Sonography of Inguinal Region Hernias

Small bowel obstruction secondary to strangulated obturator hernia with transected ileal segment: A case report

INTRODUCTION AND IMPORTANCE

Obturator hernia is a rare abdominal wall hernia (<1 % incidence) that occurs through the obturator foramen, often in elderly, emaciated women. Contrast-enhanced computed tomography (CECT) of the abdomen and pelvis is the diagnostic modality of choice, with a high accuracy of 78 %-100 %.

CASE PRESENTATION

An 84-year-old frail woman with COPD presented with generalized abdominal pain, abdominal distention, vomiting, and right thigh pain. CECT revealed a right-sided obturator hernia causing small bowel obstruction. Emergency exploratory laparotomy revealed a right-sided strangulated obturator hernia. Postoperatively, the patient developed septic shock and multiorgan dysfunction syndrome (MODS) and succumbed to death on the 5th postoperative day.

CLINICAL DISCUSSION

Obturator hernia is a rare abdominal hernia with an incidence of 0.07-1 %, an often-overlooked condition, more common in elderly women (around 70-90 years) with risk factors like low BMI, multiparity, and chronic conditions such as COPD. It presents with nonspecific symptoms, including abdominal pain, distension, and vomiting, and is often difficult to diagnose. Early CECT has improved the preoperative diagnosis rate from 43 % to 90 %, thus playing a crucial role in preventing morbidity and mortality. Treatment is surgical, but the mortality rate is high due to delayed diagnosis, bowel strangulation, and underlying preexisting illness.

CONCLUSION

Obturator hernias are a rare but important cause of small bowel obstruction, especially in elderly, frail, malnourished women without prior abdominal surgeries. Medial thigh pain and mild abdominal distension warrant high suspicion and prompt diagnosis using CECT. Early surgical intervention is critical to prevent severe complications and reduce associated morbidity and mortality.

Ultrasound and magnetic resonance imaging (MRI) assessment of piezogenic papules: A report of three cases

Piezogenic papules (PP) are protrusions of fat that form within the subcutaneous tissue, which are typically found on the heels. We herein describe the ultrasound (US) presentation (topography, echogenicity, shape, dynamic reducibility, and power Doppler activity) and magnetic resonance imaging features (topography, signal, and shape) of PP in three female patients who were referred to our institution for evaluation of soft tissue nodules of the heel. Then, we discuss the anatomy of the heel fat pad and its implication in the pathophysiology of PP. Because PP consist of herniations of subcutaneous fat from deep macrochambers to superficial microchambers through focal defects in the fibroconjunctive capsule of the heel fat pad, dynamic US can demonstrate the reducibility of PP under probe compression and therefore allows easy differentiation from other soft tissue tumors.

Ultrasound of Groin Pain in the Athlete

Groin pain is a common cause of disability in athletes. Imaging is crucial in a clinical diagnosis, given the multiple associated etiologies. The main sites of groin pain are the adductors, iliopsoas muscles, inguinal ring, hip joint, and pubic symphysis. Although magnetic resonance imaging is the gold standard to image groin pain, ultrasound (US) offers excellent accuracy in pinpointing muscle injuries, inguinal disruption, and hernias. US requires a detailed knowledge of anatomical landmarks; imaging pitfalls, and pathologic patterns. We review the complex anatomy of the groin region, the sonographic appearance of the involved structures, and the strengths and weaknesses of US.

A rare condition similar to inguinal hernia in pregnancy: A case of bilateral varicose veins of round ligament of uterus

Round ligament varicosities (RLV) are a very rare cause of an inguinal mass, which is very similar to an inguinal hernia, and should be taken seriously by women, especially in mid-pregnancy. Ultrasound can confirm the diagnosis of the RLV and can prevent unnecessary interventions. We report a case of a patient with bilateral RLV: the primigravida was 31 years old, G1P0, gestation 30+2w. The patient presented to the clinic 1 month ago due to the discovery of bilateral inguinal masses. After the diagnosis was confirmed by ultrasound, this patient received regular reviews during labor and delivery and is currently in good maternal condition. The patient came to the clinic 1 month after the discovery of bilateral inguinal area masses for 1 month.

