui-

nal hernia ultrasound with and without Valsalva maneuver (Fig.5.2), not a pelvic ultrasound, will provide the best information for accurate diagnosis of an occult inguinal hernia. The patient can be moved into different positions such as lying down and standing which can often aid in diagnosis of the hernia; as in some positions, the protrusion through the hernia defect may be more pronounced (Fig.5.3). Although the dynamic nature of ultrasound is a distinct benet, this characteristic also makes its accuracy operator dependent.

Although ultrasound is the rst-line imaging option for diagnosing an inguinal hernia, it is far from perfect. A recent meta-analysis comprised of ve ultrasound studies totaling 716 patients showed that ultrasound had a sensitivity of 86% and specicity of 77% [1]. Though these numbers may seem reasonable for diagnosis, two recent studies reported that ultrasound has a low positive predictive value after the patient is evaluated in the operating room. The rst study contained 116 patients who underwent surgery after a positive ultrasound and yielded only a 74% positive predictive value [2]. This correlated with another study of 118 patients who at the time of

Fig. 5.2 Ultrasound image showing of right groin showing fat protruding through a hernia defect that is more pro-

nounced with Valsalva

Fig. 5.3 Ultrasound image showing bowel protruding through a left inguinal hernia

5 Diagnostic Tools inHernia Disease

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operation had a 70% positive predictive value for presence of a hernia. The same study followed 141 patients with a negative groin ultrasound for a median of 3years, and no patients were later diagnosed with a hernia [3]. The most recent study on the subject by Miller showed a sensitivity of 0.33 and specicity of 0.0 [4]. These data indicate that ultrasound may be a better imaging method to help rule out a hernia diagnosis than to determine the need for surgery.

5.3.3 CT Scan

CT scan is also used to diagnose occult inguinal hernias. It is widely available, and many surgeons are accustomed to reading CT scans, which is not the case with most other imaging options. A CT scan facilitates evaluating the entire abdomen, which can occasionally identify other causes of pain or abnormalities. In a study comparing CT and herniography, CT identied bone spurs as the cause of pain in 2 of the 51 patients evaluated [5].

Despite these advantages, the usefulness of CT for inguinal hernia diagnosis is very limited. Studies using CT show a fairly low sensitivity and specicity but a fairly high positive predictive value for patients that undergo surgery. Recent data on the subject showed a sensitivity of 0.54, a specicity of 0.25, but a positive predictive value of 86% in 39 patients who underwent CT and subsequent surgery [4]. Another study evaluated 158 patients with groin pain. In these patients, 49 hernias were diagnosed via CT, and the patients were taken to surgery for evaluation and hernia repair. This study showed a positive predictive value of 92% and a negative predictive value of 96% [6]. These data indicate that CT is not the best option for the initial diagnosis of an occult hernia; however, when a hernia is identied on CT, the patient can proceed to surgery for hernia repair.

Although CT may not be the best option for the diagnosis of occult inguinal hernias, it can be useful for inguinal hernias in certain clinical circumstances such as when other intra-abdominal pathology is suspected or cases of difcult to diagnose hernias such as femoral and obturator hernias (Figs.5.4, 5.5, and 5.6).

Fig. 5.4 Computed tomography scan showing portal

venous gas from incarcerated right femoral hernia causing a bowel obstruction

Fig. 5.5 Computed tomography scan showing pneuma-

tosis from incarcerated right femoral hernia causing a bowel obstruction

Fig. 5.6 Computed tomography scan showing incarcer-

ated right femoral hernia causing a bowel obstruction which lead to ischemic intestine, pneumatosis, and portal venous gas

P. Tenzel et al.

5.3.4 MRI

MRI is useful in diagnosing occult inguinal hernias; however, it is not without disadvantages. It is more expensive than ultrasound or CT and also takes the most time to complete. Generally, surgeons are not as skilled at reading MRIs compared with reading CTs; however, MRI has several benets. Like CT, MRI can be used to evaluate the entire pelvis. Because of the ability to closely assess the bones and soft tissues in the pelvic region, MRI is useful to diagnose hernias and other musculoskeletal etiologies for groin pain (Figs.5.7 and 5.8).

