Diagnostic value of high-resolution ultrasound combined with multi-slice computer tomography (MSCT) for pediatric intra-abdominal hernias: a retrospective study

INTRODUCTION

To explore the diagnostic value of high-resolution ultrasound combined with multi-slice computer tomography (MSCT) for pediatric intra-abdominal hernias (IAHs), and to analyze the potential causes for missed diagnosis and misdiagnosis of IAHs in children.

METHODS

A retrospective analysis was conducted on 45 children with surgically confirmed IAHs. The diagnostic rate of IAHs by preoperative high-resolution ultrasound combined with MSCT was compared with that of intraoperative examination, and the potential causes for missed diagnosis and misdiagnosis by the combination method were analyzed.

RESULTS

Forty-five cases of pediatric IAHs were categorized into primary (25/45, 55.5%) and acquired secondary hernias (20/45, 44.5%). Among children with primary hernias, mesenteric defects were identified as the predominant subtype (40%). Acquired secondary hernias typically resulted from abnormal openings in the abdominal wall or band adhesions due to trauma, surgery, or inflammation. In particular, adhesive band hernias were the major type in children with acquired secondary hernias (40%). The diagnostic rate of high-resolution ultrasound was 77.8%, with "cross sign" as a characteristic ultrasonic feature. Among 10 cases of missed diagnosis or misdiagnosis, 5 were finally diagnosed as IAHs by multi-slice computer tomography (MSCT). Overall, the diagnostic rate of pediatric IAHs by preoperative ultrasound combined with radiological imaging reached 88.9%.

DISCUSSION

IAHs in children, particularly mesenteric defects, are prone to strangulated intestinal obstruction and necrosis. High-resolution ultrasound combined with MSCT greatly enhances the diagnostic accuracy of pediatric IAHs.

Computed tomography for evaluation of abdominal wall hernias-what is the value of the Valsalva maneuver?

PURPOSE

To investigate the differences in the visibility and size of abdominal wall hernias in computed tomography (CT) with and without Valsalva maneuver.

METHODS

This single-center retrospective study included consecutive patients who underwent abdominal CTs with Valsalva maneuver between January 2018 and January 2022. Inclusion criteria was availability of an additional non-Valsalva CT within 6 months. A combined reference standard including clinical and surgical findings was used. Two independent, blinded radiologists measured the hernia sac size and rated hernia visibility on CTs with and without Valsalva. Differences were tested with a Wilcoxon signed rank test and McNemar's test.

RESULTS

The final population included 95 patients (16 women; mean age 46 ± 11.6 years) with 205 hernias. Median hernia sac size on Valsalva CT was 31 mm compared with 24 mm on non-Valsalva CT (p < 0.001). In 73 and 82% of cases, the hernias were better visible on CT with Valsalva as compared to that without. 14 and 17% of hernias were only visible on the Valsalva CT. Hernia visibility on non-Valsalva CT varied according to subtype, with only 0 and 3% of umbilical hernias not being visible compared with 43% of femoral hernias.

CONCLUSIONS

Abdominal wall hernias are larger and better visible on Valsalva CT compared with non-Valsalva CT in a significant proportion of patients and some hernias are only visible on the Valsalva CT. Therefore, this method should be preferred for the evaluation of abdominal wall hernias.

Botulinum toxin A in complex incisional hernia repair: a systematic review

PURPOSE

To evaluate the safety, efficacy, and short and long-term postoperative results of using BTA.

METHODS

We conducted a systematic review following the recommendations of the PRISMA method. We systematically reviewed the MEDLINE/PubMed and SCOPUS electronic databases for studies published between January 2010 and September 2021. This systematic review was registered in PROSPERO, with registration number CRD42021252445.

RESULTS

After applying the selection criteria, 11 relevant articles were selected. The total sample size was 1058 patients. Most studies aimed to assess the rate of fascial closure, followed by the rate of recurrence and reporting of postoperative complications, as well as the need for the components separation technique (CST). None of the studies reported serious complications from using BTA. Regarding fascial closure, all articles had rates above 75%, except for one. Surgical site events ranged between 19% and 29.4%. No recurrence in the group that used BTA was recorded in five studies. The other articles reported recurrence rates ranging from 6.4 to 11.4% in the groups that received BTA. The studies had varying follow-up times ranging from 1 to 49 months, with a mean of 18.6 months (± 11.2).