Diagnostic impact of using the semi-erect position in the evaluation of inguinal hernia with superficial sonography

<b>Introduction:</b> The main cause of groin pain is inguinal hernia (IH). The most commonly used imaging test for diagnosis is sonography, which is also useful in distinguishing between indirect and direct hernias.<b>Aim:</b> In this study, measurements were made with sonography in the semi-erect position (45) in addition to the supine position and the effectiveness of this position in detecting the defect was investigated.<b>Material and methods:</b> The IH cases diagnosed by ultrasound between March 2019 and October 2023 were evaluated retrospectively. According to the diameter of the defect in the supine position, the cases were divided into three groups: Group A (≤1.5 cm), Group B (1.5-3 cm), and Group C (≥3 cm). A total of 252 patients with unilateral IH were identified.<b>Results:</b> For Group A, the mean value was 1.09 0.23 (0.64-1.48) cm in the supine position and 1.28 0.26 (0.67) cm in the semi- -erect position (p<0.001). For Group B, the mean value was 2.29 0.29 (1.57-2.82) cm in the supine position and 2.41 0.31 (1.65-2.94) cm in the semi-erect position (p<0.001). For Group C, the mean value was 3.57 0.23 (3.28-4.05) cm in the supine position and 3.62 0.24 (3.32-4.10) cm in the semi-erect position (p<0.05).<b>Conclusions:</b> Superficial ultrasound, which provides reliable results in the diagnosis of IH, is an easily accessible modality. Unlike previous studies, this study was the first to examine the semi-erect position in IH patients. It showed that it is effective in determining the optimal diameter of the defect.

The Role of Imaging in the Pre- and Postoperative Evaluation of Inguinal Hernia

Inguinal hernia repair is the most frequently performed surgical procedure. Imaging has a fundamental role in initial assessment and postoperative evaluation of inguinal hernias. Clinical implications of radiology in the preoperative setting include diagnosis of occult/complicated hernias and enhancement of diagnostic certainty. Postoperatively, imaging may assist the detection and characterization of complications. Familiarity with the normal appearance of the postoperative groin area and surgical techniques is required to avoid misinterpretation. This pictorial essay provides an overview of the expected postoperative imaging findings and highlights the role of imaging in the pre- and postoperative evaluation of inguinal hernias, with emphasis on ultrasonography.

A Radiological Review of the Unusual Contents of Inguinal Region

Background  The inguinal region is an area of complex anatomy that could contain diverse uncommon contents in routine clinical practice. Although inguinal hernia repair is one of the commonest surgeries done routinely, thorough preoperative imaging has a significant impact on the outcome of the surgery, by revealing the presence of unusual contents in the inguinal region. Aim  The aim of this article is to review the differential diagnosis of the uncommon inguinal pathologies, which can simulate an inguinal hernia, to determine, and to simplify the treatment approach. Conclusions  A profound understanding of the imaging characteristics of uncommon inguinal pathologies is crucial for both the radiologists (to prevent misdiagnosis) and the treating physicians (to avoid surgical complications) and ensure optimal management.

Gamut of Extratesticular Scrotal Masses: Anatomic Approach to Sonographic Differential Diagnosis

The commonly taught tenet that intratesticular lesions are always malignant and extratesticular scrotal lesions are always benign is a simplistic statement that erroneously minimizes the significance of extratesticular scrotal masses and their diagnosis. Yet, disease in the extratesticular space is commonly encountered by clinicians and radiologists and is often a source of uncertainty in diagnosis and management. Given the embryologically rooted complex anatomy of this region, a wide range of pathologic conditions is possible. Radiologists may not be familiar with some of these conditions; further, many of these lesions can have a specific sonographic appearance, allowing accurate diagnosis that can minimize surgical intervention. Lastly, malignancies can occur in the extratesticular space-although this is less common than in the testicles-and proper recognition of findings that warrant additional imaging or surgery is critical in optimizing outcomes. The authors present a compartmental anatomic framework for differential diagnosis of extratesticular scrotal masses and provide a comprehensive illustrative display of many of the pathologic conditions that can be encountered to familiarize radiologists with the sonographic appearances of these lesions. They also review management of these lesions and scenarios where US may not be definitive in diagnosis and selective use of scrotal MRI can be helpful. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Peri-appendicular Abscess in a Spigelian Hernia

