28

Articles

Herniography in Symptomatic Patients FollowingInguinal Hernia Repair

J. ANDREW HAMLIN, MD, and ARTHUR M. KAHN, MD, Los Angeles, California

Patients with symptoms at the site of a previous inguinal hernia repair may constitute a diagnosticdilemma. The usefulness of herniography in the assessment of these patients was evaluated at 54symptomatic sites in 46 subjects. Ten persistent or recurrent hernias were shown by herniography,only 2 of which were definitely detected on physical examination. The herniogram was normal at 44sites, of which, on physical examination, 5 were equivocal and 1 was diagnosed as a definite hernia.On the unoperated-on or asymptomatic side, a total of 14 hernias were shown herniographically. Ofthese hernias, 8 were not detected on physical examination. Herniography was found to be moresensitive than physical examination in detecting hernias at the symptomatic, previously operated-on sites, as well as at the unoperated-on or asymptomatic sites. When a herniogram provides cor-roborative evidence that hernia has not recurred, the need for reexploration may be eliminated.(Hamlin JA, Kahn AM: Herniography in symptomatic patients following inguinal hernia repair. West J Med 1995; 162:28-31)

Patients who have undergone inguinal hernioplasty orherniorrhaphy may present with persistent or recur-

rent symptoms. Occasionally these symptoms are causedby recurrence of the hernia. Recurrent hernias may be dif-ficult to detect on physical examination.

Herniography provides a method whereby the peri-toneal fossae and possible herniations can be detected ra-diographically.`7 In patients in whom the findings of aphysical examination are inconclusive or when the symp-toms and physical findings are discordant, the informa-tion provided by the herniogram is helpful in clinicaldecision making (Figure 1).

We report our radiographic technique and the resultsof hemiography in patients who previously had herniasrepaired but who experienced persistent or recurrent in-guinal pain.

Patients and MethodsPatients are asked to empty their bladders just before

lying on the fluoroscopic table. If necessary, hair isshaved from a small area of the anterior abdominal wallmidway between the umbilicus and the pubic symphysis.This area is cleaned with an iodophor detergent anddraped with a fenestrated sheet. A solution of sodium bi-carbonate (1 ml) and 1% lidocaine (9 ml) is used for anes-thesia in the skin and subcutaneous tissue in the midline.A 20-gauge spinal needle is then inserted into the peri-toneal cavity through which 50 ml of nonionic contrastmaterial (320 mg per ml of organically bound iodine) isadministered.8Fluoroscopy is used to confirm the intra-

peritoneal deposition of contrast material and monitor theinjection. After the needle is removed, a small bandage isapplied.

The table is raised to an erect position. The patient isturned and then lowered in a prone position, with the headof the table elevated to 25 degrees, permitting the contrastmaterial to flow into the inguinal fossae. The table isagain elevated for spot filming of the inguinal fossae inthe erect position (frontal and both oblique projections).While the patient is facing the table, a sponge pad isplaced between the thighs and table so that when the tableis again lowered to the previous 25-degree position, theinguinal area is elevated from the table. In this position,two overhead posteroanterior films centered at the groinare taken: 90 degrees to the table top and 35 degreescephalic angulation. All films are taken with the patientstraining.

The radiographs are interpreted in accordance withpreviously described criteria.'-5

ResultsIn a 24-month period, we saw 88 patients for herniog-

raphy. Among these patients, 43 had a previous inguinalhernia repair and had persistent or recurrent pain orswelling at the surgical site. Of these 43 patients, 39 weremen. Their average age was 41 years (range, 21 to 75years). Three of these patients had a second herniogramfor evaluation of pain following another hernia operation.Because there was surgical intervention betweenherniograms, each of these three patients was considered

Dr Hamlin is in private practice in radiology, and Dr Kahn is in private practice in surgery in Los Angeles, California.Reprint requests to J. Andrew Hamlin, MD, Tower Imaging, 8631 W Third St, #120, Los Angeles, CA 90048.

Herniography After Hernia Repair-Hamlin and Kahn 29

Figure 1.-This 42-year-old man had bilateral inguinal pain.The results of a physical examination of the inguinal canals werenegative on the left and equivocal for hernia on the right.Herniography revealed no hernia on the right and an indirecthernia on the left, thereby indicating on which side a herniaoperation should be considered.

two subjects. Therefore, the total number of subjects seenfor evaluation was 46.

Bilateral hernia repairs had previously been done in15 subjects: 8 had bilateral symptoms, and 7 were symp-tomatic on only one side. In these 7, herniographic find-ings on the asymptomatic side were consideredincidental. Thus, in 46 subjects, 54 symptomatic sites ofprevious inguinal hernia repair sites were evaluated.

