Dynamic Ultrasound of Hernias of the Groin and Anterior Abdominal Wall

Gastrointestinal and Biliary Point-of-Care Ultrasound

Point-of-care ultrasound has been shown to have excellent diagnostic accuracy for a variety of gastrointestinal and biliary pathologies. This review explores the evidence and scanning techniques for hypertrophic pyloric stenosis, intussusception, appendicitis, small bowel obstruction, diverticulitis, hernias, pneumoperitoneum, and biliary pathology.

Diagnostic performance of CT with Valsalva maneuver for the diagnosis and characterization of inguinal hernias

PURPOSE

Inguinal hernias are mainly diagnosed clinically, but imaging can aid in equivocal cases or for treatment planning. The purpose of this study was to evaluate the diagnostic performance of CT with Valsalva maneuver for the diagnosis and characterization of inguinal hernias.

METHODS

This single-center retrospective study reviewed all consecutive Valsalva-CT studies between 2018 and 2019. A composite clinical reference standard including surgery was used. Three blinded, independent readers (readers 1-3) reviewed the CT images and scored the presence and type of inguinal hernia. A fourth reader measured hernia size. Interreader agreement was quantified with Krippendorff's α coefficients. Sensitivity, specificity, and accuracy of Valsalva-CT for the detection of inguinal hernias was computed for each reader.

RESULTS

The final study population included 351 patients (99 women) with median age 52.2 years (interquartile range (IQR), 47.2, 68.9). A total of 381 inguinal hernias were present in 221 patients. Sensitivity, specificity, and accuracy were 85.8%, 98.1%, and 91.5% for reader 1, 72.7%, 92.5%, and 81.8% for reader 2, and 68.2%, 96.3%, and 81.1% for reader 3. Hernia neck size was significantly larger in cases correctly detected by all three readers (19.0 mm, IQR 13, 25), compared to those missed by all readers (7.0 mm, IQR, 5, 9; p < 0.001). Interreader agreement was substantial (α = 0.723) for the diagnosis of hernia and moderate (α = 0.522) for the type of hernia.

CONCLUSION

Valsalva-CT shows very high specificity and high accuracy for the diagnosis of inguinal hernia. Sensitivity is only moderate which is associated with missed smaller hernias.

Ultrasound manifestations and clinical features of nonpalpable testis in children

To explore the value of ultrasound in the preoperative diagnosis of nonpalpable testis (NPT) in children. A retrospective study of 254 cases with NPT from May 2017 to December 2021. The preoperative ultrasound examination results were compared with the surgical exploration and pathological results. There were 254 cases (312 testes) NPT has got surgery in our centre. The surgical age were from 6 month to 12 years old, the median age was 2.33 years. There were 103 cases (136 testes) diagnosed as intra-abdominal testis (IAT) by preoperative ultrasound, and 80 cases (103 testes) of extra-abdominal testis (EAT), 71 cases (73 testes) of non-viable testis (NVT). There were 102 cases (135 testes) consistented as IAT by the diagnostic laparoscopy, the preoperative ultrasound's coincidence of IAT was 99.02%. There were 80 cases (103 testes) consistented as EAT by the diagnostic laparoscopy, the preoperative ultrasound's coincidence rate was100%. There were 62 cases (62 testes) consistented as NVT by the diagnostic laparoscopy, there were 9 cases (11 testes) misdiagnosed, the preoperative ultrasound's coincidence rate was 84.9%. Ultrasound can provide valuable information for the preoperative diagnosis of children with nonpalpable testicles, and especially good at identifying the EAT and IAT with normal testicular morphology.

Usefulness of dynamic ultrasound in the diagnosis of epigastric herniation of stomach

Introduction

Abdominal wall hernia contents usually consist of omental or mesenteric fat or loops of small or large bowel. Gastric involvement has been only rarely reported.

