The accuracy of ultrasound in the diagnosis of clinically occult groin hernias in adults

Positive predictive value of ultrasound in correctly identifying an inguinal hernia: a single-centered retrospective pilot study

Objectives

To determine the clinical utility of preoperative ultrasound imaging for predicting an inguinal hernia in need of surgery. In addition, we aimed to identify factors associated with false positive (FP) ultrasound examinations.

Methods

In this retrospective pilot study, we included all 175 patients who underwent inguinal hernia surgery in our hospital in 2019 and of whom a positive preoperative ultrasound examination of the groin area was available. The positive predictive value (PPV) of the ultrasound examination was determined using inguinal hernia detected during surgery (yes/no) as golden standard. To identify possible predictive factors, we compared the characteristics of patients with a FP ultrasound with patients with a true positive (TP) ultrasound.

Results

PPV of ultrasound examinations to identify an inguinal hernia in need of surgery correctly was 90.9% (159/175). The patients with a FP ultrasound examination had a significantly higher body mass index (BMI) than the patients with a TP ultrasound examination (27.6 ± 4.2 vs 25.8 ± 2.3, p = 0.043).

Conclusions

With a false positive percentage of 9.1%, there is still room for improvement of preoperative diagnostic imaging. Studies with larger cohorts are necessary to establish prediction models that have the potential to reduce FP ultrasound results.

Inguinal Hernia Mesh Repair: The Factors to Consider When Deciding Between Open Versus Laparoscopic Repair

Inguinal hernia repair is one of the most commonly performed surgical procedures worldwide. An inguinal hernia occurs due to a defect in the abdominal wall, which allows the abdominal contents to pass through it. Although the placement of mesh over the defect is the gold standard to close the defect, there are various approaches to achieving it, out of which two of the most widely accepted techniques are laparoscopic inguinal hernia repair (LIHR) and open inguinal hernia repair (OIHR). However, the approach of choice widely fluctuates with regards to various factors such as patient history, type of hernias, and surgeons' preference. It is imperative to understand the variations in outcomes of different approaches and how best they fit an individual patient in deciding the technique to be undertaken. This article has reviewed many studies and compared the two techniques in terms of chronic pain, the time required to return to activity, rate of recurrence, and cost-effectiveness.

A New Approach and Old Techniques: Combined Endoscopic Repair of Inguinoscrotal Hernias

BACKGROUND

The treatment of inguinoscrotal hernias (ISH) represents one of the most challenging areas in surgical pathology. Although these hernias could be repaired through a minimally invasive approach, open repair is still considered to be the technique of choice for most surgeons. The purpose of this study is to evaluate our new combined [open+transabdominal preperitoneal (TAPP)/total preperitoneal (TEP)] method of ISH repair.

PATIENTS AND METHODS

The authors reviewed the charts of 124 patients with ISH who underwent hernia repair in different modifications: open, TAPP, TEP, and new combined method with a minimal follow-up of 3 months.

RESULTS

New combined (open+TAPP/TEP) method repair was successful in all 38 patients. Average case duration was 68.8 minutes (62 to 106 min). No recurrence was observed for the 13 months follow-up. Two patients had intraoperative serosal bowel injury, 1 patient developed postoperative seroma, and 2 patients developed several pain.

CONCLUSIONS

Combined (open+TAPP/TEP) method for ISH repair allows to minimize surgical trauma and reduce both the procedure time and the postoperative length of stay. Implementation of this method results in statistically significantly fewer wound-related postoperative complications compared with traditional methods.

Imaging modalities for inguinal hernia diagnosis: a systematic review

PURPOSE

The aim of the study was to determine which diagnostic modality [Computerized Tomography (CT), Magnetic Resonance Imaging (MRI), or ultrasound (US)] is more precise in terms of sensitivity and specificity in diagnosing inguinal hernia and sub-type of inguinal hernia (direct or indirect).

METHODS

This systematic review was reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), and a search for relevant articles was undertaken in PubMed, Embase, and the Cochrane Library. Inclusion criteria were original studies that preoperatively diagnosed patients suspected of inguinal hernia by either CT, MRI, or US and compared diagnostic findings with operative findings or definitive follow-up. The main outcomes were the diagnostic certainty of inguinal hernia and type of hernia by sensitivity and specificity. All eligible studies were searched in the Retraction Watch database to ensure that all included studies were suitable for inclusion.