The physical examination and herniographic findingsof the 54 sites were concordant at 40 sites, with both ex-

aminations finding no hernia at 38 sites and both reveal-ing a recurrent or persistent hernia at 2 sites. At 7 sites theherniogram demonstrated a hernia that was not detected

Figure 2.-A 33-year-old man had pain at the site of a previousright inguinal herniorrhaphy. No hernia could be palpated onphysical examination. An irregular direct inguinal hernia sac wasdemonstrated on the right.

Figure 3.-A 39-year-old man who had previously undergonerepair of bilateral complex inguinal hernias presented with groinpain bilaterally. The physical examination showed no abnormal-ities on the right and was equivocal for a hernia on the left. Theherniogram showed a recurrent indirect inguinal hernia on theleft (angled view) and no recurrence on the right.

on physical examination (Figure 2) whereas at one sitethe results of the physical examination were positive for ahernia, but the herniogram was normal. The findings ofthe physical examination were equivocal at 6 sites; ofthese, the herniogram was normal in 5 and showed a her-nia at only 1 site (Figures 3 and 4).

There were 31 inguinal areas that had not been previ-ously operated on, plus 7 that had undergone a previousrepair, but the patients were asymptomatic. The physicalexamination and herniogram results were concordant at25 sites. At 10 sites where the physical examinationshowed no abnormalities, the herniogram revealed a her-nia at 8 and was equivocal at 2. The physical examinationfindings were equivocal at 3 sites where the herniogramwas negative (Figure 5).

Six of the subjects had hernia operations following theherniogram. The interval between the herniogram andsubsequent surgical repair ranged from 3 to 263 days.One of these subjects had previous bilateral hernias re-paired but was only symptomatic on one side. Two of thesubjects had physical examination findings suggestive ofa recurrent hernia on the symptomatic side, only one ofwhich was confirmed by herniography. In the other foursubjects, the physical examination showed no abnormali-ties on the symptomatic side, but the herniogram was in-terpreted as demonstrating a recurrent hernia in two.

On the unoperated-on or asymptomatic side in thesesix subjects, two hernias were diagnosed by physical ex-amination and confirmed by herniography. Herniographydetected one hernia that was not evident on physical ex-amination, and in two subjects both the physical exami-nation and herniogram were negative. In the sixth patientthe physical examination findings were equivocal, but nohernia was found by herniography.

WJM, January 1995-Vol 162, No. I

Herniography After Hernia Repair-Hamlin and Kahn

45 ~~~~~~~~4544 ---- -

40

z 25-

35 . .. 1..030 ...- ........ ...Negative.Equiv

0j25g.

Figure 4.-The findings of physical examinations (black bars) are compared with those ofherniograms (gray bars) at 54 symptomatic sites of previous inguinal hernia repair.

Positive

Among these six subjects, one had a bilateral repairenabling a correlation between the herniographic and sur-gical findings at seven sites. Four hernias diagnosed byherniography were confirmed at surgery and repaired. Intwo subjects the herniogram was normal, but the symp-toms were so compelling that the inguinal areas were ex-plored and no hernia was found. At the one site where theherniographic and surgical findings were discordant,there had been a previous inguinal exploration and exci-sion of a lipoma of the spermatic cord. The herniogramwas interpreted as demonstrating a hernia, but as nonewas found surgically, this was a "false-positive"herniogram.

A maculopapular rash developed in one patient ap-proximately 24 hours after the herniogram, which mayhave been related to the contrast material. No other com-plications occurred in this series. Possible complicationsinclude contrast material reaction, peritonitis, abscess, orhematoma of the abdominal wall or viscera. No contrastmaterial was injected into a viscus or blood vessel. Theincidental administration of 1 to 5 ml of contrast materialinto the anterior abdominal wall, omentum, or mesenteryis recognized by fluoroscopy and indicates the need toreposition the needle. These injections are asymptomatic,and their frequency was not recorded.

DiscussionHerniography is a well-established modality used to

examine the inguinal fossae.' The inguinal fossae are de-fined by the peritoneal ridges that occur on the lower an-terior abdominal wall. Anatomists and authors have notagreed on the nomenclature of these ridges and fossae,2'5'6and therefore, in identifying them, we indicate the struc-

tures that produce them. Between the medial umbilicalfold (urachus remnant) and the paired lateral umbilicalfolds (umbilical artery remnants) are the supravesical fos-sae. The medial inguinal fossae lie between the lateralumbilical folds and the epigastric folds (produced by theinferior epigastric vessels), lateral to which lie the lateralinguinal fossae. These folds and fossae can be variablyidentified by positive-contrast peritoneography.5 Thefolds have also been identified by negative contrast in pa-tients with pneumoperitoneum.9

A smoothly marginated extension of contrast materialbeyond the limits of the inguinal fossa represents a hernia.An indirect inguinal hernia protrudes from the lateral in-guinal fossa, lateral to the epigastric fold, and extendsalong the inguinal canal. A direct inguinal hernia pro-trudes from the medial inguinal fossa, medial to the epi-gastric fold, with an axis perpendicular to the inguinalligament.