There is increasing evidence that MRI should be the initial study to evaluate suspected occult inguinal hernias. A study by Miller compared the use of CT, ultrasound, and MRI in 34 patients and determined that MRI was the best option for diagnosing occult inguinal hernias. The study

yielded a sensitivity and specicity of 0.91 and

0.92, respectively [4].

5.3.5 Herniography

Ducharne rst described herniography, also known as peritoneography, in Canada in 1967 [7]. Herniography consists of injecting iodinated contrast into the peritoneum and imaging the area with X-ray or CT to evaluate possible hernia defects. This imaging modality is the most invasive of the options discussed. Because this procedure is done with X-ray or CT, it exposes the patient to radiation. Despite these negatives, it is considered one of the most accurate tests used to diagnose hernias; however, it is not widely used probably because of the lack of comfort and familiarity with the study both by surgeons and by the radiology teams that would perform them

Fig. 5.7 MRI for chronic groin pain in a runner revealing mild degenerative changes of the pubic symphysis with

parasymphyseal bone marrow edema suggestions stress/reactive edema due to repetitive stress

Fig. 5.8 MRI showing small fat containing left inguinal hernia

5 Diagnostic Tools inHernia Disease

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and the emergence of other more commonly used modalities such as ultrasound, CT, and MRI.Although invasive, herniography is a fairly safe procedure. In a large review of 17 studies including 1538 patients, only three patients had complications that required hospital admission (a

0.19% major complication rate) [8]. Another retrospective study evaluated 117 herniographs performed at one hospital and identied no complications recorded [9].

Multiple studies have shown that herniography is the most accurate imaging modality. A large review by Robinson compiled data from 16 studies and convincingly supported using herniography more often to diagnosis occult hernias compared with ultrasound and CT. The pooled data showed a sensitivity of 91% and a specicity of 83% for herniography, which was much higher than the study’s ndings for CT scan [1].

5.3.6 Diagnostic Laparoscopy

Because diagnostic laparoscopy is an invasive procedure, it should be very seldom used in the diagnostic algorithm for inguinal hernias. However, it is useful to evaluate for an occult hernia when imaging is non-conrmatory or cannot be obtained. Diagnostic laparoscopy facilitates identifying hernias and other intra-abdominal pathology. Because female pelvic pain can be related to gynecologic issues, it is sometimes helpful to have an obstetrician/gynecologist available for these cases.

5.4 Summary

andRecommendations forDiagnostic Tools inInguinal Hernia

Most inguinal hernias can be diagnosed using a thorough history and physical examination. When the patient feels a bulge that is not felt during a clinical exam, an ultrasound is probably the most useful initial test. When the patient’s symptoms are not consistent with a hernia, no bulge is felt on physical exam, or the surgeon suspects other gen-

eral surgical/intra-abdominal issues, a CT scan is likely the best test to identify intra-abdominal pathology. When there is concern for an occult hernia, musculoskeletal injury/core muscle injury, or pain related to previous hernia repair, an MRI is likely the best option. An MRI should be done using special protocols and should involve a radiologist comfortable with and interested in these techniques/imaging modalities.

5.5 Diagnostic Tools forVentral Hernia

The principal imaging modalities for the diagnosis of ventral and incisional hernias and preoperative planning for their repair are ultrasound, CT, and MRI.Given their advantages and disadvantages, each has a role in specic clinical scenarios to produce favorable outcomes.