Case report

We present a case of a 62-year-old woman who was admitted to our hospital due to epigastric pain and vomiting. On physical examination, the only observed abnormality was a soft, painless, epigastric bulge located in the upper midline. Based on the clinical presentation, the patient was diagnosed with a probable epigastric hernia. Dynamic ultrasound evaluation of the palpable bulge confirmed the presence of epigastric hernia demonstrating the movement of abdominal contents through a large wall defect. Surprisingly, the herniated contents were found to contain also the anterior wall of the distal stomach together with omental fat and vessels. The patient opted for surgery, which confirmed the presence of an epigastric hernia containing the distal portion of stomach.

Discussion

In this case, dynamic ultrasound provided added value over computed tomography by clearly demonstrating stomach passing from the abdominal cavity to enter into the hernia sac and it is therefore reported for both its rarity and interest. To our knowledge, this is the first such ultrasound-based case report presented in literature and certainly the best sonographically documented.

Conclusion

We anticiapte that this case report will promote the use of dynamic ultrasound in current practice as an effective imaging tool to recognise unusual types of hernias.

Association of pediatric inguinal hernia contents with patient age and sex

BACKGROUND

Although pediatric inguinal hernia (IH) is a very common disease, systematic reviews of herniated organs are scarce. The current study aims to clarify the contents of pediatric IH using preoperative ultrasonography (US) in association with patient age, sex, and risk for developing irreducible/strangulated hernia.

METHODS

The medical records of pediatric IH patients who underwent inguinal US examination prior to surgery between 2014 and 2019 were reviewed. Hernia contents were categorized into four groups based on US findings: bowel, omentum, ovary with or without fallopian tube, and ascites.

RESULTS

A total of 524 IH lesions found in 220 men and 304 women were analyzed. The most common hernia content in patients under 12 months of age was the bowel (91.0%) in males and ovaries (89.5%) in females. The omentum became the most common herniated organ in both men (78.6%) and women (88.0%) aged 2 years and older. Emergency operations were performed in 3 patients (0.57%) due to irreducible IH, where 2 patients with irreducible ovaries, 5 and 7 months old, developed ovarian torsion and needed to undergo emergent salpingo-oophorectomy.

CONCLUSIONS

The contents of pediatric IH depended on patient age and sex. Herniated ovaries in infants can twist in the hernia sac and become strangulated. It is important for clinicians to expect the herniated organ and take appropriate measures in the pediatric primary care setting.

Complicated, Complete, Indirect, Irreducible Right Inguinoscrotal Hernia

Inguinal hernias are the most common of all hernias. A complicated hernia is irreducible, and the contents are obstructed or strangulated. Sonography is considered the imaging modality of choice for the diagnosis of abnormalities of the inguinal area. This case study is about a patient with an inguinal hernia that had not been repaired and progressed into a life-threatening, complicated inguinoscrotal hernia. The patient’s complaints and clinical findings required sonographic examinations of the abdomen, pelvis, inguinal canal, and scrotum. Sonographic findings were corroborated by findings with computed tomography (CT). After the compromised intestine was resected and the hernia was repaired, the patient developed a deep vein thrombosis (DVT), identified sonographically. The patient was successfully treated and discharged.

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.

Ultrasound of Soft Tissue Masses and Fluid Collections

Soft tissue masses and fluid collections are frequently encountered in sonographic practice, either as principal indication for diagnostic examination or as an incidental finding during an examination performed for other indications. Sonography is a good first-line imaging modality for evaluation of superficial masses and fluid collections, but requires meticulous attention to technique to avoid diagnostic pitfalls. Although many superficial masses are diagnosed with ultrasound, there are several potential diagnostic challenges, including differentiating hematomas from sarcomas. This article provides an image-rich review of the sonographic features of common soft tissue masses, with emphasis on practical tips to accurately recognize important pathology.

Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment in groin pain in athlete

The nomenclature and the lack of consensus of clinical evaluation and imaging assessment in groin pain generate significant confusion in this field. The Groin Pain Syndrome Italian Consensus Conference has been organised in order to prepare a consensus document regarding taxonomy, clinical evaluation and imaging assessment for groin pain. A 1-day Consensus Conference was organised on 5 February 2016, in Milan (Italy). 41 Italian experts with different backgrounds participated in the discussion. A consensus document previously drafted was discussed, eventually modified, and finally approved by all members of the Consensus Conference. Unanimous consensus was reached concerning: (1) taxonomy (2) clinical evaluation and (3) imaging assessment. The synthesis of these 3 points is included in this paper. The Groin Pain Syndrome Italian Consensus Conference reached a consensus on three main points concerning the groin pain syndrome assessment, in an attempt to clarify this challenging medical problem.

