Langenbecks Arch Surg DOI 10.1007/s00423-017-1604-7

ORIGINAL ARTICLE

Groin hernia diagnostics: dynamic inguinal ultrasound (DIUS) Henning Niebuhr 1 & Anita König 2 & Maciej Pawlak 3 & Marco Sailer 4 & Ferdinand Köckerling 5 & Wolfgang Reinpold 6

Received: 4 January 2017 / Accepted: 10 July 2017 # Springer-Verlag GmbH Germany 2017

Abstract Purpose Although clinical examination is the gold standard for the diagnosis of groin hernia, imaging procedures can improve the detection of femoral hernias, incipient hernias, and less-common types of hernias (e.g., an obturator hernia). The aim of this study is to evaluate the sensitivity and specificity of dynamic inguinal ultrasound (DIUS). Materials and methods Between July 2010 and June 2015, 4951 clinical and ultrasound examinations of the groin area were conducted at the Hanse-Hernienzentrum in Hamburg, Germany. The ultrasonographic findings were prospectively evaluated to determine the number of inguinal and femoral hernia diagnoses that were ultrasonically confirmed and also to consider cases in which clinical examination overlooked these diagnoses. The results were compared with the intraoperative findings.

Results The results show that standardized ultrasound examination of the groin area with high-frequency, small-part linear transducers also serves to accurately display femoral and small or occult groin hernias. The high-level specificity (0.9980) and sensitivity (0.9758) are proof of the procedure’s quality. Conclusions To ensure high-quality hernia treatment, regular use of standardized ultrasound examinations is recommended. Keywords Inguinal hernia . Groin hernia . Diagnostic . Dynamic inguinal ultrasound . Clinical examination

Introduction Pain in the groin region is not always caused by herniation and may be triggered by a variety of different causes (Table 1).

Henning Niebuhr and Anita König have contributed equally to the publication * Henning Niebuhr [email protected]

1

Hanse-Hernienzentrum Hamburg, Alte Holstenstrasse 16, 21031 Hamburg, Germany

2

Abteilung für Anästhesiologie und Operative Intensivmedizin, Bethesda Krankenhaus Bergedorf, Glindersweg 80, 21029 Hamburg, Germany

Maciej Pawlak [email protected]

3

Department of Vascular Surgery, Institute of Hematology and Transfusion Medicine, Warsaw, Poland

Marco Sailer [email protected]

4

Klinik für Chirurgie, Bethesda Krankenhaus Bergedorf, Glindersweg 80, 21029 Hamburg, Germany

Ferdinand Köckerling [email protected]

5

Vivantes Klinikum Spandau, Klinik für Chirurgie—Visceral- und Gefäßchirurgie, Neue Bergstraße 6, 13585 Berlin, Germany

Wolfgang Reinpold [email protected]

6

Chirurgische Abteilung, Wilhelmsburger Krankenhaus Groß-Sand, Groß-Sand 3, 21107 Hamburg, Germany

Anita König [email protected]

Langenbecks Arch Surg Table 1

Differentiation of pain in the groin region

Orthopedics muscular / tendon

Orthopedics / Traumatology osseous / cartilaginous

gracilis

pubic symphysis

sartorius

stress fractures

adductor longus

hip joint: arthrosis / impingement

iliopsoas

avulsion fractures (juvenile)

rectus femoris

slipped capital femoral epiphysis

quadratus lumborum

Perthes disease

Hernia Surgery soft tissue

Neurology / Hernia Surgery postoperative nerve syndromes

inguinal hernia

ilioinguinal syndrome

femoral hernia

genitofemoral syndrome

obturator hernia

iliohypogastric syndrome

sportsman’s groin / hernia bursitis swelling of lymph nodes Neurology / Orthopedics referred pain

Neoplastic Alterations

neural impingement syndrome

hemangioma

sacroiliitis

fibromatosis

sacroiliac joint (SIJ) blockage

neurinoma

lumbar disc herniation (LDH)

osteoid osteoma

Urology/Gynecology referred pain

fibrosis / dysplasia

urinary tract epididymitis

infection

/

prostatitis/

testicular torsion

endometriosis / ovarian cyst ligament varicosities [10/12]

bone cysts

Angiology /Vascular Surgery varia /

round

vascular diseases

Langenbecks Arch Surg

The current practice of conducting only a clinical examination cannot fully encompass the complexity of the issues that need to be addressed. Employing diagnostic imaging can contribute to a better process of differentiation, as well as improve the detection of incipient hernias, occult hernias, and less common types of hernias, such as an obturator hernia. Dynamic examination, particularly real-time imaging of the abdominal wall and its movement during Valsalva maneuvers, plays a major role in the diagnostics of the groin region. Employing these procedures is the only way to depict the penetration and reduction of a hernia sac through the hernia orifice. In theory, all imaging methods (ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI)) may be used for this type of diagnosis. Nonetheless, US should primarily be preferred, as it is widely available, portable, relatively inexpensive, noninvasive, uncomplicated, and an easily learned technique [1]. The more complex and time-consuming MRI, although more sensitive in cases of occult hernias, is useful in only the fewest number of cases [2].