Ultrasound is the quickest, least expensive technique for detecting small ventral or incisional midline or lateral hernias. There were many different institution-based methods for the use of ultrasound until 2013 when Beck etal. published a standardized method called dynamic abdominal sonography for hernia (DASH). In this study, the DASH method achieved a sensitivity of 98% and specicity of 88% [10]. This method uses a standard linear ultrasound probe and requires the user to make ve vertical passes starting at the midline and alternating laterally in parallel lines (Figs.5.9 and 5.10). In a subsequent study, the DASH method was shown not only to have diagnostic ability but also to accurately characterize hernias, even very large defects (≥10cm in diameter) and even in obese populations with an average BMI of 39.2 kg/m2 [11]. Historically, ultrasound has had several barriers to widespread use. One of the primary issues was difculty in obtaining reliable image quality for obese patients. The DASH method may provide a solution to this problem for certain obese patients. Ultrasound has many benets and can be a quick and relatively costeffective way to diagnose smaller hernias; however, it still has not gained wide acceptance in the preoperative planning of known hernias or in patients with obese abdomens.

P. Tenzel et al.

Fig. 5.11 Computed tomography scan showing lumbar

hernia

Fig. 5.9 The use of dynamic abdominal sonography for

hernia (DASH) to evaluate for a ventral hernia

Fig. 5.10 Layers of the abdominal wall seen on dynamic

abdominal sonography for hernia (DASH)

CT is the most widely used imaging modality for the characterization of known ventral hernias and has the benet of being a relatively quick study that produces images with excellent image quality for many different types of ventral hernias

Fig. 5.12 Computed tomography scan showing Spigelian

hernia

(Figs. 5.11, 5.12, 5.13, and 5.14). In contrast to ultrasound, the images can characterize large defects and can be used with severely, morbidly obese patients. Preoperative planning has been enhanced by CT measurements of ventral hernia defect size and abdominal wall thickness, which have been used to predict wound complications and the need for component separation [12]. Prior techniques on estimating the need for component separation relied on hernia location, and unique variabilities in the patient’s anatomy were not considered. In a retrospective review of patients who underwent abdominal wall reconstruction, Franklin et al. demonstrated that CT could be used to predict midline approximation using

5 Diagnostic Tools inHernia Disease

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Fig. 5.13 Computed tomography scan showing recurrent

hernia with mesh being pushed into hernia sac

Fig. 5.14 Computed tomography scan showing recurrent

hernia and tack xation in hernia sac

abdominal wall defect ratios and hernia defect areas [13]. The predictive value of CT imaging is very important in preoperative planning to avoid bridged repairs. A recent investigation into a quantitative anatomical labeling protocol was undertaken to predict the need for mesh bridge closure and was able to more accurately predict this than the metrics used in the European Hernia Society Classication for Ventral Hernia (EHSCVH) [14]. Calculating loss of domain is a challenge for the preoperative assessment of ventral hernias. CT 3D reconstruction continues to improve its predictive capacity and has been shown to predict hernia area and volume, which may contribute to more accurate preoperative risk assessment of loss of domain and risk of abdominal compartment syndrome [15]. Unfortunately,

CT requires exposure to ionizing radiation; however, the excellent image quality and recent advances in 3D reconstruction have facilitated better characterization of large, complex hernias and assessment of potential loss of domain while attempting to avoid bridged repairs.

MRI has shown some utility in the assessment of patients with adhesions to mesh after ventral hernia repairs and could be of value in patients requiring complex mesh repairs when explantation of mesh is being considered. MR has been shown to detect adhesions between both bowel and the abdominal wall in patients who have a history of both laparoscopic and open VHR [16]. Functional cine MRI has been used to evaluate intra-abdominal adhesions and preoperative planning for mesh explantation. This method is used to detect “visceral slide” by comparing images when the patient is at rest and when performing the Valsalva maneuver. Lienemann et al. demonstrated that when this method was compared with intraoperative ndings in a group of 27 patients, the sensitivity was

87.5%, and the specicity was 92.5% [17]. In a larger retrospective study enrolling 90 patients, similar results were obtained in which the overall MRI accuracy was 89% [18]. While cine MR has the benet of visualizing ePTFE mesh, it has not been shown to adequately visualize polypropylene mesh [19]. There are benets in the appropriation of MR in the analysis of complex ventral hernias, patients with adhesions or abdominal wall dysmotility, or when explantation of synthetic mesh is considered. However, MRI should be used judiciously and should not be used for routine classication of hernias due to cost, length of exam, and marginal improvements in picture quality compared with CT.