US of the Inguinal Canal: Comprehensive Review of Pathologic Processes with CT and MR Imaging Correlation

Ultrasonography (US) has a fundamental role in the initial examination of patients who present with symptoms indicating abnormalities of the inguinal canal (IC), an area known for its complex anatomy. A thorough understanding of the embryologic and imaging characteristics of the contents of the IC is essential for any general radiologist. Moreover, an awareness of the various pathologic conditions that can affect IC structures is crucial to preventing misdiagnoses and ensuring optimal patient care. Early detection of IC abnormalities can reduce the risk of morbidity and mortality and facilitate proper treatment. Abnormalities may be related to increased intra-abdominal pressure, which can result in development of direct inguinal hernias and varicoceles, or to congenital anomalies of the processus vaginalis, which can result in development of indirect hernias and hydroceles. US is also helpful in assessing postoperative complications of hernia repair, such as hematoma, seroma, abscess, and hernia recurrence. In addition, it is often the modality initially used to detect neoplasms arising from or invading the IC. US is an important tool in the examination of patients suspected of having undescended testes or posttraumatic testicular retraction and is essential for the examination of patients suspected of having torsion or infectious inflammatory conditions of the spermatic cord. Online supplemental material is available for this article. ^©RSNA, 2016.

Static and dynamic sonography for diagnosis of abdominal wall hernias

Sonography is a fast, painless, inexpensive, and widely available tool usually regarded as a first-line imaging modality for abdominal wall evaluation. This article provides illustrative images and videos on the use of sonography for diagnosis of abdominal wall hernias. A variety of pitfalls that may present clinically as pseudohernias are also described.

Imaging of the inguinal canal in children

The inguinal canal is often seen at the edge of the field of view on plain radiography, computed tomography, or magnetic resonance imaging and may often not be scanned when performing sonography of the scrotum or abdomen. As a result, pathology in this anatomical region may be easily overlooked. The peculiar embryology of the inguinal canal makes the identification of pathology in the inguinal region significant, as some of the processes that take place within the scrotum may originate in the abdomen, and vice versa. This article reviews the relevant embryology of the inguinal canal, discusses abdominal and scrotal conditions that involve the inguinal region, and illustrates associated pathology.

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.

Dynamic power Doppler ultrasonography of anterior abdominal wall hernias: confirmation of incarceration

PURPOSE

Power Doppler ultrasonography (PD-US) is a motion-sensitive modality that can display flow characteristics regardless of the direction. This increased motion sensitivity can be used as a parameter to show the tissue motion on artificially generated fremitus images. This study aimed to confirm any signs of incarceration in abdominal wall hernias proven by herniorrhaphy by examination with dynamic PD-US (during manual compression-decompression maneuvers).

METHODS

Twenty-seven patients with anterior abdominal wall hernia with a narrow neck (<1 cm in diameter) were examined firstly with gray-scale ultrasonography (GS-US), and then with dynamic PD-US. Two independent radiologists, who were blinded to the real-time images showing the orientation and motion of the hernia neck, completed the examinations. These images were evaluated for any signs of incarceration, as well as the orientation of the hernia neck.

RESULTS

Orientations of the hernia neck were not described on GS-US images in 13 lesions and on dynamic PD-US images in 3 lesions. While the GS-US examination revealed incarcerated hernia in four of the patients, the dynamic PD-US examination revealed an additional seven patients with symptoms associated with incarceration.

CONCLUSION

Dynamic PD-US may show the orientation of the hernia neck and any sign of incarceration more accurately and clearly than conventional GS-US. Being informed about these features preoperatively is of utmost importance. Thus, anterior abdominal wall hernias should be examined by dynamic PD-US.