RESULTS

Bubble charts depicting the size of each patient cohort and percentual range for both sensitivity and specificity showed that US was better than CT and MRI in diagnosing inguinal hernia. Bubble charts for US and CT depicted high values within the studies that reported sensitivity and specificity in diagnosing type of hernia.

CONCLUSIONS

We found that US had the highest sensitivity and specificity. However, it must be taken into consideration that performance is highly dependent on the operator's level of expertise. Based on this systematic review, ultrasound may be the preferred imaging modality when physical examination is inconclusive, given that local expertise in performing US examination for hernia disease is adequate.

Pain resolution in non-operatively managed ultrasound-only groin hernias: 3-year follow-up

BACKGROUND

General surgeons frequently see patients with groin lumps and pain. However, in the absence of a lump, an ultrasound scan identified groin hernia is a diagnostic and management challenge. Some surgeons recommend inguinal hernia surgery while others do not. The outcome of non-operative management is uncertain.

METHODS

This study represents a minimum 3-year follow-up of all non-operatively managed patients seen in general surgical outpatient clinic over a 12-month period. To be included, patients needed to meet all four criteria: groin pain, no clinical hernia, groin hernia identified on ultrasound scan requested by the general practitioner and non-operative management. Patients were interviewed via a standardised telephone survey. Primary outcome measure was groin pain which was assessed with the Sheffield Pain score.

RESULTS

From July 2014 to June 2015, 67 patients met the inclusion criteria. 42 participated (37 men and 5 women). Two-thirds were pain free (68%). Only 2 patients underwent hernia surgery. Women were more likely to describe developing a lump (60% vs 14%; p = 0.013), to see a surgeon (40% vs 8%; p = 0.039) and undergo hernia surgery (20% vs 3% p = 0.088).

CONCLUSION

At least in the medium term, non-operative management of men who present with groin pain (with an ultrasound scan reporting a hernia but no lump) is reasonable.

Orientações da Sociedade Brasileira de Hérnia (SBH) para o manejo das hérnias inguinocrurais em adultos

RESUMO As hérnias inguinais são um problema frequente e o seu reparo representa a cirurgia mais comumente realizada por cirurgiões gerais. Nos últimos anos, novos princípios, produtos e técnicas têm mudado a rotina dos cirurgiões que precisam reciclar conhecimentos e aperfeiçoar novas habilidades. Além disso, antigos conceitos sobre indicação cirúrgica e riscos de complicações vêm sendo reavaliados. Visando criar um guia de orientações sobre o manejo das hérnias inguinais em pacientes adultos, a Sociedade Brasileira de Hérnias reuniu um grupo de experts com objetivo de revisar diversos tópicos, como indicação cirúrgica, manejo perioperatório, técnicas cirúrgicas, complicações e orientações pós-operatórias.

Effectiveness of endoscopic totally extraperitoneal (TEP) hernia correction for clinically occult inguinal hernia (EFFECT): study protocol for a randomized controlled trial

Background

Groin pain is a frequent complaint in surgical practice with an inguinal hernia being at the top of the differential diagnosis. The majority of inguinal hernias can be diagnosed clinically. However, patients with groin pain without signs of an inguinal hernia on anamnesis or physical examination provide a diagnostic challenge. If ultrasonography shows a hernia that could not be detected clinically, this entity is called a clinically occult hernia. It is debatable if this radiological hernia is the cause of complaints in all patients with inguinal pain.

The objective of this study is to assess whether watchful waiting is non-inferior to endoscopic totally extraperitoneal (TEP) inguinal repair in patients with a clinically occult inguinal hernia.

Methods

The EFFECT study is a multicenter non-blinded randomized controlled non-inferiority trial. Adult patients with unilateral groin pain and a clinically occult inguinal hernia are eligible to participate in this study. A total of 160 participants will be included and randomized to TEP inguinal hernia repair or a watchful waiting approach. The primary outcome of this study is pain reduction 3 months after treatment, measured by the Numeric Rating Scale (NRS). Secondary outcomes are quality of life, cost-effectiveness, patient satisfaction and crossover rate. Eight surgical centers will take part in the study. Participants will be followed-up for 1 year.

Discussion

This is the first large randomized controlled trial comparing treatments for patients with groin pain and a clinically occult inguinal hernia. To date, there are no interventional studies on the effect of surgery or a watchful waiting approach in terms of pain or quality of life in this subset of patients. A trial comparing the outcomes of the two approaches in patients with a clinically occult inguinal hernia is urgently needed to provide data facilitating the choice between the two treatment options. If watchful waiting is not inferior to surgical repair, costs of surgical repair may be saved.