Materials and methods To determine the number of inguinal and femoral hernia diagnoses that were ultrasonographically confirmed and to consider the cases in which US examination led to detection of a hernia when the clinical examination overlooked this diagnosis, the ultrasound examinations of the groin area performed in the past 5 years were analyzed prospectively. The results were compared with the intraoperative findings. Between July 2010 and June 2015, 4951 ultrasound examinations of the groin area were carried out at the HanseHernienzentrum in Hamburg. All patients had undergone physical and US examination according to the standardized four-step technique described below in brief. All patients were examined and operated on by a single surgeon. Clinical examination, in both the upright and supine positions, consisted of palpation of the groin area, with and without employing the Valsalva maneuver, and examination of the scrotum and inguinal canal via the external inguinal ring. Ultrasound examination followed the clinical examination. It was carried out using a BK Medical Profocus Ultraview color duplex system with a multi-frequency linear small-part transducer, normally with 9 MHz (frequency response 7– 12 MHz) and was performed according to a standardized four-step technique: Step 1: Vertical/longitudinal transducer position (t.p.) depicting the pubic symphysis and the rectus muscle. Step 2: Diagonal t.p. (apical-lateral and caudal-medial) to display the spermatic cord (hyperechoic), the vessels of the

Table 2

Baseline characteristics of the group n=

%

Patients

4951

100

Male

4258

86

Female Average age

693 53 years (male) and 49 years (female)

14

DIUS between July 2010 and June 2015

spermatic cord (hypoechoic) and the surrounding tissues (strong echo line). At this point, the Valsalva maneuver will be executed for the first time to display any protrusion of the hernia sac parallel to the spermatic cord. Subsequently, the transducer will be rotated 90° to receive a cross-section picture. At this angle, the epigastric vessels are easily identified. They make it possible to distinguish lateral (indirect) and medial (direct) hernias during the course of the next Valsalva maneuver. Step 3: Vertical t.p. to reach the femoral and iliac vessels. While employing the Valsalva maneuver, this position will visualize any protrusion (femoral hernia) beneath the inguinal ligament within the vascular lacuna and in projection to the femoral vein. Step 4: Finally, examination of the groin area is completed by aligning the transducer laterally to visualize the psoas muscle (the muscular lacuna) and its tendinous attachment to the femoral bone with a view of the femoral head.

Statistical analysis All calculations were performed with the SAS System v.9.4 (licensed by SAS Institute, Cary, USA). Continuous variables were expressed as median and mean with standard deviation (SD). Categorical variables were expressed as percentages.

Results All consecutive patients with groin complaints who presented for regular hernia consultation at Hanse-Hernienzentrum in Hamburg were included in the study (Table 2 and Fig. 1). In 3659 (73.9%) cases, a hernia was diagnosed with both the clinical and US examinations. Those patients qualified for surgery. In 975 (19.7%) examinations of the groin area, no clinical or ultrasonographic evidence of herniation either above or below the inguinal ligament was found.

Langenbecks Arch Surg Inguinal complaints 4,951/ 100 %

CE + US pos. 3,659 / 73.9 %

CE + US neg. 975 / 19.7 %

CE neg. US pos. 25 / 0.5 %

Further differential diagnosis 975

LAP diagnosis 19 fem., 3 ing, 3 neg.

Further differential therapy 975

Operation 3,659

Operation 22

CE pos US neg. 292 / 5.9 %

LAP diagnosis 91 pos., 12 neg.

No operation 3

Operation 91

Watchful waiting 189

No operation 12

No further complaints to date 204

Total number of operations 3,772

Fig. 1 Patient flow

In 292 (5.9%) cases, the clinical examination resulted in the suspicion of a small hernia, which was later ruled out by US examination. In 25 (0.5%) cases, there was no clinical evidence of a hernia but patients complained of inguinal pain. An ultrasound examination was performed. In 19 patients, a femoral hernia was diagnosed, and in three patients, a small inguinal hernia was found; no hernia was detected in the three remaining patients. Within the time period studied, 3659 patients with hernias confirmed by both examinations were submitted to surgery, and also 91 (31.1%) of the 292 hernias diagnosed only clinically and 22 of 25 hernias diagnosed only sonographically (total number n = 3772). The findings consisted of both inguinal hernias (n = 3546 (94%)) and femoral hernias (n = 226 (6%)). The transabdominal preperitoneal (TAPP) procedure was employed in 3546 (94%) cases (3291 (92.8%) inguinal and 255 (7.2%) femoral hernias). In 226 (6%) hernias (223 (98.7%) inguinal and three (1.3%) femoral), open surgery was the method of choice, using a Lichtenstein procedure for the inguinal hernias and direct suture technique for the femoral hernias.

