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Treating Inguinal Recurrences
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Scott Roth and John E. Wennergren
48
Introduction
Treatment of inguinal hernia disease is as old as
recorded time itself with descriptions of the ailment affecting fi fteenth century Egyptians as
written on papyrus . It is the second most common
general surgical procedure performed annually.
Over the centuries, its treatment was really one of
symptom control with very poor results. It has
only been within the last hundred years or so, with
the advent of Bassini’s repair in the late 1800s to
modern day mesh repairs, where treatment of
inguinal hernias has gone from one of little
recourse to one with treatment strategies where
complications and recurrence rates are low. With
that said, anywhere from 1 to 10% of repairs,
depending on operative method used, will unfortunately develop a recurrence during their lifetime. This rate is much higher for primary/
meshless repairs [ 1 ]. Approximately 10–15% of
all inguinal hernias performed in a Danish study
involve recurrent inguinal hernias [ 2 ]. In the
USA, this is estimated to be around 100,000
recurrent inguinal hernia repairs annually with a
S. Roth (*)
Department of Surgery/General Surgery ,
A.B. Chandler Medical Center, University of
Kentucky , Lexington , KY , USA
jsroth2@uky.edu
e-mail:
J. E. Wennergren
Department of Surgery , University of Kentucky
Chandler Hospital , Lexington , KY , USA
john.wennergren@uky.edu
e-mail:
cost of approximately $40,000,000 [ 2 ]. The
advent of mesh repairs has added another layer of
complexity, one in which a surgeon requires
extensive knowledge of inguinal anatomy and
surgical skill to attempt repair of recurrences with
obliterated planes and unclear anatomic structures. Failure rates of attempted anterior repairs of
recurrent hernias are estimated in some studies to
be as high as 36% [ 3 ]. Since inguinal hernia sur-
gery is one of the most common general surgical
procedures performed annually, this is a problem
every general surgeon will deal with during his or
her practice. It is with this in mind that we present
various options and methodology in dealing with
this complex problem.
Pathophysiology
Etiology of inguinal hernias is complex and likely
multifactorial. To evaluate this further a group
using Danish data wanted to see if there was a difference in recurrence rates between Indirect (IIH)
and Direct (DIH) inguinal hernias. Over a 4 year
follow-up period and approximately 85,000
patients, they found a recurrence rate of 3.8% for
all-comers. When subdivided into IDH and DIHs
and controlled for operative technique, the recurrence rates were 2.7% and 5.2%, respectively
( p < 0.001). At reoperation, 93% were found to be
recurrent inguinal hernias while 7% were found to
be either femoral hernias, pantaloons hernias, or
negative for any hernia. The most signifi cant risk
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_48
491© Springer International Publishing Switzerland 2016
492
S. Roth and J.E. Wennergren
factor identifi ed was DIH at initial operation compared to IIH. In fact, not only was it a major risk
factor leading to increased rates of recurrence but
was also found to lead to earlier recurrences compared to IIHs [ 1 ].
There is no concrete evidence to explain this
discrepancy. Many have argued that the reason
this occurs is technical in nature, due to insuffi cient overlap of mesh at the pubic tubercle.
Another explanation may be that while one (IIH)
may be due to a developmental disorder, the
other (DIH) may be due to a systemic disorder of
collagen synthesis. For a long time it has been
argued that inguinal hernias were a direct result
of structural defects, but, as has been shown
recently, there is a rising body of evidence to suggest that defi ciencies in connective tissue metabolism may very well likely play a larger role in
their development. Recently, a group released
fi ndings of a positive correlation between not
only family history and increased risk for development of inguinal hernias, but found that mutations within the COL1A1 gene (responsible for
transcription of 1(I) protein chain of type I collagen which has been shown to be involved in connective tissue disorders such as Ehlers–Danlos
and osteogenesis imperfect) was also implicated
in increased risk for development of inguinal hernias [ 4 ]. The implications of this understanding
knowledge are only just being understood, but
ultimately may modify our practice on operative
approach and usage of mesh.
Preoperative Evaluation
Evaluation of a patient for a recurrent inguinal
hernia is not quite as straightforward as one
might think. Postoperative complication rates,
mainly defi ned as recurrence, long-term pain and
overall patient comfort, range from 4 to 40% [ 5 ].
