Herniography

Herniography (peritoneography) for diagnosis of Spigelian hernia

BACKGROUND

Spigelian hernia is a rare clinical condition. It is difficult to diagnose in absence of obvious clinical signs. Ultrasound scan, cross-sectional imaging and contrast studies like herniography have been widely used for detecting occult abdominal wall hernias in symptomatic patients.

AIM AND METHODS

We present our experience of detecting a clinically occult Spigelian hernia in a 56-year-old symptomatic male patient, who had concomitant left sided inguinal and Spigelian hernias. In this patient, the Spigelian hernia was not detected on ultrasound scan. We also present a review of literature on the role of herniography in the diagnosis of this rare condition.

RESULTS AND CONCLUSION

Herniography is a sensitive investigation for evaluation of occult hernias. However, it is an invasive contrast study and therefore must be used selectively. Non-invasive real-time imaging like ultrasonography remains the first line of investigation for detecting occult hernias.

Inguinal hernias: MRI and ultrasound

This article presents an overview of the key anatomic structures of the groin region as seen on gross anatomy and the appearance of these structures on ultrasound and magnetic resonance imaging (MRI). An overview of the sonographic and MRI techniques used in preoperative diagnosis of inguinal hernias is provided, and their value is discussed. Finally, the role of ultrasound and MRI after surgical inguinal hernia repair is addressed.

Peritoneography (herniography) for detecting occult inguinal hernia in patients with inguinodynia

OBJECTIVE

To evaluate the usefulness of peritoneography in patients referred with inguinal pain (inguinodynia) and clinically absent inguinal hernia on physical examination.

SUMMARY BACKGROUND DATA

In patients with chronic groin pain, peritoneography is a seldom-used yet available technique that can detect an occult inguinal hernia. The value of peritoneography in the diagnosis of occult inguinal hernia has been previously shown.

METHODS

During a 60-month period, 80 consecutive patients with complaints of persistent inguinal pain (inguinodynia) without evidence of hernia on clinical examination were referred for outpatient evaluation by peritoneography. Twenty-nine patients had prior inguinal surgery in the region of their current pain. Peritoneography was performed using a midline or paraumbilical approach. Radiographs were obtained with patients in prone and prone oblique positions with the head elevated 20 degrees to 25 degrees, both with and without provocative maneuvers. All available records were retrospectively reviewed for radiographic findings and outcome.

RESULTS

Of the 80 patients undergoing peritoneography, 36 (45%) were diagnosed radiographically to have inguinal hernias that were not detectable clinically. Twenty-seven of these patients subsequently underwent inguinal exploration, and a hernia was confirmed in 24 (89%). Of the patients having prior inguinal surgery in the region of their pain, 12/29 (41%) were diagnosed by peritoneography with a hernia. Two complications (2.5%), both colon perforations that did not require significant intervention, occurred as a result of peritoneography.

CONCLUSIONS

Peritoneography is highly reliable for detecting clinically occult inguinal hernia and has a low complication rate. Its usefulness is shown in a prospective consecutive series for detection of occult hernias in patients with chronic inguinal pain. The authors conclude that peritoneography is a safe and useful diagnostic test in the setting of persistent inguinal pain and a negative clinical examination.

[Diagnosis of non-hernia groin masses]

Hernia is the most frequent etiology of a groin mass except in 1 or 2% of cases. Seven cases of atypical groin masses were reported. The different etiologies of the masses were reminded, with useful investigative procedures. A precise history and a detailed physical examination are necessary to determine the most valuable exam in each patient.

The incidence and differential diagnosis of acute groin injuries in male soccer players

This prospective cohort study evaluated the incidence of acute groin injuries and estimated the distribution of differential diagnoses in male soccer players. Two senior male soccer divisions (21 teams, 326 players) were followed for 1 year. Patients with groin injuries were examined clinically as well as by herniography, sonography and by plain x-ray of the pelvic bones. Groin injuries accounted for 8% of all injuries. The incidence of groin injury was 0.8/1000 h of exposure. Thirteen (52%) of the 25 patients were clinically considered to have a muscle/tendon injury. However, when using sonography, muscle/tendon injury was only verified in 1 patient. Clinical suspicion of hernia or incipient hernia was evident in 4 (16%) of the patients, while 14 (56%) had a pathological finding at herniography. Clinical and paraclinical (i.e. diagnostic methods using imaging and other advanced techniques) diagnoses do not correspond very well in acute groin injury.

Inguinal hernia repair. The Nyhus posterior preperitoneal operation

The posterior preperitoneal approach for prosthetic hernioplasty is a safe and sound procedure for the repair of adult groin hernias. The authors' results, 0 mortality, 2.1% minor morbidity, and 2.1% overall recurrence rate (1.26% for mesh hernioplasty), compare favorably with results in contemporary literature. This operation can be performed as an outpatient procedure or 1-night stay surgery. Pain is significantly less than with the traditional anterior Cooper's ligament repair, and rapid return to ordinary daily activities is possible. The authors favor the use of mesh prostheses in most cases of adult Nyhus types 2, 3 (not necessary in crural hernias), and 4 hernias. The authors recognize the value of two new approaches to hernia repair, that is, the laparoscopic extraperitoneal method and the tension-free mesh-plug hernioplasty, which share many of the anatomophysiologic principles with the posterior preperitoneal mesh repair.