All diagnoses made by both examinations were intraoperatively confirmed. In all patients in whom hernia was revealed in both studies, also intraoperatively, those diagnoses have been confirmed. Of the 292 cases with only clinical suspicion of a hernia and without sonographical confirmation of a hernia in the Valsalva maneuver, were diagnosed further with CT or MRI to differentiate other causes of disease (according to Table 1). After further consultations, 189 were scheduled for watchful waiting and 103 underwent diagnostic laparoscopy because of severe complainments. Following this, 91 were confirmed intraoperatively to have a hernia, and mesh repair was undertaken. The 12 remaining patients with no confirmation of hernia did not undergo mesh implantation. These patients were also scheduled for further watchful waiting. After diagnostic laparoscopy, 22 of the 25 cases with ultrasonographic, but no clinical suspicion of hernia underwent mesh implantation. Nineteen patients were diagnosed intraoperatively with a femoral hernia, three with a small inguinal hernia. In the remaining three, there was no need for hernioplasty. Table 4

Table 3

US true positive, confirmed by surgery

CE and US pos., conf. by surgery

CE neg., US positive, conf. by surgery

3659 of 3659 = 100% Total, 3659 + 22 = 3681 of 3659 + 25 = 3684 (99.9%)

22 of 25 = 88%

Inguinal complaint

CE and US pos. CE and US neg. CE pos., US neg. CE neg., US pos. 3659/73.9%

975/19.7%

292/5.9%

25/0.5%

CE clinical examination and US ultrasound, 7/2010–6/2015, N = 4951

CE clinical examination, US ultrasonography

Langenbecks Arch Surg Table 5

US false positive, not confirmed by surgery

CE and US pos., not conf. by surgery CE neg., US pos., ot conf. by surgery 0 of 3659 = 0%

Table 7

US false negative

CE and US false neg., no hernia up to date

CE pos., US false neg., diagnostic laparoscopy in 103 cases, mesh repair in 91 cases, no mesh repair in 12 cases

0 of 975 = 0%

91 of 292 = 31.2%

3 of 25 = 12%

Total, 0 + 3 = 3 of 3659 + 25 = 3684 (0.1%)

Total, 91 of 975 + 292 = 1267 (7.2%)

CE clinical examination, US ultrasonography CE clinical examination, US ultrasonography

The 204 (189 + 12 + 3) cases that did not receive surgical treatment were subjected to further observation. To date, none of the cases needed surgical treatment (mean observation time, 27 months). All the sonographically diagnosed femoral hernias were confirmed intraoperatively. A specificity of 0.9980 and a sensitivity of 0.9758 were obtained for the hernia detection rate of the inguinal ultrasound examination (Tables 3, 4, 5, 6, 7 and 8).

Discussion Groin hernia is one of the most common surgical conditions worldwide, with inguinal hernia repair being the most frequently undertaken operation in routine surgical practice. The lifetime Brisk^ of inguinal hernia repair is high: 27% for men and 3% for women [3]. Of groin hernia repairs, 10% are performed in emergency settings. Therefore, appropriate diagnostics and timely treatment are important. The gold standard in hernia diagnostics is clinical examination (CE) of the groin area, with a sensitivity of 0.745 and a specificity of 0.963, based on the research of van den Berg [1]. To date, three consensus guidelines [4–6] have been published on the topic of treatment of groin hernias. All the published statements with regard to the diagnostic workup are weak and mainly focus on clinical examination (CE) alone. Only cases of obscure pain and/or doubtful swelling (known as Boccult hernias^) in the groin are described as requiring further diagnostic investigation [7–9]. No consensus on which diagnostic modality is the best solution for diagnosis has been reached. It is indisputable that CE alone can reveal the vast majority of groin hernias. However, it can miss a number of hernias, Table 6

US true negative, scheduled for watchful waiting

CE and US neg., scheduled for watchful waiting

CE pos., US neg., surgery in 91 cases, no surgery in 189 cases

975 of 975 = 100% Total, 12 + 189 + 975 = 1176 of 975 + 292 = 1267 (92.8%)