The previous operative planes, depending on the
operative approach used, may be obliterated and
the anatomy made unclear. As several randomized control trials have demonstrated, use of
tension- free mesh repair has revolutionized treatment of the disease with overall decrease in
recurrence rates. However, with this also comes
the unfortunate consequence of infl ammatory
reaction caused by the mesh, thereby making
repeat dissection much more diffi cult and potentially leading to increased risk of injury to nerves
and increased pain. Indeed, one must be certain
of the decision to reoperate on a patient for a
recurrent inguinal hernia.
In this regard, the surgeon must evaluate the
patients’ potential risk factors which fi rst will
determine whether or not the patient is an optimal
surgical candidate and if so, then address modifi able risk factors to maximize outcomes. These
risk factors include age >50, smoking, family
history, type of hernia, and obesity [ 6 ].
In situations where a diagnosis of a hernia is
diffi cult to make clinically, imaging may be
required. These hernias, in the literature defi ned
as occult hernias , typically present with chronic
pain without evidence of recurrence or palpable
bulge clinically. It is these circumstances where
either US, CT, or MRI may be used, however,
data as to the usefulness of each modality is
widely variable. A recent meta-analysis demonstrated a sensitivity and specifi city for each
modality of 86% and 77%, 80% and 65%, 91%
and 83%, respectively [ 7 ]. Another retrospec-
tive study found a sensitivity and specifi city of
each to be 56% and 0%, 77% and 25%, 91%
and 92%, respectively for all-comers [ 8 ]. These
numbers are even worse if used in patients with
the diagnosis of occult hernias : 33% and 0%,
54% and 25%, 91% and 92%, respectively [ 8 ].
Classically, US has been used as a fi rst-line
strategy in the diagnosis of inguinal hernias
because of its availability and low cost.
However, it’s been noted that in the case of
occult hernias , US and CT may not suffi ce thus
leaving MRI as the mainstay of diagnosis. It
has been our practice in cases where it is clinically diffi cult to confi rm the diagnosis to begin
with an US followed by CT, if uncertainty
remains. However, in cases of chronic pain or
occult hernia, we proceed straight to MRI
which is more sensitive in identifying neuromas or problems with the mesh.
In deciding when to operate, it appears that
time is on our side. A randomized multicenter
trial performed in 2006 found that watchful waiting was an acceptable option in management of
both fi rst time and recurrent inguinal hernias in
48 Treating Inguinal Recurrences
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493
men that were asymptomatic or minimally symptomatic. Their study found that the risk of strangulation was extremely rare and that postoperative
complication rates were not affected by watchful
waiting [ 9 ]. Therefore, there is no rush to take an
asymptomatic patient back to surgery. Rather,
care and planning should precede any operative
intervention, operating only on those patients
symptomatic enough to warrant therapy in order
to avoid potential complications.
Once the decision is made to reoperate, one
must then decide which method to use. It is
important at this juncture to review the
patients’ previous surgical history and whenever possible obtain operative reports where
one can learn about what previous types of
mesh, if any, have been used. These options
can be broken down broadly into two categories: Open vs Laparoscopic. Although not
entirely prohibitive, in patients with a history
of pelvic radiation one may find that a laparoscopic approach may be difficult and therefore opt for an anterior open repair. In those
patients who have undergone a prostatectomy,
excision of the peritoneum makes a laparoscopic repair difficult making an open repair
likely a better-suited repair.
The use of mesh is generally required in
patients undergoing recurrent repair due to a high
likelihood of wound healing abnormalities such
as collagen abnormalities. Rare cases involving
infected hernia mesh may preclude placement of
a mesh and require special consideration. While
recent studies have begun to show no signifi cant
difference between biologic and synthetic mesh
with regard to quality of life, complication rates
and rates of recurrence, use of biologic mesh has
been customarily reserved for use in contaminated cases [ 10 , 11 ]. Lightweight polypropylene
mesh (LWPPM) is advantageous due to decreased
pain, decreased mesh sensation, and theoretical
greater ingrowth of the mesh to provide a more
durable repair [ 12 ]. However, in situations where
a wide bridged repair would be required, such as
a large direct inguinal hernia, the use of standard
weight polypropylene mesh should be considered
to minimize the risk of postoperative mesh eventration or recurrence [ 13 ].