CONCLUSION

This review described most of the key points about the preoperative use of BTA in hernia repair. It can be concluded that the use of BTA is a safe and effective practice that promotes good short and long-term results. However, the limitations of the current literature prevent more accurate conclusions on the subject.

Uncovering a Rare Case of Hepatic Round Ligament Epigastric Hernia

Abdominal wall hernias are one of the most common surgical diseases present in both males and females nowadays. However, with only a few cases reported in the literature, hepatic round ligament hernias are a rare clinical manifestation. This case shows how a common symptom such as epigastric pain can be associated with this rare condition. In general, abdominal computed tomography (CT) images are the choice of study to evaluate complications and the involvement of different intestinal sections. Some laboratory tests can be performed to suspect intestinal ischemia secondary to strangulated hernias. Primary repair utilizing mesh is the preferred surgical treatment. This procedure can be performed through laparoscopic or open technique, depending on the surgeon's skills and patient preference.

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.

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.

Extraprostatic incidental findings on prostate mpMRI: A pictorial review from the ESUR junior network

The role of multiparametric MRI (mpMRI) in prostate cancer setting is increasingly consolidated and, as a result, its usage in clinical practice is in exponential growth. However, beyond the prostate gland, several key structures are included in the field of view of mpMRI scans. Consequently, various extra-prostatic incidental findings (IFs) belonging to different anatomical systems can be accidentally recognized. Therefore, it is mandatory for a radiologist to be familiar with the wide range of pathologies potentially encountered, to guide management and avoid patient anxiety and costs due to additional work-up prompted by clinically insignificant extra-prostatic findings. With this pictorial review, we aim to illustrate a wide range of IFs that can be detected when performing mpMRI of the prostate, focusing on their imaging characteristics, differential diagnosis, and clinical relevance. Additionally, we propose the CheckDEEP, the Checklist for DEtection of ExtraProstatic findings, to be used for a thorough evaluation of target areas within each anatomical system.

Caesarean-section scar endometriosis (CSSE): clinical and imaging fundamentals of an underestimated entity

Caesarean-section scar endometriosis (CSSE) is a form of extra-pelvic endometriosis developing through endometrial cell implantation anywhere along the route of a previous caesarean section (CS) surgery, including the skin, subcutaneous tissue, abdominal wall muscles, intraperitoneally, and the uterine scar itself. Synchronous intra-abdominal endometriosis is not a prerequisite. Given the rising prevalence of CS, CSSE may be underrepresented in the literature and occur more frequently than previously thought. Locating a painful soft-tissue mass-like lesion along the path of a previous CS scar is the most indicative sign that should initially alarm physicians towards suggesting CSSE, especially if symptoms are typical (cyclically reoccurring with menstruation). The detection of hyperintense (haemorrhagic) foci on T1 fat-saturated sequences will strongly support the diagnosis on magnetic resonance imaging (MRI), the most sensitive imaging method for CSSE assessment. A non-specific, contrast-enhancing, hypodense nodule with spiculate edges may be suggestive if the lesion was originally detected on computed tomography (CT). Although ultrasound is frequently the first imaging method used, the findings are non-specific; therefore, making it more useful for ruling out other differentials and for image-guided biopsy. In any case, histopathology provides the definitive diagnosis. Surgical excision is the mainstay of treatment; however, minimally invasive, percutaneous techniques have also been implemented successfully.

