Preliminary Diagnosis: Direct Inguinal Hernia

I. What imaging technique is first-line for this diagnosis?

  • Ultrasound (Gray Scale and Doppler).

II. Describe the advantages and disadvantages of this technique for diagnosing direct inguinal hernia.

Advantages

  • The operator can use positioning and dynamic maneuvers (Valsalva) to diagnose a hernia, to document motion in real time, alter its size and contents, and evaluate its reducibility.

  • Allows assessment of tenderness and findings concerning for obstruction or strangulation.

  • Can differentiate between direct and indirect inguinal, spigelian and femoral hernias.

  • Relatively inexpensive and portable imaging modality.

  • Does not require use of ionizing radiation.

Disadvantages

  • Ultrasound imaging is limited with assessment of the intraperitoneal bowel.

  • There may be limited evaluation in obese patients.

  • Ultrasound imaging is highly operator dependent.

III. What are the contraindications for the first-line imaging technique?

No significant contraindications exist.

IV. What alternative imaging techniques are available?

  • CT (with IV and oral contrast).

  • Abdominal radiographs (plain film).

V. Describe the advantages and disadvantages of the alternative techniques for diagnosing direct inguinal hernia.

CT with IV and oral contrast
Advantages

  • Can evaluate for obstruction or strangulation as well as secondary pathology and complications.

  • Can differentiate between direct and indirect inguinal, spigelian and femoral hernias.

  • Relatively quick imaging procedures that require minimal patient cooperation and is less susceptible to motion artifact than MRI.

Disadvantages

  • Exposure to ionizing radiation.

  • Contrast may cause allergic reaction and damage to kidneys.

Abdominal radiographs
Advantages

  • Incarceration and strangulation may be suggested and secondary complications of obstruction are well visualized.

  • Quick, inexpensive test.

  • Far less radiation exposure than CT imaging.

Disadvantages

  • Not sensitive and unlikely to characterize the specific inguinal hernia.

VI. What are the contraindications for the alternative imaging techniques?

CT with IV and oral contrast

  • Contraindicated in pregnant patients, especially during the first two trimesters.

  • IV contrast is contraindicated in patients with renal function impairement (Cr less than 1.6).

  • History of allergic reaction to contrast is a contraindication if there is no adequate preparation.

Abdomen Radiographs

  • There is a relative contraindication during early pregnancy.

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