Background Spigelian hernias are a rare type of lateral ventral abdominal hernia and their content can include any of the intra-abdominal organs. Many cases have described the presence of a variety of abdominal organs in Spigelian hernias, but only few cases report the presence of an incarcerated appendicitis. Imaging is an important step in the diagnosis to avoid the lack of knowledge in such cases. Surgical treatment can be through open or laparoscopic approach, with or without using a mesh according to the size of the defect.

Case Report We report a case of an 82-year-old patient who presented with an acute appendicitis with peri-appendicular abscess strangulated in a right Spigelian hernia. The patient was successfully treated by a laparoscopic appendectomy, a surgical drainage of the abscess, and direct muscle approximation without using of mesh due to inflammation.

Conclusion Spigelian hernias with acute appendicitis in their content are a very rare condition. Clinical diagnosis is usually difficult and challenging and computed tomography scan is the imaging modality of choice. The treatment is surgical.

The Cyst of the Canal of Nuck: Anatomy, Diagnostic and Treatment of a Very Rare Diagnosis-A Case Report of an Adult Woman and Narrative Review of the Literature

The cyst of the canal of Nuck is an extremely rare female hydrocele, usually occurring in children, but also in adult women. It is caused by pathology of the canal of Nuck, which is the female equivalent to the male processus vaginalis. Due to its rarity and the lack of awareness among physicians, the cyst of the canal of Nuck is a seldom-encountered entity in clinical practice and is commonly misdiagnosed. We report on a case of cyst of the canal of Nuck in a 42-year-old woman, who presented with a painful swelling at her right groin. In addition, we conducted a review of the current available literature. This review gives an overview of the anatomy, pathology, diagnostics, and treatment of the cyst of the canal of Nuck. The aim of this review is not only to give a survey, but also to raise awareness of the cyst of the canal of Nuck and serve as a reference for medical professionals.

Early CT Ameliorates the Diagnostic Dilemma of "Little Old Lady's Hernia": A Case Report

Encountering an obturator hernia itself is a rare entity for practicing surgeons globally. Synonymously known as the "old lady's hernia" is usually seen in fragile geriatric multiparous female patients. We share our experience of this rare entity where the patient presented with features of small bowel obstruction. Her diagnosis was delayed in the previously attended other centre as the possibility of an obturator hernia was overlooked. A timely clinical examination of the patient complemented by a computed tomography scan of the abdomen and pelvis helped us to obtain a diagnosis and proceed with immediate surgery. Intraoperatively the rarity was present bilaterally although the obstruction was on one side only. Prompt diagnosis and treatment benefits patients in this potentially lethal condition.

Keywords

case report; computed tomography; obturator hernia; X-ray.

Point-of-Care Ultrasound in the Diagnosis of an Incarcerated Inguinal Hernia

Emergency physicians can use point-of-care ultrasound to diagnose inguinal hernias as well as their potential complications, including small bowel obstruction, incarceration, and even strangulation. We provide an overview of the sonographic appearance of inguinal hernias, as well as the diagnostic criteria of serious complications. In this case report, point-of-care ultrasound findings included a non-reducible inguinal hernia associated with significant bowel dilation in multiple loops without signs of intestinal ischemia or necrosis.

The advantage of laparoscopic surgery in the treatment of Spigelian hernia: A report of two cases

INTRODUCTION AND IMPORTANCE

The usefulness of laparoscopic surgery in the treatment of Spigelian hernias and the appropriate insufflation pressure remains unclear.