12 + 189 of 292 = 70.5%

CE clinical examination, US ultrasonography

especially small inguinal hernias in the early stages and femoral hernias in women [10]. To close this diagnostic gap, it is important to have additional tools, such as US, MRI, CT, and herniography. This study shows that CE alone, with the above-mentioned specificity and sensitivity of 0.745 and 0.963, respectively [1], cannot actually be the current gold standard of hernia diagnostics. Regardless, the authors did not intend to compare the modalities of CE and dynamic inguinal ultrasound (DIUS) as, for example, Bradley did in his research [11] but to show the superiority of the combination of both tools over the use of CE alone. This approach is similar to that of Kim et al. [12] and Light et al. [9]. This statement is confirmed by the fact that the highest hernia-detection rate was obtained in our study when the diagnostic combination of CE and ultrasound examination of the groin was employed. All diagnoses made by both diagnostic modalities (3659 cases, 73.9% of the cohort) led to surgery and were intra-operatively confirmed. More interesting is the diagnostic gap mentioned previously. In 25 (0.5%) cases, there was no clinical evidence of hernia but all patients complained of inguinal pain. Ultrasound examination was performed. In 19 patients, a femoral hernia was diagnosed, and in three patients, a small inguinal hernia was diagnosed; no hernia was found in three other patients. After diagnostic laparoscopy, 22 of the 25 cases with ultrasonographic but no clinical suspicion received surgical treatment. Nineteen patients were diagnosed intraoperatively with a femoral hernia, three with a small inguinal hernia and three with no hernia [13]. There were also limitations to the ultrasound diagnostics. In 292 (5.9%) cases with a suspicion of a small hernia in the clinical examination ultrasound with the Valsalva maneuver was negative. All of these 292 cases were further differentially diagnosed, as a result, 189 patients could be scheduled for Table 8

Specificity and sensitivity

Specificity 1176, (1176 + 3)

Sensitivity 3681, (3681 + 91)

0.9975

0.9758

Langenbecks Arch Surg

watchful waiting and 103 had to underwent diagnostic laparoscopy due to high suspicion of occult hernia and persistent ailments. Ultimately, 91 hernias were confirmed intraoperatively and mesh repair was undertaken. In the remaining 12 cases, there was no need for surgical repair, as the peritoneal cavity checkout did not reveal any hernia. Therefore those patients were also scheduled for consultations with other specialists: orthopedics or neurologists. Of further interest are those cases where neither clinical nor ultrasonographic examination revealed the suspicion of a hernia. In 975 (19.7%) examinations of the groin area, neither clinical nor ultrasonographic evidence of herniation either above or below the inguinal ligament was found. Ultrasound (DIUS) can be helpful to make several differential diagnoses [14, 15]. Our results cannot be considered as proof of whether diverse types of hernias (e.g., bump-, tube-, hourglass-shaped) can be displayed using a standard ultrasound examination, or whether Bwatchful waiting^ should be recommended as an alternative to planned, in-time surgery for specific types of hernias [16, 17]. This illustrates the limitation of this study. Van den Berg’s study [1] from 1999 resulted in an ultrasound examination specificity of 0.945 and a sensitivity of 0.815. Therefore, he preferred MRI examination with a specificity of 0.963 and a sensitivity of 0.945 over US examination. Robinson et al. have shown in their recent meta-analysis [18] that ultrasound of the groin region had a specificity of 0.86 and a sensitivity of 0.77. Our results show that, with a specificity of 0.9980 and a sensitivity of 0.9758 (known to be strongly dependent on the examiner), the recent technical developments in ultrasound equipment with high-frequency transducers may lead to considerable improvements in these results. The uniqueness of this study derives from the fact that DIUS was performed exclusively by one dedicated US examiner/surgeon. Therefore, we believe that the described results can be achieved by following and performing the abovementioned DIUS technique as often as possible, i.e., in every patient attending the special hernia consultation. The results show that standardized ultrasound examination of the groin area with high-frequency, small-part linear transducers also serves to accurately display small occult hernias, especially femoral hernias in women. The high-level specificity and sensitivity are proof of the procedure’s quality.

Conclusions To ensure high-quality diagnosis in hernia centers, regular use of standardized ultrasound examinations in combination with clinical pre- and postoperative examinations is recommended.

For the physicians, it should be recommended that in case of doubt, a patient with suspected hernia and an uncertain CE result should be referred to a specialized hernia center where the diagnosis should be confirmed, ideally using a combination of CE and DIUS examination. Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Ethical approval This article does not contain any studies with animals performed by any of the authors. Informed consent Informed consent was obtained from all individual participants included in the study.

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