The diagnosis and classification of inguinal and femoral hernia on multisection spiral CT.

AIM: To assess the contribution of high-quality multiplanar reconstructions of the groin from multisection computed tomography (CT) to the accurate diagnosis of inguinal and femoral hernias. MATERIALS AND METHODS: Twenty-eight patients who had undergone both a contrast-enhanced CT and a herniorrhaphy were identified from hospital records. Seventeen were excluded, as the images did not include the groin area. The remaining 11 images were re evaluated on a workstation without knowledge of the surgical findings and the hernias were identified and classified using the axial data and coronal and sagittal reconstructions. Anatomical structures and radiological details that hindered or aided this classification were recorded. RESULTS: Hernias were identified in nine out of the 11 patients. Of the seven inguinal hernias, six were identified with the correct side recorded in each case. Of the four patients with surgical data that distinguished direct from indirect inguinal hernias, the correct diagnosis was provided in all cases using CT. Of the four patients with a femoral hernia CT was used to correctly classify three. Among the three available planes, the axial was particularly poor for the identification of the inguinal ligament compared with the other planes. In contrast, the coronal views were very useful in the evaluation of femoral hernias. CONCLUSIONS: The high-resolution coronal and sagittal images available from multisection CT now permit the accurate diagnosis of groin hernias. Using simple anatomical criteria, direct and indirect inguinal hernias and femoral hernias can be reliably distinguished, abolishing the need for surrogate markers, which was hitherto necessary.

Rare inguinal hernia forms in children.

Rare inguinal hernia forms are encountered more frequently in the laparoscopic technique than in the open approach. The reasons are subject to speculation. The incidence of unusual inguinal hernia forms was studied in a series of inguinal hernias corrected laparoscopically in 452 children (334 boys and 118 girls aged 4 days--14 years, median age 1.6 years). The videos were retrospectively evaluated. Direct hernias were found in 10 children (2.2%), femoral hernias in five (1.1%), hernias en pantalon in three (0.7%), and a combination of indirect and femoral hernia and a combination of indirect, direct, and femoral hernia in one child each (0.2%). Routine videorecording during laparoscopy provides for the first time an objective and absolute picture of the true incidence of these unusual hernia forms.

Classification systems for groin hernias.

All groin hernia classifications are somewhat arbitrary and artificial. Currently, there is no consensus among either general surgeons or hernia specialists as to a preferred system. A survey by Zollinger in 1998 of hernia specialists in North American and Europe showed, that although the Nyhus, Gilbert, and Schumpelick-Arit systems were commonly used, the majority of these specialists still used the traditional classification for groin hernias. It is apparent that only the traditional classification of groin hernias has stood the test of time. As stated by Fitzgibbons, "the primary purpose of a classification system for any disease is to stratify for severity so that reasonable comparisons can be made between various treatment strategies." Given the multiplicity of operative techniques and approaches for the repair of groin hernias, it appears that no one classification system can satisfy all. With time, it is likely that we surgeons will settle upon a given operation for a specific type of inguinal hernia. For that given operation to be accepted as proven best, however, it is essential the competing operations be applied to simliar (classified) groups of groin hernia patients.

Mesh plug repair and groin hernia surgery.

Since the mid-1980s, dramatic progress has been made in the evolution of hernia surgery, highlighted by the increasing use of prosthetic mesh. Among the mesh-based "tension-free" hernioplasties, the use of mesh plugs has garnered a large number of spirited enthusiasts, and plug herniorrhaphy has become the fastest growing hernia repair currently employed by the American surgeon. To demonstrate the simplicity and effectiveness of mesh plugs, a 9-year experience with almost 3300 patients is reported. Technical details are discussed and presentation of a literature search serves to further emphasize the utilitarian nature of this elegantly unsophisticated surgical operation.

[A proposed classification of inguinocrural hernias. The classification of hernias in the inguinal and crural regions in the adult as a function of their surgical therapy]. / Proposta di classificazione delle ernie inguino-crurali. la classificazione delle ernie della regione inguinale e crurale nell'adulto in funzione della terapia chirurgica.