CASE PRESENTATION

Case 1 involved an 81-year-old woman presented with a right abdominal protrusion. CT scan demonstrated a defect in the abdominal wall at the lateral edge of the right rectus abdominis muscle. We diagnosed as Spigelian hernia and performed laparoscopic hernia repair. The insufflation pressure was set at 10 cm H ₂ O, and the IPOM method was selected as the repair method. Case 2 involved a 74-year-old male presented with a right abdominal painful bulging. Strangulation was released and CT scan demonstrated a defect in the abdominal wall at the lateral edge of the right rectus abdominis muscle. We diagnosed as Spigelian hernia and performed laparoscopic hernia repair. The insufflation pressure was set at 10 cmH ₂ O, and the repair was performed by the hybrid method.

CLINICAL DISCUSSION

In both cases, the positions of the hernia portals marked preoperatively based on the tender areas and confirmed laparoscopically were not accurate. Although Spigelian hernia is a rare disease and various laparoscopic techniques have been reported in recent years, laparoscopic surgery is very useful to obtain an accurate diagnosis and to observe the abdominal wall from inside the abdominal cavity under insufflation, and it is better to decide the repair method according to the situation of each case and institution.

CONCLUSION

Laparoscopic surgery is important for accurate diagnosis in surgery of Spiegel's hernia, and insufflation pressure of 10 cmH2O was sufficient.

Gangrenous appendicitis contained within a Spigelian hernia

A 66-year-old man with abdominal pain had a 5-year-old mass subsequently identified as a Spigelian hernia. Exploratory laparotomy revealed a strangulated and gangrenous appendix contained within the hernia, necessitating an appendectomy. This case highlights the importance of early identification and exploration of this rare hernia, so that early management can prevent the development of more serious and dangerous symptoms.

Using Point-of-Care Ultrasound to Characterize Acute Inguinal Swelling of Young Children in the Pediatric Emergency Department

Acute inguinal swelling in young children is frequently assumed to be an inguinal hernia, often prompting a bedside reduction attempt. We report 3 cases of inguinal swelling where the use of point-of-care ultrasound changed the patients' management by identifying an alternate diagnosis, thus avoiding unnecessary and painful procedures as well as their associated sedation risks.

Ultrasound in the evaluation of necrotic bowel in children: A pictorial essay

Necrotic bowel is a serious condition involving death of gastrointestinal tissue. The diagnosis is difficult to make clinically, and plain radiography is often inconclusive. Ultrasonography is an inexpensive, portable and readily available complementary diagnostic tool. In some cases, ultrasonography can detect features of necrotic bowel earlier than plain radiography or when plain radiography is equivocal and does not correlate with the clinical findings. This pictorial essay aims to compare the ultrasonography features of normal bowel and necrotic bowel in children. The role of ultrasonography and the ultrasonographic features of necrotic bowel will be illustrated by discussing some of the causes of necrotic bowel in children. Correlation with plain radiographs and pathological specimens is made. Frequent causes of necrotic bowel in neonates include necrotising enterocolitis, malrotation with small bowel volvulus and incarcerated inguinal hernias. Causes in older children include intussusception, complications of Meckel's diverticulum, post-surgical adhesions, internal hernias and vasculitic abnormalities. Ultrasonography features suggestive of necrotic bowel include persistently dilated loops of aperistaltic bowel, increase or decrease of bowel wall thickness, intramural or portal venous gas, loss of bowel wall perfusion, and free intraperitoneal gas and fluid. The diagnosis of necrotic bowel may be made earlier on ultrasonography than on abdominal radiographs alone. This pictorial essay will familiarise the reader with the role of ultrasonography and the ultrasonographic features of necrotic bowel through a wide range of conditions that may cause necrotic bowel in children. Familiarity with these findings will facilitate timely imaging diagnosis of necrotic bowel before complications develop.