Operative Approach
Determining the operative approach is generally
predicated upon the patient’s medical and surgical history. Those patients with previous open
repairs generally benefi t from a laparoscopic
repair. We prefer a totally extraperitoneal
approach, as this minimizes the potential for
intra- abdominal adhesions, although transabdominal preperitoneal repairs (TAPP) are also
utilized in these situations. The type of prior open
repair should be considered as several techniques
for hernia repair with placement of preperitoneal
mesh through an anterior incision have been
described (i.e., Kugel repair, Prolene Hernia
System, Plug and patch repairs). The extent of
prior preperitoneal dissection will determine the
feasibility of a totally extraperitoneal approach.
In our experience, the extent of preperitoneal dissection associated with the open preperitoneal
repairs does not prevent a totally extraperitoneal
approach. As the most commonly performed
anterior inguinal hernia repair is the Lichtenstein
approach, a totally extraperitoneal repair is generally feasible and is no more diffi cult than a
laparoscopic repair for a primary inguinal hernia.
Following a Lichtenstein repair, the preperitoneal space has not been violated, the prior mesh
is anterior to the abdominal musculature, and few
traces of a prior surgical repair are evident.
Unless prior mesh has resulted in chronic pain or
other complications, removal is not required. In
the event mesh removal is desired, a combined
anterior and laparoscopic approach may be
required. Additional benefi ts of a laparoscopic
approach for recurrent hernias include the ability
to explore the contralateral groin and repair bilateral hernias when necessary. Whether for primary or recurrent inguinal hernias, laparoscopic
repair results in more rapid recovery for patients
requiring bilateral repairs [ 14 , 15 ].
For patients with large recurrent hernias, or
inguinoscrotal recurrences, laparoscopic repair
can be more challenging. Identifi cation and visualization of the contents of a chronically incarcerated recurrent inguinal hernia may be limited
through an extraperitoneal approach. A TAPP
approach allows for direct visualization of the
494
S. Roth and J.E. Wennergren
incarcerated contents and serial reduction of the
contents while visualizing the contents of the
hernia sac. In the event the hernia sac is not fully
reducible, the hernia sac may be dissected from
the cord structures and divided leaving the distal
hernia sac open while the proximal hernia sac is
later closed with the peritoneal fl aps. While division of challenging hernia sacs is feasible, we
reserve this technique for the most challenging
situations, as there is a potential for development
of postoperative hydrocele as a result of the remnant hernia sac within the inguinal canal and
scrotum. In the event of postoperative hydrocele
formation, we would advocate observation for
months prior to consideration for excision. As a
matter of practice, we will typically utilize a TEP
approach for recurrent inguinal hernias following
prior anterior repairs when the hernia is reducible
following induction of anesthesia. If the hernia
remains non-reducible following anesthetic
induction, a TAPP approach is preferred.
When trying to decide between using a TEP or
a TAPP repair, other than in select situations, the
choice is often based upon surgeon experience. A
recent randomized prospective study tried to
identify any differences between the two operative approaches. While there was signifi cantly
higher acute pain postoperatively and longer
operative times associated with a TAPP repair,
there was no difference between the two procedures when looking at quality of life, chronic
groin pain and resumption of normal activities or
cost [ 16 ].
In addition, a previous history of laparoscopic
hernia repair, either TEP or TAPP, doesn’t necessarily eliminate the ability to address the recurrence with another attempt laparoscopically. A
retrospective study found that out of 51 patients
with recurrent inguinal hernias after laparoscopic
repair (70% TAPP, 23% TEP, 7% other), 49
underwent successful redo TAPP repair with the
other two converting to open anterior repairs due
to dense adhesions. There was a 32% post-op
complication rate including hematoma/seroma
formation and one port site infection. There was
also one case where the vas deferens was ligated
due to dense adhesions to the mesh and four
patients with complaints of persistent chronic
pain. However, there were no recurrences at 70
month follow-up. Of interest, in about two thirds
of these patients, the location of the recurrence
was found to happen either caudal or medial to
previous mesh placement [ 17 ].
How about cases where the patient has had
both open and laparoscopic repairs? What if you
fi nd yourself doing a TAPP repair only to realize
that there isn’t enough peritoneum to close over
the mesh? In such instances, the use of an
Intraperitoneal Onlay Mesh (IPOM) can be used.