Surgery for the treatment of inguinal and femoral hernias has recent years acquired numerous increasingly modern, innovative techniques. This has been possible thanks modern, innovative techniques. This has been possible thanks to the introduction of prosthetic material which is better tolerated by the tissues and to the utilization of new ways of approach. A new method of hernia classification, no longer based on anatomical criteria but on a broader evaluation which takes multiple aspects into account, is now needed to decide on valid criteria for choice of operation, at the same time expressing themselves in a common language which will allow the results to the verified.

[Classification of inguinal hernias]. / Klassifikation von Inguinalhernien.

Classification of inguinal hernia is a necessary prerequisite for a reliable analysis of different methods of repair. The underlying categorization is done intraoperatively based on the localization ('M' medial, 'L' lateral, 'F' femoral) and transverse diameter (I = < 1.5 cm, II = 1.5-3.0 cm, III = > 3.0 cm) of the hernial orifice. In cases of combined hernias the diameters of both fascial defects is added up, the hernia is classified according to the part of major importance for the development of recurrences, the medial defect, with the index 'c'. The classification can be applied to open as well as laparoscopic approaches. The diameters of the tip of the index finger or the length of branch of endoscopic scissors (1.5 cm), respectively, serve as standards for measurement.

Hernioplastía inguinofemoral laparoscópica / Laparoscopic inguinofemoral hernioplasty

Se presenta un estudio de hernioplastía inguinofemoral laparoscópico. En 104 pacientes se realizó 124 hernioplastías. Se comunica la estandarización de la técnica, una clasificación anatómica de acuerdo al tamaño del defecto. En todos se utilizó un parche de malla de polipropileno adicionando trozos planos del mismo material en aquellos casos que tenían una dilatación importante del anillo inguinal profundo o una destrucción completa de la pared posterior. No hubo conversión en la serie. La morbilidad fue leve y transitoria. No ha habido morbilidad a largo plazo o escuelas. El 100 por ciento de la serie se ha seguido. Se comentan siete recurrencias precoces en el primer mes

A study of 101 patients treated with extraperitoneal endoscopic laparoscopic herniorrhaphy.

One hundred twenty-two hernias were repaired in 101 male patients through a total extraperitoneal approach. Patients ranged from 18 to 78 years old. All repairs were done with polypropylene mesh. Five patients (5%) required conversion to an open or transabdominal approach. Patients have been followed from 6 to 20 months, with a mean of 12 months. No recurrence has developed to date. Complications included urinary retention, groin hematoma, trocar site infection, and lateral femoral cutaneous nerve neuralgia. Six patients underwent simultaneous extraperitoneal endoscopic pelvic lymph node dissections, and two patients had varicoceles repaired simultaneously. Patients returned to usual activity within 1 week.

Iliopubic tract repair of inguinal and femoral hernia. The posterior (preperitoneal) approach.

There are two arms of inguinal hernia treatment herein presented--the approach and the repair. Whereas the posterior approach is not new, the repairs are unique, and details given are precise and must be followed carefully to obtain proven excellent long-term results. A classification of hernia types is outlined.

The femoral cone and its clinical implications.

The transversus abdominis aponeurosis and its investing sheath of transversalis fascia are the first line of defense against groin herniation. If transversus abdominis fibers insert on the superior pubic ramus as a narrow band, a cone shaped defect will result. With an increase in intra-abdominal pressure, preperitoneal fat, with or without a peritoneal sac, can enter this femoral cone. It is an asymptomatic internal hernia that will be detected only if the preperitoneal space is explored during inguinal herniorrhaphy. This is stage I in the development of a femoral hernia. Should the contents within the femoral cone protrude through its narrow distal orifice, a stage II external hernia results. Incarceration or strangulation may then occur. Herniation into and through the femoral cone was encountered in 159 instances while repairing 3,609 hernias of the groin in adults. Sixty-seven external (stage II) hernias were diagnosed preoperatively. Sixteen per cent were irreducible, 18 per cent were incarcerated and 3 per cent were strangulated. During inguinal herniorrhaphy, an unsuspected stage II femoral hernia was found in 12 instances, and a stage I precursor was present in 80. Flexibility in management is important. The choice of the low, inguinal or preperitoneal approach is determined by the mode of presentation of the hernia.