Epiploic Appendagitis in a Femoral Hernia

Both epiploic appendagitis and femoral herniae are rare diagnoses individually. No radiological cases of a patient having epiploic appendagitis within a femoral hernia have been documented in the literature. We present a case of a 65-year-old patient who underwent clinical work-up for a tender left groin lump. When undergoing a CT scan for investigating possible lymphadenopathy, she was found to have epiploic appendagitis contained within an incarcerated left sided femoral hernia. In this case report, we review the relevant anatomy, aetiology, patient demographics, as well as clinical and imaging findings and management.

Howship-Romberg Sign and Bowel Obstruction: A Case Report

Small bowel obstruction (SBO) is associated with high morbidity and mortality in acute care surgery practice, with hernias constituting a significant portion of the underlying etiology. Physical examination and maneuvers such as changing the extremity position of the patient can further improve clinician's diagnostic acumen to identify the cause of the disease. We present a case of SBO in an 83-year-old female whose physical exam was consistent with an underlying obturator hernia.

Imaging of inguinal-related groin pain in athletes

Inguinal canal-related groin pain is common in athletes and may involve numerous structures such as the conjoint tendon and the transversalis fascia. Ultrasound is the only dynamic tool that shows the passage of preperitoneal fat at the level of the Hesselbach triangle and allows excluding true inguinal hernias. Fascia transversalis bulging and inguinal ring dilatation may also be described. MRI assesses injuries of rectus abdominis and adductor longus enthesis and osteitis symphysis but its accuracy for the diagnosis of inguinal-related groin pain remains debated.

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.

Ultrasound evaluation of inguinoscrotal pain: an imaging-based review for the ultrasonographer

Emergencies involving the inguinal region and scrotum are common and can be caused by a plethora of different causes. In most cases, such conditions have nonspecific symptoms and are quite painful. Some inguinoscrotal conditions have high complication rates. Early and accurate diagnosis is therefore imperative. Ultrasound is the method of choice for the initial evaluation of this vast range of conditions, because it is a rapid, ionizing radiation-free, low-cost method. Despite the practicality and accuracy of the method, which make it ideal for use in emergency care, the examiner should be experienced and should be familiarized with the ultrasound findings of the most common inguinoscrotal diseases. On the basis of that knowledge, the examiner should also be able to make an accurate, direct, precise report, helping the emergency room physician make decisions regarding the proper (clinical or surgical) management of each case. Here, we review most of the inguinoscrotal conditions, focusing on the imaging findings and discussing the critical points for the appropriate characterization of each condition.

Case of Spigelian hernia with incarcerated appendix

Spigelian hernias are uncommon lateral ventral wall hernias with a significant rate of incarceration; these hernias often produce nonspecific clinical signs and symptoms as well as elusive imaging findings. Although there are reported cases of incarcerated appendices within Spigelian hernias, this case specifically illustrates the diagnostic difficulty these hernias present to both surgeons and radiologists. Additionally, we discuss important anatomy, demographics and risk factors, clinical symptoms, imaging pitfalls and recommendations for repair based on a review of literature.

The challenging sonographic inguinal canal evaluation in neonates and children: an update of differential diagnoses

Bulging of the inguinal region is a frequent complaint in the pediatric population and sonographic findings can be challenging for radiologists. In this review we update the sonographic findings of the most common disorders that affect the inguinal canal in neonates and children, with a focus on the processus vaginalis abnormalities such as congenital hydroceles, indirect inguinal hernias and cryptorchidism, illustrated with cases collected at a quaternary hospital during a 7-year period. We emphasize the importance of correctly classifying different types of congenital hydrocele and inguinal hernia to allow for early surgical intervention when necessary. We have systematically organized and illustrated all types of congenital hydrocele and inguinal hernias based on embryological, anatomical and pathophysiological findings to assist readers in the diagnosis of even complex cases of inguinal canal ultrasound evaluation in neonates and children. We also present rare diagnoses such as the abdominoscrotal hydrocele and the herniation of uterus and ovaries into the canal of Nuck.

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.