Ventral Hernia in the Al-Ahsa Region, Saudi Arabia: Risk Factor Knowledge Assessment

Introduction A ventral hernia is defined as a non-inguinal, non-hiatal defect in the fascia of the abdominal wall. Approximately 350,000 ventral hernia procedures are performed each year. Ventral hernia can have a negative impact on a person's quality of life and, in severe situations, lead to hospitalization and even death. Aim This study aimed to assess the knowledge of the general population living in the Al-Ahsa region regarding the risk factors of ventral hernia. Subjects and methods This is a cross-sectional study conducted among the general population living in the Al-Ahsa region of Saudi Arabia. A self-administered questionnaire was distributed among the population using an online platform. The questionnaire includes basic demographic characteristics (age, gender, and body mass index (BMI)) and a nine-item questionnaire to assess the knowledge of risk factors of ventral hernia. Results Of the 803 respondents involved, 42.1% were aged between 22 and 28 years old, and 44.4% were either overweight or obese. According to participants' knowledge, the most common risk factor of ventral hernia was heavy weight lifting (87.4%), and pregnancy and labor (64.1%). The overall mean knowledge score was 5.78 (standard deviation (SD): 2.68) out of 12 points. Nearly half (49.4%) were considered to have poor knowledge levels, 40.2% were considered to have moderate knowledge levels, and only 10.6% were considered to have good knowledge levels. Increased knowledge was seen more frequently in younger participants, males, and respondents with normal or underweight BMI. Conclusion The knowledge of the general population regarding the risk factors of ventral hernia was insufficient. Of all the population, male respondents who were younger and had a normal body mass index demonstrated a better understanding of the ventral hernia's risk factors compared to the rest of the subjects. Further research is needed to establish the knowledge of the general population regarding the risk factors of ventral hernia in our region.

The influence of preoperative CT imaging on surgical delay in patients with acutely symptomatic abdominal wall hernias

PURPOSE

Abdominal wall hernias are common in the UK and many present in an emergent fashion. The widespread introduction of computed tomography (CT) imaging has transformed surgical practice but out of hours access can be limited by hospital resources and introduce delays. We investigated the influence of preoperative CT imaging in acutely symptomatic hernia and the association with surgical delay and risks of bowel ischemia.

METHODS

A retrospective analysis of patients undergoing emergency hernia surgery between 2013 and 2021 in a busy UK district general hospital. We evaluated the role of preoperative CT and its influence on timing of surgery, postoperative complications, critical care admission and hospital length of stay.

RESULTS

Five hundred and five patients were studied. Of these, 191 had a preoperative CT scan. Sites of hernia included inguinal in 164 patients (33%); umbilical in 164 (33%); femoral in 69 (14%); incisional in 69 (14%); epigastric in 30 (6%) and Spigelian hernia 9 (2%). Preoperative CT imaging was associated with surgical delay (22.0 h vs 13.0 h, p < 0.001) and an increased need for bowel resection (12% vs 6%, p = 0.027). Delay in surgery was not associated with increased postoperative complications (5% vs 4%, p = 0.474) but was associated with increased critical care admission (11.0% vs 4.8%, p = 0.014).

CONCLUSIONS

Preoperative CT scan for emergent hernias can delay often inevitable surgery and is associated with an increasing need for more complex, resectional surgery .

Abdominal wall hernia is a frequent complication of polycystic liver disease and associated with hepatomegaly

BACKGROUND AND AIM

Polycystic liver disease (PLD) is related to hepatomegaly which causes an increased mechanical pressure on the abdominal wall. This may lead to abdominal wall herniation (AWH). We set out to establish the prevalence of AWH in PLD and explore risk factors.

METHODS

In this cross-sectional cohort study, we assessed the presence of AWHs from PLD patients with at least 1 abdominal computed tomography or magnetic resonance imaging scan. AWH presence on imaging was independently evaluated by two researchers. Data on potential risk factors were extracted from clinical files.

RESULTS

We included 484 patients of which 40.1% (n = 194) had an AWH. We found a clear predominance of umbilical hernias (25.8%, n = 125) while multiple hernias were present in 6.2% (n = 30). Using multivariate analysis, male sex (odds ratio [OR] 2.727 p < .001), abdominal surgery (OR 2.575, p < .001) and disease severity according to the Gigot classification (Type 3 OR 2.853, p < .001) were identified as risk factors. Height-adjusted total liver volume was an independent PLD-specific risk factor in the subgroup of patients with known total liver volume (OR 1.363, p = .001). Patients with multiple hernias were older (62.1 vs. 55.1, p = .001) and more frequently male (22.0% vs. 50.0%, p = .001).