This mesh is customarily a permanent mesh with
anti-adhesive barrier, much like one used in laparoscopic ventral hernia repairs (Fig. 48.1 ). While
reports of such repair are uncommon with regard
to inguinal hernia surgery, it does appear that
when compared to Lichtenstein repair, there is no
signifi cant difference in chronic pain [ 18 ]. Other
studies have shown no difference in seroma formation, recurrence, mesh migration, bowel
obstruction, or fi stula [ 19 ]. It is our practice to
reserve IPOM for such situations where TEP,
TAPP, or open repairs are unavailable due to
concerns of increased adhesion rates. One must
keep in mind, and as will be discussed later, tacks
Fig. 48.1 IPOM—Placement of mesh covering an internal hernia. The cord structures are visible along the underside of the mesh
48 Treating Inguinal Recurrences
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495
used to secure mesh in this fashion must be done
with extreme caution so as to avoid bladder and/
or neurovascular injury. Therefore, tacks are
placed above the ileopubic tract, with the use of
fi brin glue along the lower edge of the mesh for
fi xation to prevent bowel migration behind the
mesh. If possible, a small peritoneal fl ap can be
raised to cover the lower edge of the mesh and
secured to the mesh above the ileopubic tract.
Additionally, there is the scenario where a
patient has had both open and laparoscopic
repairs but is known to have a “hostile” abdomen, leaving an open repair the only safe option.
Mesh Fixation
The role of mesh fi xation in laparoscopic inguinal hernia repair is an area of continuous debate.
While some believe that fi xation is necessary in
order to prevent mesh migration and to minimize
recurrence rates, others feel that mesh fi xation
unnecessarily increases risk of postoperative pain
due to injury to nerves. A randomized control
trial from the Mayo clinic looked at whether fi xation should be used at all and found that in those
patients where no fi xation was used, there was
less analgesic usage in the PACU, less urinary
retention, and shorter hospital length of stay but
no difference in postoperative pain [ 20 ]. A more
recent study found that there was no difference in
pain scores at 1 day, 1 week, 1 month, 1 year, and
2 year follow-up. There was no difference in
length of hospital stay, resumption of normal
activity, seroma formation, and recurrence rates
(no recurrences in either group at 2 years) [ 6 ].
Our Approach
Recurrent inguinal hernias are approached in our
practice by utilizing an algorithm. While most
patients may be treated utilizing this standardized
strategy, certain patient characteristics may occasionally require individualization. The decision as
to the best approach is based upon a combination
of surgical history, comorbidities, ability to tolerate an operation, as well as patient preferences.
Although inguinal hernia repair can be safely
performed in most individuals, there may be
some patients that are best managed non-operatively, recognizing the small risk of incarceration
and strangulation resulting in emergent repair.
Examples of situations in which nonoperative
treatment for recurrent hernias include medical
conditions limiting a patient’s ability to tolerate
anesthesia, uncorrected coagulopathies, advanced
liver disease, or severe cardiopulmonary conditions. Occasionally, patients will not be suitable
for general anesthesia, yet will be considered a
reasonable risk for a procedure under local anesthesia. While it is technically feasible to perform
a recurrent inguinal hernia repair under a local
anesthesia, we favor a nonoperative approach in
these individuals, as a recurrent inguinal hernia
repair can be quite involved and unanticipated
diffi culties may necessitate conversion from a
local to general anesthetic.
Among patients suitable for a general anesthetic, the decision for recurrent repair type is
made based upon the prior surgical history.
Patients with a previous anterior repair
(Lichtenstein, McVay, Plug and Patch, Bassini,
etc.) will undergo a laparoscopic repair. We
favor a totally extraperitoneal approach for our
laparoscopic inguinal hernia repairs in the
majority of patients. However, patients with a
history of prior abdominal surgery involving an
incision below the umbilicus are approached
transabdominally (TAPP). On the other hand,
patients with prior laparoscopic abdominal surgery or limited prior open procedures (i.e.,
appendectomy) are considered for an extraperitoneal approach. We always obtain prior operative notes to determine the details of prior
operations as occasionally patients will have
undergone a prior open operation involving
placement of a mesh in the preperitoneal space
such as a Kugel or plug repair. Repairs involving prior mesh in the preperitoneal space can be
more challenging, particularly when the preperitoneal space has been widely dissected. We
will occasionally place a port in the left upper
quadrant to allow visualization of the peritoneal
cavity in situations in which dissection of the
peritoneum from the prior plug is challenging;
496
S. Roth and J.E. Wennergren
however, in most cases the peritoneum is easily
dissected from the plug. In patients with a prior
open preperitoneal repair such as a Kugel repair,
we will generally perform a laparoscopic transabdominal preperitoneal inguinal hernia repair.