Sonographic evaluation of inguinal lesions

Abnormalities in the inguinal region are varied. The most common abnormality in the inguinal region is the hernia: direct or indirect inguinal hernia and femoral hernia. There are many hernia-mimicking lesions, such as spermatic cord hydrocele, undescended testis, hematoma, inflammation, abscess, benign or malignant tumors, metastatic or benign lymph node enlargement, round ligament varicosities or mesothelial cyst, and herniated ovary. Ultrasonography is currently the primary imaging modality used in assessing inguinal lesions and helpful for the differential diagnosis of a broad spectrum of these diseases. Familiarity with clinical setting and certain ultrasonography details will facilitate prompt and accurate diagnosis and treatment.

Sonographic evaluation of athletic pubalgia

Athletic pubalgia, or "sports hernia", represents a constellation of pathologic conditions occurring at and around the pubic symphysis. These injuries are primarily seen in athletes or those involved in athletic activity. In this article, we review the sonographic appearance of the relevant complex anatomy, scanning technique for ultrasound evaluation of athletic pubalgia, and the sonographic appearances of associated pathologic conditions.

Role of Sonography in Clinically Occult Femoral Hernias

OBJECTIVES

The purpose of this article is to evaluate the diagnostic accuracy of sonography in clinically occult femoral hernias and to describe our sonographic technique.

METHODS

The clinical and imaging data for 93 outpatients referred by general surgeons, all of whom underwent sonographic evaluation and surgery, were reviewed retrospectively. Of these, 55 patients who underwent surgical exploration for groin hernias within 3 months of sonography and met all inclusion criteria were included in the study. The sonographic technique involves using the pubic tubercle as an osseous landmark to identify and appropriately visualize the femoral canal. The Valsalva maneuver is then used to differentiate the movement of normal fat (a potential pitfall) from true herniation in the femoral canal. Surgical findings were used as the reference standard by which sonographic results were judged. Two-by-two contingency tables were used to calculate the sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

In these 55 patients, surgery revealed 15 femoral hernias. Eight femoral hernias occurred in women, and 7 occurred in men. For diagnosing femoral hernias, sonography demonstrated sensitivity of 80%, specificity of 88%, a positive predictive value of 71%, and a negative predictive value of 92%. True-positive cases of femoral hernias have a sonographic appearance of a hypoechoic sac with speckled internal echoes. When examining during the Valsalva maneuver, a femoral hernia passes deep to the inguinal ligament, expands the femoral canal, displacing the normal canal fat, and effaces the femoral vein.

CONCLUSIONS

Sonography can exclude femoral hernias with high confidence in light of its exceptional negative predictive value. With attention to technique and imaging criteria, the diagnostic accuracy of sonography can be enhanced.

Rare cause of bilateral groin swelling: Round ligament varicosities

Round ligament varicosity (RLV) is rare and almost all cases are pregnant women. RLV appears as a unilateral or bilateral groin swelling. Pain and tenderness may present. Clinical evaluation is inadequate for exact diagnosis because inguinal hernia has similar findings. Ultrasonography (US) is essential when a groin swelling is detected in a pregnant woman. We present gray scale US and colour Doppler US findings of a 32-week pregnant woman with bilateral RLVs at the inguinal canal, parauterine area and in the myometrium.

Sports hernias: experience in a sports medicine center

PURPOSE

Chronic pain of the inguino-crural region or "pubalgia" explains the 0.5-6.2% of the consultations by athletes. Recently, areas of weakness in the posterior wall called "sports hernias," have been identified in some of these patients, capable of producing long-standing pain. Several authors use different image methods (CT, MRI, ultrasound) to identify the lesion and various techniques of repair, by open or laparoscopic approaches, have been proposed but there is no evidence about the superiority of one over others due to the difficulty for randomizing these patients. In our experience, diagnosis was based on clinical and ultrasound findings followed by laparoscopic exploration to confirm and repair the injury. The present study aims to assess the performance of our diagnostic and therapeutic management in a series of athletes affected by "pubalgia".