CONCLUSION

AWHs occur frequently in PLD with a predominance of umbilical hernias. Hepatomegaly is a clear disease-specific risk factor.

Pre- and postsurgical imaging findings of abdominal wall hernias based on the European Hernia Society (EHS) classification

Abdominal wall hernias are common and can present as technical challenges to surgeons. When large, hernias diminish quality of life. Various classifications of incisional hernias have been proposed; however, there are many terms, sometimes causing confusion (1). Radiologists must know the normal anatomy of the abdominal wall, the CT protocol, and what if any maneuvers can be performed to better identify an abdominal wall defect. The description of the radiological approach for primary and incisional wall hernias is based on the 2007 European Hernia Society classification, with particular emphasis on presurgical and postsurgical imaging findings. This classification provides a simple and reproducible method to describe hernias to offer proper surgical management. We highlight this classification so that radiologists and surgeons can have a unified language.

Prevalence and risk factors of abdominal hernia among Saudi population

Objective:

Studies assessing prevalence and risk factors of abdominal hernia are scarce in Saudi Arabia, that is why this study aimed to find out the prevalence and risk factors of abdominal hernia among the Saudi Population in 2020.

Methods:

A cross-sectional study was done on 500 participants. A pre-designed questionnaire included three sections: Section A consisted of sociodemographic, Section B had items for three dimensions: pain at the site of the hernia or the hernia repair, restriction of activities, cosmetic discomfort; Section C included medical history and other associated risk factors of hernia.

Results:

The prevalence of abdominal hernia in our study was found to be 38.8%. The participants in 18-25 years had less prevalence (21.2%). participants with BMI >25 (Overweight and Obese) had higher prevalence than others. The mean EuraHS-QoL score in participants who had abdominal hernia was significantly higher than patients who didn't have AH. Age >40 years, male gender, BMI >25, congenital anomalies, history of abdominal surgery, history of abdominal trauma, family history, grand multipara, chronic cough, chronic bronchitis, and smoking were potential predictive factors of AH.

Conclusion:

Abdominal hernia is a common problem in Saudi Arabia. Abdominal hernias are more common in men than women, there is an obvious relationship between obesity, history of abdominal surgery, history of abdominal trauma, family history and hernias. Early diagnosis, easily accessible health facilities and health education are important to prevent complications and improve quality of life.

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.

Risk factors for parastomal hernia of loop stoma and relationships with other stoma complications in laparoscopic surgery era

Background

Laparoscopic approach is now a widespread technique used worldwide, but there are few recent studies on risk factors for parastomal hernia. Therefore, this study was performed to analyze the incidence of parastomal hernia in laparoscopic and open surgery in which a loop stoma was created and was intended to be temporary, and to determine risk factors for parastomal hernia formation. Associations between parastomal hernia and other stoma-related complications were also analyzed.

Methods

A retrospective analysis of patient and surgical characteristics was performed in 153 consecutive patients who underwent a temporary diverting loop ileostomy or colostomy after surgery related to malignant diseases at our hospital from January to December 2016.

Results

Parastomal hernia developed in 77 cases (50.3%), including 39 (25.5%) diagnosed by physical examination and 38 (24.8%) detected by CT alone. On multivariate analysis, a stoma not passing through the middle of the rectus abdominis muscle was the only independent risk factor for parastomal hernia formation (p = 0.005) during the median follow-up of 245.0 days. When we analyzed the factors that were associated with a stoma not passing through the middle of the rectus abdominis muscle, the only independent factor associated with this misplacement of the stoma was a laparoscopic approach (p = 0.012). An analysis of stoma-related complications showed that peristomal skin disorders were significantly associated with parastomal hernia (p = 0.049).

