Management of groin hernias detected by ultrasound: a comprehensive study

INTRODUCTION

It remains unclear whether ultrasound-detected hernias (UDH) are the sole cause of pain in patients with groin pain, and clinical examination plays a complementary role. The aim of our study is to describe the evolution of patients with ultrasound detected hernias in terms of development of groin hernia detected by physical examination, pain resolution, and alternative diagnosis.

METHODS

An observational, descriptive, longitudinal study of a prospective case series including patients with UDH with groin pain. Follow-up evaluation included the following: follow-up time, side of pain, its evolution, time to resolution, clinical hernia (CH) development, need for surgical resolution, and the presence of postoperative pain and alternative diagnosis.

RESULTS

A total of 98 patients with complete follow-up for groin pain and UDH were included. Seven patients (7.1%) developed CH, with a median time to conversion of 8 months. Four of them (4.1% of the total and 57.1% of the ones who developed CH) ended up having surgery. Fifty-three patients (54.1%) resolved their pain in a median time to resolution of 2 months, and 75.5% of them did so spontaneously. The majority of patients with persistent pain (73.3%) were able to lead a normal life and only reported pain with movement. More than half of the patients (53.3%) reached a specific diagnosis. Among those patients who did not develop CH, 39.6% reached an alternative diagnosis, the majority being musculoskeletal pathologies.

CONCLUSION

Watchful waiting and a thorough search for other alternative causes of groin pain in UDH and clinically occult hernia would be a reasonable option.

The Shouldice Method: an expert's consensus

BACKGROUND

Hernia repairs are a commonly performed surgical procedure and the Shouldice Repair of inguinal hernias has been well described before in terms of its outcomes. However, the purpose of this paper was to understand what experts from Shouldice Hospital consider to be the essential steps to the Shouldice Method.

METHODS

Utilizing a Delphi Methodology, surgeons at Shouldice Hospital who are considered content experts, provided their answers on what is essential to the Shouldice Method. The median, interquartile range, and percent agreement from the responses as well as the Delphi's overall Cronbach's Alpha were determined. All Delphi items were ranked on a five-point Likert scale and consensus was reached when Cronbach's Alpha was ≥ 0.8. The items from the survey that ranked as 5-completely agree or 4-partially agree by ≥ 80% of participants on the five-point Likert scale were included in the final framework.

RESULTS

The final consensus for the Shouldice Method included 39 items with 7 overarching steps: preoperative preparation of the patient, anesthetic component, incision and nerve identification, treatment of the cremasteric muscles, hernia identification and treatment, reconstruction of the posterior wall, and post-operative management of patients.

CONCLUSION

The results of this consensus provide a step-by-step approach to the Shouldice Method, as well as information that is timely and can be utilized by surgeons incorporating non-mesh hernia repairs into their practice.

Impact of ultrasound on inguinal hernia repair rates in Australia: a population-based analysis

BACKGROUND

Inguinal hernias are a common pathology that often requires surgical management. The use of groin ultrasound (GU) to investigate inguinal hernias is a growing area of concern as an inefficient use of healthcare resources. Our aim was to assess changes in the rates of GU and the impact on surgical practice.

METHODS

Medicare Item Reports and the Australian Institute of Health and Welfare Database were used to estimate annual GU and inguinal hernia repair (IHR) rates per 100 000 population for the period 2000/2001-2017/2018. Pearson's correlation coefficients and linear regression analyses were performed to assess associations between these variables.

RESULTS

Over the 18-year period, GU rates increased 13-fold from 88 to 1174 per 100 000 population. Overall, total IHR rates decreased from 217 to 192 per 100 000. Overall, unilateral IHR rates have decreased (182-146 per 100 000), bilateral IHRs have increased (35-46 per 100 000), laparoscopic IHR has increased (30-86 per 100 000) and open surgery has declined (187-106 per 100 000). The increase in GU rates were strongly associated with the decrease in unilateral (r = -0.936, P = <0.001) and increase in bilateral IHR rates (r = 0.924, P = <0.001).

CONCLUSION

The use of GU has increased substantially, potentially representing an unnecessary cost to the healthcare system. Rising GU rates are not associated with an increase in IHR, however, may contribute to the increasing rates of bilateral IHRs. This study supports the opinion that more extensive clinical and health policy initiatives are needed in Australia to address this health issue.