METHODS

1450 athletes coming from the orthopedic office of a sport medicine center were evaluated. In 590 of them (414 amateur and 176 professionals) sports hernias were diagnosed through physical examination and ultrasound. We performed laparoscopic "TAPP" repair and, thirty days after, an assessment was performed to determine the evolution of pain and the degree of physical activity as a sign of the functional outcome. We used the U Mann-Whitney test for continuous scale variables and the chi-square test for dichotomous variables with p < 0.05 as a level of significance.

RESULTS

In 573 patients ultrasound examination detected some protrusion of the posterior wall with normal or minimally dilated inguinal rings, which in 498 of them coincided with areas affected by pain. These findings were confirmed by laparoscopic exploration that also diagnosed associated contralateral (30.1%) and ipsilateral defects, resulting in a total of 1006 hernias. We found 84 "sport hernias" in 769 patients with previous diagnosis of adductor muscle strain (10.92%); on the other hand, in 127 (21.52%) of our patients with "sport hernias" US detected concomitant injuries of the adductor longus tendon, 7 of which merited additional surgical maneuvers (partial tenotomy). Compared with the findings of laparoscopy, ultrasound had a sensitivity of 95.42% and a specificity of 100%; the positive and negative predictive values were 100 and 99.4% respectively. No postoperative complications were reported. Only seven patients suffered recurrence of pain (successful rate: 98.81%); the ultrasound ruled out hernia recurrence, but in three cases it diagnosed tendinitis of the rectus abdominis muscle.

CONCLUSIONS

Our series reflects the multidisciplinary approach performed in a sports medicine center in which patients are initially evaluated by orthopedic surgeons in order to discard the most common causes of "pubalgia". "Sports hernias" are often associated with adductor muscle strains and other injuries of the groin allowing speculate that these respond to a common mechanism of production. We believe that, considering the difficulty to design randomized trials, only a high coincidence among the diagnostic and therapeutic instances can ensure a rational health care.

Bilateral obturator hernia diagnosed by computed tomography: a case report with review of the literature

Obturator hernia is a rare form of abdominal hernia and a diagnostic challenge. It is commonly seen in elderly thin females. Its diagnosis is often delayed with resultant increased morbidity and mortality due to bowel ischemia/gangrene. It is mistakenly diagnosed as femoral or inguinal hernia on USG. Computed tomography is diagnostic and is a valuable tool for preoperative diagnosis. This report presents a case of 70-year-old thin female presenting with intestinal obstruction due to left sided obstructed obturator hernia. USG showed small bowel obstruction and an obstructed left sided femoral hernia. CT scan of abdomen and pelvis with inguinal and upper thigh region disclosed left sided obturator hernia. It also detected clinically occult right sided obturator hernia. Early diagnosis and surgical treatment contribute greatly in reducing the morbidity and mortality rate.

Sonography of sports injuries of the hip

CONTEXT

Sports-related injuries of the hip are a common complaint of both competitive and recreational athletes of all ages. The anatomic and biomechanical complexity of the hip region often cause diagnostic uncertainty for the clinicians evaluating these injuries. Therefore, obtaining additional diagnostic information is often crucial for providing injured athletes with a prompt and accurate diagnosis so they can return to activity as soon as possible. Musculoskeletal ultrasound is becoming increasingly important in evaluating and treating sports-related injuries of the hip.

EVIDENCE ACQUISITION

The PubMed database was searched in May of 2013 for English-language articles pertaining to sonography of sports injuries of the hip using the following keywords in various combinations: musculoskeletal, ultrasound, hip, hip sonography, and sports.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Musculoskeletal ultrasound is currently being used for both diagnosis and treatment in a wide range of acute and chronic conditions affecting the hip, including tendinosis, tendon/muscle strains, ligamentous sprains, enthesopathies, growth plate injuries, fractures, bursitis, effusions, synovitis, labral tears, and snapping hip. Therapeutically, it is used to guide injections, aspirations, and biopsies.

CONCLUSION

Musculoskeletal ultrasound use is expanding and will likely continue to do so as more clinicians realize its capabilities. Characteristics, including accessibility, portability, noninvasiveness, dynamic examination, power Doppler examination, and low cost highlight the potential of ultrasound.