Our technique for performing herniography variesfrom that of others in needle placement. The left lowerquadrant, at the lateral border of the rectus abdominismuscle, has been recommended as the location for enter-ing the peritoneal cavity.3-',6 Because the lateral border ofthe rectus abdominis muscle may be difficult to identify,and to avoid the unintentional pricking of the inferior epi-gastric artery or vein, we think the midline subumbilicalapproach is preferable.

In our subjects, a hernia was demonstrated at 18.5%of the symptomatic sites. This is less than the 35% to 42%previously reported.4" The herniogram was normal at 44of the symptomatic sites and revealed a persistent or re-current hernia at 10 sites. Of those 10 hernias, only 2 werediagnosed on physical examination. One patient diag-

30 WJM, January 1995-Vol 162, No. I

\legative Equivocal

Herniography After Hernia Repair-Hamlin and Kahn 31

Figure 5.-The findings of physical examinations (black bars) areherniograms (gray bars) on the unoperated-onoperated-on side (7 sites).

nosed with a persistent or recurrent hernia on physical ex-amination did not have a hernia on herniography. Theherniogram was, therefore, useful for identifying thosepatients whose symptoms could be associated with per-sistent or recurrent hernias who might benefit from reex-ploration. Conversely, by demonstrating the absence of ahernia, some of these patients were undoubtedly saved asecond operation.

On the unoperated-on or asymptomatic side, theherniogram confirmed the hernias detected on physicalexamination in six subjects. Eight additional hernias werediscovered by herniography that were not detected on

physical examination (Figure 5). Herniography would ap-

pear, therefore, to be more sensitive than physical exami-nation in detecting hernias.

Six subjects underwent seven inguinal explorationsfollowing herniography. The other patients with herniashad not yet decided on another hernia operation or hadsought medical care elsewhere and were unavailable forfollow-up. Of the seven explorations, four were at thesites of symptoms following previous herniorrhaphies.The herniographic and surgical findings were concordantin three of the four. At two sites, surgical procedure con-firmed the hernia demonstrated radiographically. At one

site, the herniogram was normal, but compelling symp-toms led to surgical intervention, and no hernia wasfound. The one site with discordant findings was thefalse-positive herniogram that occurred in a patient withanatomic distortion from a previous operation. Herniaswere demonstrated on the previously unoperated-on sidein three subjects and confirmed surgically in each. One of

compared with those ofside (31 sites) or the asymptomatic previously

these hernias was not detected on physical examination.The true incidence of falsely positive and falsely negativeherniograms will require a much larger number of pa-tients who come to surgery following herniography.

Herniography is valuable in the postoperative evalua-tion for persistent symptoms in patients who do not haveclinically detectable hernias on physical examination.4"0When the radiographic information provides corrobora-tive evidence that hernias have not recurred, the need forreexploration may be eliminated. The herniogram also al-lows the identification of patients in whom recurrent her-nias have developed that are not detected on physicalexamination.

REFERENCES1. van den Berg JC, Strijk SP: Groin hernia: Role of hemiography. Radiology

1992; 184:191-1942. Gullmo A, Broom6 A, Smedberg S: Herniography. Surg Clin North Am

1984; 64:229-2443. Ekberg 0, Fork FT, Fritzdorf J: Herniography in atypical inguinal hernia.

Br J Radiol 1984; 57:1077-10824. Ekberg 0, Blomquist P, Fritzdorf J: Hemiography in patients with clinically

suggested recurrence of inguinal hernia. Acta Radiol [Diagn] (Stockh) 1985;25:225-229

5. Ekberg 0: Inguinal hemiography in adults: Technique, normal anatomy,and diagnostic criteria for hemias. Radiology 1981; 138:31-36

6. Shackelford GD, McAlister WH: Inguinal hemiography. AJR Am JRoentgenol 1972; 1 15:339-407

7. White JJ, Parks LC, Haller JA Jr: The inguinal hemiogram: A radiologic aidfor accurate diagnosis of inguinal hemia in infants. Surgery 1968; 63:991-997

8. Ekberg 0, Nilsson PE: Hemiography: Comparison of morbidity and imagequality after use of high and low osmolality contrast media. Invest Radiol 1986;21:404-407

9. Bray JF: The 'inverted V' sign of pneumoperitoneum. Radiology 1984;151:4546

10. Smedberg SG, Broome AE, Elmer 0, Gullmo A: Herniography: A diag-nostic tool in groin symptoms following hernial surgery. Acta Chir Scand 1986;152:273-277

30 -- --- 29

22

.20

Eli 14

_ Pi N Eqivca

IU-~~~~~~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~OE"FMMI0 ~ ~ .,

Pos.itiv Negtiv Equivoca

WJM, January 1995-Vol 162, No. 1