Role of Sonography in Clinically Occult Femoral Hernias

Incidence of groin hernia repairs in women and parity: a population-based cohort study among women born in Sweden between 1956 and 1983

INTRODUCTION

The aim of this study was to evaluate the association between parity and the incidence rate of groin hernia repair in women.

METHOD

This study was based on two Swedish national registers, the Medical Birth Register (MBR), and the Swedish Hernia Register (SHR). The cohort constituted of women born between 1956 and 1983. Data on vaginal and cesarean deliveries were retrieved from the MBR. The birth and hernia registers were cross matched to identify hernia repairs carried out after deliveries.

RESULTS

A total of 1,535,379 women were born between 1956 and 1983. Among these, 1,417,237 (92.3%) were registered for at least one birth. The incidence rate for Inguinal Hernia Repair (IHR) and Femoral Hernia Repair (FHR) was 10.7 per 100,000 person-year and 2.6 per 100,000 person-year, respectively. Compared with women registered for one delivery, the incidence rate ratio for IHR was 1.31 (95% Confidence Interval: 1.23-1.40) among women registered for two deliveries, 1.70 (1.58-1.82) among women registered for ≥ 3 deliveries. Additionally, the incidence rate ratios were higher 1.30 (1.14-1.49) and 1.70 (1.49-1.95) for FHR among women with two and  ≥ 3 registered deliveries, respectively.

CONCLUSION

In the present cohort, higher parity was associated with a higher incidence of inguinal as well as FHRs.

Comparison of patient characteristics and treatment approaches for femoral and inguinal hernias utilizing dynamic ultrasound at a single institution

PURPOSE

To assess the differences in management approach to femoral versus inguinal hernias and to identify patient characteristics associated with each hernia type.

METHODS

Imaging studies for patients who had undergone dynamic ultrasound evaluation for the symptom of groin pain between January 1, 2010, and March 31, 2019, at a single institution Musculoskeletal Department were analyzed. Positive femoral hernia imaging studies were compared to studies for inguinal hernias and matching medical records for imaging studies were analyzed. Association of patient characteristics (age, sex, smoking, diabetes) with hernia type was assessed. Primary outcomes were surgical versus non-surgical approach, type of surgery, number of follow-up visits, and pain resolution.

RESULTS

A total of 1319 patients presented with groin pain and were assessed with dynamic ultrasound (534 female; 785 male; mean [± SD] age 48.2 ± 16.5). While 409 (31.0%) patients had a femoral hernia detected, 666 (50.6%) had an inguinal hernia detected (p < .05). Significantly more inguinal hernias were surgically repaired than femoral hernias (65.0% vs 53.9% p = .008), and more inguinal hernias than femoral hernias were treated with open surgery (71.0% vs 57.7%; p = .014). Patients with femoral hernias had significantly more follow-up clinic visits than patients with inguinal hernias (mean [± SD] 2.65 ± 4.80 vs 1.76 ± 1.27; p = .010). No difference in the percentage of patients who had pain resolution was observed (82.2% inguinal vs 75.0% femoral; p = .13).

CONCLUSIONS

Femoral hernias were managed more conservatively than inguinal hernias at our institution.

ACR Appropriateness Criteria® Hernia

Abdominopelvic hernias are common clinical entities composed of a wide variety of congenital, traumatic, and iatrogenic etiologies. Any weakness in the body wall may result in hernia of cavity contents with concomitant risks of morbidity and mortality. Presentations may be specific, palpable body wall mass/bulge, or vague, nonspecific pain through bowel obstruction. This document focuses on initial imaging of the adult population with signs of symptoms prompting suspicion of abdominopelvic hernia. Imaging of the abdomen and pelvis to evaluate defects is essential for prompt diagnosis and treatment. Often CT and ultrasound are the first-line modalities to quickly evaluate the abdomen and pelvis, providing for accurate diagnoses and management of patients. MRI protocols may be useful as first-line imaging studies, especially in patients with orthopedic instrumentation. Although often performed, abdominal radiographs and fluorographic procedures may provide indirect evidence of hernias but are usually not indicated for initial diagnosis of hernia. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Sonographic "speech bubble/speech box sign" in clinically occult femoral hernias: ultrasound findings and anatomical basis

Femoral hernia is the protrusion of a peritoneal sac through the femoral ring into the femoral canal lying deep and inferior to the inguinal ligament. The hernia sac usually contains preperitoneal fat, omentum, bowel, or fluid. Ultrasound is recommended as the first-line investigation for diagnosing clinically occult femoral hernias in nonemergency settings, whereas CT is the imaging of choice in emergency settings. High accuracy of the ultrasound in clinically occult femoral hernia is further validated with further CT and MRI. In this article, we propose sonographic detection of the physiological peritoneal fluid herniating through capacious femoral ring manifesting as a "speech bubble/speech box appearance." This is a potentially invaluable sonographic sign for clinically occult femoral hernias, differentiating them from inguinal hernias and cysts of the canal of Nuck in females and preventing inadvertent attempts to aspirate.

Evaluation of dynamic ultrasound scanning in the diagnosis of equivocal ventral hernias with surgical comparison

OBJECTIVES

This study aims to compare ultrasonography for ventral hernias with surgical findings and establish its accuracy in equivocal cases. Comparison is also made against groin hernia ultrasound scanning, which has a positive predictive value ranging from 71-100%.

METHODS

A retrospective review of all patients who underwent an ultrasound scan between June 2011 and June 2015 was performed. The word "hernia" in the referral information was the sole inclusioncriterion. Patients who were found to have a clinically evident ventral hernia, unrelated hernia in aseparate location or had a known hernia were excluded. Thus, only patients with a clinically suspected ventral hernia and equivocal clinical assessment were included. These patients were followed up for at least 12 months and subsequent operation notes, if any, were also analysed.

RESULTS

348 scans were included (F = 198, M = 150, F:M ratio = 1.32:1). The mean age was 53.4 years (range = 16-97 years). 101 scans were positive for hernias (29.0%), 190 were negative (54.3%), and 57 had other findings (e.g. seroma, lipoma; 16.3%). 54 patients were taken to surgery (15.5%), including 5 who were found to be negative on ultrasound. Of these, 45 were truepositives, 4 true-negatives, 4 false-negatives, and 1 false-positive, giving a sensitivity of 91.8% and positive predictive value of 97.8%.

CONCLUSION

This study confirms that ultrasound scans are effective in the diagnosis of equivocal ventral hernias. Advances in knowledge: The accuracy of ultrasound scanning specifically for ventral hernias is quantified, and are comparable to that of groin hernias.