Ultrasonographic diagnosis of round ligament varicosities mimicking inguinal hernia: report of two cases with literature review

Round ligament varicosities are rare, and the mass mimics an inguinal hernia. Round ligament varicosities should be considered in the differential diagnosis of a groin swelling in a female, especially during pregnancy. The diagnosis of round ligament varicosities can be established on grayscale and color Doppler ultrasonography. We report two cases of round ligament varicosities in a 33-year-old non pregnant woman and a 28-year-old pregnant woman, and these patients were diagnosed using ultrasonography. We also reviewed the literature on round ligament varicosities including the present cases. Ultrasonography is diagnostic and can prevent unnecessary surgical intervention and associated morbidity.

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.

Obturator hernia: A case report and review of the literature

INTRODUCTION

An obturator hernia is a rare condition but is associated with the highest mortality of all abdominal wall hernias. Early surgical intervention is often hindered by clinical and radiological diagnostic difficulty. The following case report highlights these diagnostic difficulties, and reviews the current literature on management of such cases.

PRESENTATION OF CASE

We present the case of an 86-year-old lady who presented with intermittent small bowel obstruction, clear hernial orifices, and right medial thigh pain. Pre-operative CT imaging was suggestive of an obstructed right femoral hernia. However, intra-operatively the femoral canal was clear and an obstructed hernia was found passing through the obturator foramen lying between the pectineus and obturator muscles in the obturator canal.

DISCUSSION

Obturator hernias are notorious for diagnostic difficulty. Patients often present with intermittent bowel obstruction symptoms due to a high proportion exhibiting Richter's herniation of the bowel. Hernial sacs can irritate the obturator nerve within the canal, manifesting as medial thigh pain, and often no hernial masses can be detected on clinical examination. Increasing speed of diagnosis through early CT imaging has been shown to reduce the morbidity and mortality associated with obturator hernias. However, over-reliance on CT findings should be cautioned, as imaging and operative findings may not always correlate.

CONCLUSION

A high suspicion for obturator hernia should be maintained when assessing a patient presenting with bowel obstruction particularly where intermittent symptoms or medial thigh pain are present. Rapid clinical and appropriate radiological assessment, followed by early surgery is critical to successful treatment.

Appendicitis in a Spigelian hernia: an unusual cause for a tender right iliac fossa mass

Spigelian hernias are a rare type of hernia through the Spigelian aponeurosis, whose contents commonly include omentum or small bowel. In the absence of incarceration or strangulation, they can be difficult to diagnose clinically. In the emergency setting, they can present rarely as a painful abdominal mass and computed tomography provides a reliable diagnostic imaging modality. We report an emergency presentation of a Spigelian hernia containing the appendix.

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.

Imaging findings of angiomyxolipoma of the spermatic cord mimicking inguinal hernia

We report the case in a 72-year-old man who presented with a right inguinal mass and with a one month history that was initially interpreted as an inguinal hernia. Ultrasonography (US) and computed tomography (CT) demonstrated a right inguinal mass, including myxoid and fat component, extending from the right spermatic cord to the right inguinal subcutaneous layer. Mass excision was performed, and the diagnosis turned out to be angiomyxolipoma. Angiomyxolipoma is a rare tumor and the preoperative diagnosis of this disease is very difficult. However, angiomyxolipoma of the spermatic cord should be considered in the differential diagnosis in patients with an irreducible inguinal mass. Imaging diagnosis, such as US and CT may help to make a preoperative diagnosis.

Critical procedures in pediatric emergency medicine

Children comprise approximately one-quarter of all visits to most emergency departments. Children are generally healthier than adults, yet there are similar priorities in assessment and management of pediatric patients. The initial approach to airway, breathing, and circulation still applies and is first and foremost in the evaluation of young infants and children. There are certain anatomic, physiologic, developmental, and social considerations that are unique to this population and must be taken into account during their evaluation and treatment. In this review, we present and discuss an evidence-based approach to high-yield procedures necessary for all emergency physicians taking care of children.