Conclusions

This study showed that a stoma that is not formed through the middle of the rectus abdominis muscle is a risk factor for parastomal hernia formation, and that a laparoscopic approach is associated with this risk factor. Moreover, parastomal hernia is significantly associated with peristomal skin disorders.

Amyand's Hernia: Perforated Appendix in an Incarcerated Inguinal Hernia

Amyand’s hernia is an unusual condition characterized by the presence of a normal or inflamed appendix located within an inguinal hernia. We present a rare situation wherein a 56-year-old male patient presented with an incarcerated inflamed appendix in a right inguinal hernia. He was emergently taken to the operating room, with diagnostic laparoscopy changed to open, due to incarcerated cecum and terminal ileum. The incarcerated segment had to be resected with primary anastomosis. The inflamed and purulent contents were washed out, and the hernia defect was left unrepaired due to the presence of abscess in the inguinal canal. 

Multidetector Computed Tomography Findings of Adhesive Internal Hernias

OBJECTIVE

To identify multidetector computed tomography (MDCT) findings of surgically confirmed adhesive internal hernias (IHs).

METHODS

Two gastrointestinal radiologists performed blinded, independent, and retrospective reviews of MDCT findings from a consecutive cohort of 35 adhesive IH and 41 adhesive small-bowel obstruction cases that had undergone surgery within 48 hours after MDCT. Univariate statistical analyses were performed to assess CT signs of adhesive IHs and CT findings of intestinal necrosis in patients presenting with adhesive IHs.

RESULTS

Dislocated cluster of the intestine (P = 0.005), 2 transitional zones (P = 0.002), and presence of fat in the center sign (P = 0.001) were key CT outcomes that were significantly associated with adhesive IHs. Additionally, intramural hemorrhage was found the MDCT feature indicative of intestinal necrosis (P = 0.028).

CONCLUSIONS

This study illustrates specific MDCT findings of IHs, and these observations may help guide early clinical management of the condition.

Long-Term Consequences of Nonclosure of Mesenteric Defects after Traditional Right Colectomy

Background

There are still discrepancies among general/colorectal surgeons regarding closure of mesenteric defect in scientific literature. This study aimed to assess the long-term consequences of nonclosure of the mesenteric defect after open right colectomy.

Methods

A 7-year retrospectively collected and continuous database revealed 212 consecutive patients who had undergone traditional right colectomy without closing the mesenteric defects at Kaohsiung Chung-Gung Memorial Hospital; all patients were operated by a single surgeon. Among these patients, 17 were excluded (those who died within 30 days after surgery or those who received an end ileostomy). The mean age of the 195 patients (58% men and 42% women) was 61.6 ± 12.6 years, and the follow-up period was 4.1 ± 2.8 years (interquartile range 0.09 ~ 10.4).

Results

Forty-four patients (22.5%) encountered intestinal obstruction. Nine (20.4%) required surgical intervention. The cause of intestinal obstruction was adhesion (n=1), ventral hernia (n=1), and cancer recurrence (n=7). Conservative treatment was successful in 35 patients. The intestinal obstruction group (n = 44) were similar to the no-intestinal obstruction group (n = 151) in terms of the following parameters: age, sex, previous abdominal surgery, indication for colectomy, and procedure related complications. Carcinomatosis was found to increase the incidence of intestinal obstruction. No patient developed intestinal obstruction because of the nonclosure of mesenteric defects after right colectomy.

Conclusion

This study suggested that routine procedure of closing the mesenteric defect after open right colectomy might not be beneficial. Additional studies with extended long-term follow-up periods are needed to confirm the benefits of the nonclosure.

A Coupled Magnetoelastic Strain Sensor Array for Guiding and Monitoring Hernia Repairs

OBJECTIVE

Ventral hernia repairs using mesh prosthetics suffer from high recurrence rates, with 10%-20% of repairs failing within three years. Uneven distribution of stress within the implanted mesh prosthetic is thought to contribute to the high recurrence rate. We propose a method for providing quantitative guidance and monitoring of hernia repairs using an array of magnetoelastic strain sensors.