Trial registration

The study protocol (NL61730.100.17) is approved by the Medical Ethics Committee (MEC-U) of the Diakonessenhuis, Utrecht, The Netherlands. The study was registered at the Netherlands Trial Registry (NTR6835) registered on November 13, 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2711-7) contains supplementary material, which is available to authorized users.

Evaluation of hernia of the male inguinal canal: sonographic method

Sonography of the male inguinal canal for hernia is a common request. There is debate about the accuracy and even need for sonographic assessment of inguinal hernia. A clear, concise method is presented, with correlated diagrams and sonographic images, which aims to improve the ability of sonographers to easily identify inguinal herniae.

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.

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.

Radiological and clinical examination in the diagnosis of Spigelian hernias

INTRODUCTION

Spigelian hernia are rarely reported lateral abdominal wall hernias. Clinical diagnosis of a suspected hernia can be challenging owing to vague presenting symptoms and signs. This study aimed to investigate the accuracy of preoperative imaging and clinical examination in the diagnosis of Spigelian hernias.

METHODS

A retrospective analysis was performed of patients who presented to North Tyneside and Wansbeck General Hospitals between 1998 and 2010. All patients were assessed by a consultant general surgeon in the outpatient clinic or on the surgical admissions ward. Patients were included who presented with a history suggestive of a Spigelian hernia and a palpable lump or equivocal clinical examination. All patients proceeded to surgery, which was used as the reference standard.

RESULTS

Overall, correlation with operative findings showed computed tomography (CT) to have a sensitivity of 100% and a positive predictive value (PPV) of 100%. Ultrasonography had a sensitivity of 90% and a PPV of 100%. Clinical assessment alone had a sensitivity of 100% and a PPV of 36%.

CONCLUSIONS

This study shows that ultrasonography and CT have a high sensitivity and PPV in relation to occult Spigelian hernias. When no obvious Spigelian hernia is present, patients should be evaluated with radiological investigation to establish a diagnosis. Owing to diagnostic uncertainty, a laparoscopic approach should be favoured.

Local Investigation of outcomes Based on Ultrasound Examinations for Suspected Inguinal Hernia Performed by Sonographers and Radiologists

Inguinal hernia is the most common surgical repair performed in England with more than 73,000 cases in 2007. The majority of inguinal hernias are diagnosed clinically, but ultrasound is fast becoming the imaging modality of choice for diagnosing occult hernia, due to its non-invasive nature and lack of radiation. At the Norfolk and Norwich University Hospitals NHS Foundation Trust, ultrasound of the groin was performed only by radiologists, but recently sonographers have also begun examining patients for inguinal hernia. This study investigates the accuracy of ultrasound diagnosis of hernia and compares the performances of radiologists and sonographers over a nine-month period involving 124 patients. Our results indicate that both professional groups have a high detection rate and that there is no significant difference in accuracy. An incidental finding was that many general practitioner referrals diagnosed with an inguinal hernia did not proceed to surgery. Since many ultrasound departments are experiencing demand versus capacity issues, it may be that further investigation into the value of diagnosis when surgery is unlikely is warranted.

Meta-analysis of sonography in the diagnosis of inguinal hernias

Groin hernias are common conditions, and there is a need for accurate imaging when the clinical diagnosis is not clear. A meta-analysis was undertaken to investigate the diagnostic accuracy of sonography in the diagnosis of inguinal hernias. After review of literature searches, 9 original articles were included. Data were pooled and statistically analyzed. In the studies included, sensitivity ranged from 92.7% to 100%; specificity ranged from 22.2% to 100%; the positive predictive value ranged from 83.3 to 100%; and the negative predictive value ranged from 40 to 100%. Sonography has overall sensitivity of 96.6 %, specificity of 84.8%, and a positive predictive value of 92.6%. In cases of diagnostic uncertainty, sonography offers value as an initial imaging modality. It has advantages over other radiologic methods, as it is inexpensive and has minimal complications. When the clinical diagnosis of an inguinal hernia is uncertain, sonographic findings should be interpreted in conjunction with clinical judgment, as its diagnostic accuracy is reduced in the absence of any clinically palpable hernia.

Herniography influences the management of patients with suspected occult herniae and patient factors can predict outcome

PURPOSE

Patients with groin pain and no palpable hernia are a diagnostic challenge for the surgeon. It is recognised that some patients will have an occult hernia and benefit from surgical repair. Herniography remains popular in some units, as it has a high diagnostic sensitivity.