5.6 Summary

andRecommendations forDiagnostic Tools inVentral/Incisional Hernia

Most simple ventral/incisional hernias in nonobese patients can be diagnosed using a thorough history and physical examination.

Table 5.1 Advantages and disadvantages of imaging modalities for diagnosing ventral/incisional hernia

Advantages Disadvantages

Ultrasound – Good for diagnosis and characterization of

Computed tomography

Magnetic resonance

small, simple ventral or incisional hernias – Cost effective – Time effective – Noninvasive – No ionizing radiation – Quick to perform – Rapid interpretation – Excellent image quality – Good for diagnosis and characterization of

complex or recurrent hernias – Facile use in morbidly obese patients – 3D imaging to better classify loss of domain

and avoid bridged repairs – Better image quality than CT – Can image ePTFE mesh – No ionizing radiation – Cine MRI proving advantageous for

preoperative planning of ventral hernias with

known adhesions

– Difcult to use in morbidly obese patients – Difcult to characterize complex or recurrent

hernias – Cannot visualize prior synthetic mesh – Image quality not as good for preoperative

planning as CT or MRI – Comfort of operator carrying out exam – Minimal detection of adhesions – Ionizing radiation – Not cost-effective to use for initial diagnosis

of clinically unapparent hernias – Cannot be done in the ofce compared with

DASH – Cannot visualize adhesions or mesh – Not cost-effective for the routine use of

simple hernia diagnosis or characterization – Not time effective for the routine use of

simple hernia diagnosis or characterization – Cannot visualize polypropylene mesh

P. Tenzel et al.

Table 5.1 is a list of advantages and disadvantages of the various diagnostic technologies. Due to the complex nature of incisional hernias, imaging is often warranted. The well-described DASH technique gives the surgeon a reproducible and standardized way to use ultrasound for diagnosing ventral/incisional hernias; however, it hasn’t gained widespread acceptance. Because of the many advantages associated with this technique, we encourage surgeons to learn about the DASH technique and to use this as a rstline diagnostic tool in appropriate patients when the technology and training are available. CT scanning is likely the most common imaging tool for diagnosing ventral/incisional hernias, because it not only helps with diagnosis but also with operative planning and can help identify other intra-abdominal pathology or previous mesh in some cases. Another benet of CT is that most surgeons are skilled in reading CTs. Because of these advantages, for complex cases or when ultrasound is not available, CT is likely the best option. Although MRI has some indications for diagnosing ventral/incisional hernia, unless your center/hospital/radiology department has a special interest in this technology, it should be used rarely and only in special circumstances.

Conclusion

Surgeons should understand the various imaging and diagnostic tools for inguinal and ventral/incisional hernias. Although history and physical examination will most certainly be the mainstay for diagnosis in most patients, surgeons interested in hernia disease should learn about new diagnostic technologies and should become skilled in the DASH technique and in reviewing imaging studies. Surgeons should work closely with their local institutions and specically their radiology departments to successfully use these tools in appropriate patients.

References

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s00464-012-2412-3.

2. Light D, Ratnasingham K, Banerjee A, Cadwallader R, Uzzaman MM, Gopinath B.The role of ultrasound scan in the diagnosis of occult inguinal hernias. Int J Surg. 2011;9(2):169–72. https://doi.org/10.1016/j.

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3. Alabraba E, Psarelli E, Meakin K, Quinn M, Leung M, Hartley M, etal. The role of ultrasound in the man-

5 Diagnostic Tools inHernia Disease

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

agement of patients with occult groin hernias. Int J Surg. 2014;12(9):918–22.

ijsu.2014.07.266

https://doi.org/10.1016/j.

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5. Markos V, Brown EF. CT herniography in the diagnosis of occult groin hernias. Clin Radiol. 2005;60(2):251–

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https://doi.org/10.1007/s10029-011-0899-5.

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