Removal of the prior mesh is performed, if feasible, to facilitate new mesh placement. If prior
mesh is unable to be removed, we will remove
as much as possible while avoiding injury to the
vas deferens, gonadal vessels, and other structures. If the peritoneum is not amenable to closure following dissection, a tissue separating
mesh is utilized with the barrier placed adjacent
to the viscera. We will then affi x the mesh to the
abdominal wall with fi brin glue along the inferior most edge and subsequently glue the peritoneum over the inferior aspect of the mesh to
prevent bowel from migrating behind the inferior aspect of the mesh.
Patients with a prior history of a laparoscopic
inguinal hernia repair (TAPP, TEP, or IPOM)
with an ipsilateral recurrence will undergo an
open mesh hernia repair through an anterior
approach (i.e., Lichtenstein repair). Patients with
a contralateral inguinal hernia following a prior
laparoscopic repair are approached laparoscopically. Although the prior preperitoneal space has
been dissected, as long as mesh has not been
placed into the space, it is generally feasible to
dissect the peritoneum from the abdominal wall
without diffi culty.
Patients with multiple recurrent inguinal hernias with prior repairs from both an anterior and
laparoscopic approach represent unique challenges. The details of the prior operations are
carefully considered and a repair is tailored to
the patient. Our approach is to generally utilize
a TAPP repair, with conversion to an open repair
if necessary. When conversion is required, we
will perform either a Lichtenstein hernia repair
or an open preperitoneal repair (i.e., Stoppa).
We will make every attempt feasible to remove
prior mesh to allow for maximal integration of
the newly placed prosthetic into the abdominal
wall. A careful informed consent discussion is
mandatory in these situations as there is a signifi cant risk for injuries to the cord structures
and testicle, which may result in the need for
orchiectomy.
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Nonoperative Treatment of Sports
Hernia
Terra Blatnik
49
Introduction
Groin pain is an extremely common complaint
among athletes of all ages. Incidence of groin
pain ranges from 0.5% to as high as 43% in a
group of elite Finnish hockey players [ 1 , 2 ]. The
anatomy of this area is extremely complex and
can make diagnosis and treatment challenging.
Pain in the setting of no appreciable hernia can
result from something as simple as an adductor
strain or can be more complex involving several
structures or even the hip joint itself.
The term “sports hernia” has been used to
describe a number of complaints in the groin of
athletes. Other terms such as “athletic pubalgia,”
“Gilmore groin,” and “sportsman’s hernia” have
all been used to describe the same entity. A consensus defi nition does not exist and the term is
used to describe a wide variety of pathology in
the groin area of athletes. In 2014, the British
Hernia Society developed a position statement on
treatment of sportsman’s groin [ 3 ]. This position
statement labeled this type of injury an “inguinal
disruption” and defi ned it as pain in the groin
area near the pubic tubercle where “no other
pathology exists to explain the symptoms.”
Several other studies advocate for the use of fi ve
signs and symptoms that indicate a likely sports
T. Blatnik (*)
Cleveland Clinic , Twinsburg , OH , USA
Terra.blatnik@yahoo.com
e-mail:
hernia: (1) deep groin or lower abdominal pain,
(2) that worsens with sports-specifi c activity, (3)
tenderness on palpation over the pubic ramus or
the conjoint tendon, (4) pain with resisted hip
adduction, and (5) pain with resisted abdominal
sit-up [ 4 ]. Regardless the terminology, sports her-
nia is a common complaint in active individuals
that participate in high-risk sports and this chapter will discuss its diagnosis and treatment.