METHODS

The magnetoelastic strain sensors presented here are based on a coupled design to achieve measurements with higher signal-to-noise ratio (SNR). A first magnetoelastic element (the transducer) is bonded to the mesh prosthetic and is characterized by a strain-dependent magnetic field. The resonance frequency of a second magnetoelastic element (the resonator) encased in a rigid casing is biased by the transducer element's magneticity and can be measured noninvasively using an external interrogation coil. The coupled magnetoelastic strain sensors are assembled using a combination of photochemical machining, patterning, and heat sealing.

RESULTS

The dynamic range of the coupled sensors can be tuned by altering the transducer geometry. Additional spring elements are integrated onto the transducer element to achieve high dynamic range measurements saturating at 74 millistrains.

CONCLUSION

A coupled magnetoelastic strain sensor combines a transducer with an encased resonator element to measure strain with high SNR on an implantable flexible hernia mesh substrate.

SIGNIFICANCE

This study provides surgeons and researchers with a clinically relevant tool to quantify the strain distributions within implanted mesh prosthetics, with the ultimate goal of reducing the recurrence rate of ventral hernia repairs.

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.

Cesarean-Section Scar Endometrioma: A Case Report and Review of the Literature

Endometriomas can occur after any surgery where there is endometrial manipulation, and there are a number of reports of endometriomas developing in the abdominal wall at the site of the Pfannenstiel incision following Cesarean-section. Although this is ultimately a histopathologically-confirmed diagnosis, preoperative imaging including ultrasound, computed tomography, and magnetic resonance imaging may be helpful in the diagnosis and assessment. We report a pathology-confirmed case of Cesarean-section endometrioma with a classic, clinical presentation and imaging findings on computed tomography. A comprehensive literature review and discussion of the multi-modality imaging appearance of Cesarean-section endometrioma is also provided.

Adhesive internal hernia: multidetector CT findings and clinical relevance

AIM

To review the clinical and multidetector computed tomography (MDCT) features of adhesive internal hernias (IHs) and to ascertain specific MDCT criteria to assist in the diagnosis of adhesive IHs and the early detection of intestinal strangulation.

MATERIALS AND METHODS

Medical records and preoperative abdominal MDCT findings of 34 patients with surgically confirmed abdominal adhesive IHs were analysed retrospectively.

RESULTS

The specific MDCT features of adhesive IHs included the following: dislocating and clustering of intestinal segments (100%); stretching and crowding of the mesenteric vessels (100%); presence of hernial orifice (88.2%), peritoneal adhesive bands (76.5%); and the fat notch sign (85.3%). In addition, the significant MDCT features indicative of intestinal strangulation compared with those without intestinal strangulation were bowel wall thickening (p=0.009), intramural haemorrhage (p=0.007), and abnormal bowel wall enhancement (p=0.023). Furthermore, bowel obstruction occurred in 17 (50%) patients, and mesenteric whirl was apparent in 8 (23.5%) patients.

CONCLUSION

This article illustrates the specific MDCT criteria of adhesive IHs. Knowledge of MDCT findings in adhesive IHs and their complications is essential for making the correct diagnosis and may help guide early clinical management.

Computed tomography of bowel obstruction: tricks of the trade

Bowel obstruction (BO) is a frequent cause of hospitalization and surgical consultation for acute abdominal pain. It is usually suspected at physical examination, but clinical and laboratory data are often nonspecific. Thus, computed tomography plays a crucial role in a correct diagnosis of BO. Indeed, computed tomography can confirm a diagnosis of BO, and identify the location and cause of the obstruction. In this review, the computed tomography appearances of common and uncommon causes of BO and pseudo-obstruction are reviewed.

Bowel Obstruction

Small bowel obstruction and large bowel obstruction account for approximately 20% of cases of acute abdominal surgical conditions. The role of the radiologist is to answer several key questions: Is obstruction present? What is the level of the obstruction? What is the cause of the obstruction? What is the severity of the obstruction? Is the obstruction simple or closed loop? Is strangulation, ischemia, or perforation present? In this presentation, the radiologic approach to and imaging findings of patients with known or suspected bowel obstruction are presented.