Herniography in the investigation of groin pain in adults

Herniography is a useful investigation in adults with unexplained groin pain in whom there is no clinical evidence of a hernia, thus ensuring appropriate surgery. The technique is described, normal anatomy and different types of hernias illustrated.

Evaluation of direct and indirect inguinal hernia by computed tomography

The importance of venous distension of the pampiniform plexus in the prevention of inguinal hernia was evaluated. Functional closure of the inguinal canal was investigated by computed tomography during a Valsalva manoeuvre in a normal individual and 12 men with unilateral inguinal herniation, one of whom had previously undergone herniorrhaphy. Thus, 13 normal canals were evaluated along with five with direct and seven with indirect hernia. In all normal canals a rise in intra-abdominal pressure increased the cross-sectional area of the part of the pampiniform plexus located in the medial end of the canal, thereby filling the empty space and preventing herniation. In the lateral part the plexus was compressed against the external aponeurosis by the fascia transversalis in a valve-like fashion. In cases of direct inguinal herniation the distended pampiniform plexus was displaced by the hernia sac during the Valsalva manoeuvre, but in indirect hernia impaired swelling of the pampiniform plexus was seen. It is suggested that this observation could help to explain the normal mechanism of closure of the inguinal canal.

Role of herniography in the diagnosis of occult hernias

Twenty-two patients with groin or incisional pain and normal physical examinations underwent herniography. Eight patients were found to have 11 unsuspected hernias. Seven were direct, two indirect, and two incisional. Six of nine groin hernias were recurrent. Exploration confirmed the herniographic findings in all patients. Follow-up evaluation of patients undergoing herniorrhaphy revealed resolution of symptoms. Ten of the 14 patients with normal herniograms were asymptomatic 3 months after herniography. In these 22 patients, herniography resulted in a savings of $31,000. We conclude that herniography is cost-effective and useful in patients with abdominal wall pain of obscure etiology.

Herniography in 79 patients with unexplained pain in the groin: a retrospective study

To assess the safety and accuracy of herniography for the diagnosis of inguinal hernia in young military men with unexplained pain in the groin, a retrospective study in 79 patients with unexplained pain in the groin who underwent a herniography is presented. Nineteen patients (24%) showed a positive herniogram which was confirmed in 15 out of 16 patients who subsequently underwent surgery. All 60 (76%) patients with a negative herniography were followed-up. An inguinal hernia was subsequently found at surgery in two patients out of eight who were operated on later. In our series no serious complications occurred. Herniography has been shown to be a safe and reliable method to demonstrate or exclude an inguinal hernia in young military men with unexplained pain in the groin. The differential diagnosis in this specific patient group is discussed.

Spigelian hernia

The diagnosis of spigelian hernia presents greater difficulties than its treatment. The clinical presentation varies, depending on the contents of the hernial sac and the degree and type of herniation. The pain, which is the most common symptom, varies and there is no typical pain of spigelian hernia. Findings to facilitate diagnosis are palpable hernia and a palpable hernial orifice. Large, easily palpable spigelian hernias are not a diagnostic problem. It is small hernias and hernial orifices that are overlooked because they are masked by the subcutaneous fat and an intact external aponeurosis. In the absence of a palpable orifice or sac, persistent point tenderness in the spigelian aponeurosis with a tensed abdominal wall most strongly suggests the diagnosis. Spigelian hernia can be ruled out in patients without palpable tenderness. Ultrasonic scanning can be recommended for verification of the diagnosis in both palpable and nonpalpable spigelian hernia. The hernial orifice and sac can also be demonstrated by computed tomography, which gives more detailed information on the contents of the sac than does ultrasonic scanning. The treatment of spigelian hernia is surgical, and the risk of recurrence is small. A gridiron incision is excellent for operations for palpable hernias. If the hernia cannot be palpated preoperatively, preperitoneal dissection through a vertical incision is recommended. This gives good exposure, facilitates hernioplasty, and permits preperitoneal exploration and treatment of other abdominal wall hernias. The incision is also suitable for exploratory laparotomy, which should be performed on patients with abnormal ultrasonographic or computed tomographic findings in whom no palpable hernia can be detected preoperatively.

Herniography

Herniographic examinations were performed on more than 4,000 patients. The method was found to be of great value in patients with obscure symptoms in the groin or pelvis. Herniography shows not only hernial sacs but also the general condition and tissue strength of the inguinal part of the abdominal wall. The different types of hernias have different signs that, as a rule, allow an exact diagnosis. The pelvic floor and the pouch of Douglas can always be evaluated. Young athletes with severe symptoms in the groin, in most instances, were found to have some type of hernial rupture and often osteochondritis in the pubic symphysis as well. In women, the clinical diagnosis of hernia is often difficult. Herniography was of great value in these patients.