METHODS

Presenting symptoms and signs were recorded, along with herniogram findings, management plan and outcome for all patients undergoing herniography between July 2004 and December 2009. Demographic factors and individual symptoms and signs were analysed for their ability to predict a positive herniogram.

RESULTS

There were a total of 72 positive and 132 negative herniograms. For positive herniograms, only 41 (59%) patients underwent surgery and six (16%) patients were found not to have a hernia. The most common reasons for not proceeding to surgery were herniogram findings thought to be insignificant and the herniogram being positive on the contralateral side. For negative herniograms, despite a negative herniogram, four (3%) patients underwent surgery and a hernia was confirmed in two patients. Regarding predictive symptoms and signs, history of a groin lump and greater patient age were significantly associated with a positive herniogram and a confirmed hernia at surgery.

CONCLUSIONS

After a positive herniogram, less than two-thirds of patients undergo surgery. The majority have improved symptoms on review and we, therefore, suggest a period of watchful waiting prior to herniography. Older patients and a history of a groin lump are associated with a positive herniogram and confirmed hernia at surgery, and could be used to select patients for laparoscopic exploration.

Abdominal hernias in pregnancy

A hernia is an area of weakness or complete disruption of the fibromuscular tissues of the body wall. In addition to the body wall, hernias can occur in the diaphragm, pelvic wall, perineum, pelvic floor, and internal abdominal viscera (hernias through omental or mesenteric defects, ligaments and folds). Surgical repair of different types of hernia is the most common general surgical procedure with more than 20 million hernioplasties performed each year. Abdominal wall hernias are not common during pregnancy. Hernias can be symptomless or have minimal symptoms, including slight discomfort or pain. Such hernias are not life-threatening and should be controlled on regular basis. After spontaneous delivery and uterine involution, they should be repaired on an elective basis. It is of utmost importance for a clinician to diagnose emergent situations, which include incarceration, strangulation and perforation caused by hernia because consultation with a surgeon and emergency operation are mandatory. There is still no consensus for irreducible hernia during pregnancy, but complications during pregnancy outweigh elective operation. Therefore, hernioplasty is recommended during pregnancy, especially in early gestation.

European Hernia Society guidelines on the treatment of inguinal hernia in adult patients

The European Hernia Society (EHS) is proud to present the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS. They are evidence-based and, when necessary, a consensus was reached among all members. The Guidelines have been reviewed by a Steering Committee. Before finalisation, feedback from different national hernia societies was obtained. The Appraisal of Guidelines for REsearch and Evaluation (AGREE) instrument was used by the Cochrane Association to validate the Guidelines. The Guidelines can be used to adjust local protocols, for training purposes and quality control. They will be revised in 2012 in order to keep them updated. In between revisions, it is the intention of the Working Group to provide every year, during the EHS annual congress, a short update of new high-level evidence (randomised controlled trials [RCTs] and meta-analyses). Developing guidelines leads to questions that remain to be answered by specific research. Therefore, we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment. In addition, a short summary, specifically for the general practitioner, is given. In order to increase the practical use of the Guidelines by consultants and residents, more details on the most important surgical techniques, local infiltration anaesthesia and a patient information sheet is provided. The most important challenge now will be the implementation of the Guidelines in daily surgical practice. This remains an important task for the EHS. The establishment of an EHS school for teaching inguinal hernia repair surgical techniques, including tips and tricks from experts to overcome the learning curve (especially in endoscopic repair), will be the next step. Working together on this project was a great learning experience, and it was worthwhile and fun. Cultural differences between members were easily overcome by educating each other, respecting different views and always coming back to the principles of evidence-based medicine. The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project.

Herniography: analysis of its role and limitations

INTRODUCTION

Herniography is a radiographic procedure shown to be valuable in the examination of groin symptoms. It is useful in clinical situations, including the detection of occult hernia, the investigation of groin hernia when physical findings are equivocal, and the assessment of pain after inguinal hernia repair.

OBJECTIVE

To systematically review the current literature on the use of herniography and to evaluate its reliability, risk, and limitations.

METHOD

The Medline database was searched for publications on herniography.

RESULTS

Herniography has a low false-positive rate, ranging from 0 to 18.75%. The sensitivity rate ranges from 81 to 100%, and the specificity rate ranges from 92 to 98.4%.

CONCLUSION

Herniography is a safe and effective diagnostic procedure for assessing obscure groin symptoms. It has the potential of reducing the incidence of unnecessary operations. It should be considered in the evaluation of patients where the etiology of inguinal pain is unclear.