Epidemiology
Sports hernia is most common in sports like
soccer, ice hockey, and Australian rules football
(similar to American rugby). Any sport that
requires a twisting motion of the torso places an
athlete at increased risk. Traditionally, sports hernias happened predominately in men, but over the
last 5 years women are making up a larger proportion of those athletes diagnosed, with estimates of
up to 15.2% in one study [ 5 ]. Sports hernia is
most common in athletes in their mid-20s.
There are numerous areas in the groin that can
be potential sources of pathology in athletes with
groin pain. The pubic symphysis seems to be the
central location of pathology in this condition, as
this area is the central point for several tendinous
attachments from the adductor musculature. The
internal and external obliques, rectus abdominus,
and transversus abdominus also insert in this
region. In men, these muscles extend from the
spermatic fascia which, if injured, can lead to
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_49
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T. Blatnik
pain that radiates into the testicular region. In
addition to the complex muscle crossings in this
area, the hip joint can also contribute to groin
pain. The labrum in the hip and issues from femoral acetabular impingement have often been
identifi ed as potential sources of pain [ 7 ].
The common consensus is that sports hernia
may result from imbalance between the strong
adductor muscles of the leg and the weaker muscles of the abdomen [ 6 , 8 , 9 ]. Athletes use their
adductor muscles to stabilize the leg during single leg support, and this imbalance in strength
between the adductor leg muscles and core muscles leads to tears and other pathology in this
region. Chronic groin pain in athletes has also
been correlated with reduced hip abduction and
internal/external rotation [ 6 ]. The restricted
motion may lead to additional stress on the
attachments of the musculature.
Presentation/Physical Exam
The presentation for sports hernia can be quite
variable, but most athletes will complain of an
insidious onset of unilateral or bilateral groin
pain. Pain may radiate to the scrotum and testicles in men [ 6 ]. On rare occasions, there will be
an acute precipitating event for the onset of pain.
Athletes will complain that the pain worsens with
activity, but improves with rest. Rest will tend to
resolve the pain, but it will often worsen again
once sports are resumed.
Physical exam of patients with exerciseassociated groin pain needs to include the groin,
hip, and lower back regions. During passive palpation, patients may have tenderness over the
inguinal canal and/or pubic tubercle, hip adductor origin (at the pubic symphysis), or a dilated
superfi cial inguinal ring. In addition to these
areas, the examiner needs to palpate the obliques,
transversus abdominus, and the pubic symphysis,
to see if pain can be reproduced [ 3 ]. On active
exam, a resisted sit-up or abdominal crunch may
cause pain in the distal rectus abdominus insertion. Valsalva maneuvers may also reproduce
groin pain in patients who have a sports hernia.
Resistance testing of the hip fl exors or adductors
on the affected side may also demonstrate
weakness compared with the contralateral
muscle group [ 6 ].
There should not be any pain on palpation of
the lumbosacral spine or sacroiliac joint region
unless a concomitant injury is occurring. A full
hip exam including testing of internal hip rotation, FABER (fl exion, abduction, and external
rotation), and FADIR (fl exion, adduction, and
internal rotation) can help identify any intraarticular pathology (Fig. 49.1 ). Testicular exam
should also be conducted along with exam looking for true inguinal hernias.
Figure 49.2 demonstrates the additional areas
that should be points of focus during physical
exam in athletes with groin pain. Each of these
areas can be the source of pain or occur concurrently with a diagnosis of sports hernia.
Imaging
Imaging for sports hernia has evolved signifi cantly over the last 5–10 years. Plain radiographs
including an AP pelvis and a lateral view of the
femur should be done on the affected side initially to exclude obvious bony pathology [ 7 ].
This may show a femoral neck stress fracture,
degenerative hip disease, femoral acetabular
impingement, osteitis pubis, or apophyseal avulsions. Ultrasound was initially touted as being
important but it was found to be very operatordependent, and thus diffi cult to interpret the fi ndings. Non-contrast magnetic resonance imaging
(MRI) has become the most important imaging
modality for identifying the underlying pathology of sports hernia. Many institutions have
developed MRI protocols specifi cally for sports
hernia. These include large-view sequences of
the bony pelvis and smaller fi eld-of-view
sequences of the pubic symphysis [ 10 ]. A num-
ber of abnormalities have been found on MRI
that may occur with sports hernia (Fig. 49.3 ).
Several studies have shown that there are potentially two signs identifi able on MRI, the “superior cleft sign” and the “secondary cleft sign,”
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