Peritoneography (herniography) for detecting occult inguinal hernia in patients with inguinodynia

Abstract

Objective: To evaluate the usefulness of peritoneography in patients referred with inguinal pain (inguinodynia) and clinically absent inguinal hernia on physical examination.

Summary background data: In patients with chronic groin pain, peritoneography is a seldom-used yet available technique that can detect an occult inguinal hernia. The value of peritoneography in the diagnosis of occult inguinal hernia has been previously shown.

Methods: During a 60-month period, 80 consecutive patients with complaints of persistent inguinal pain (inguinodynia) without evidence of hernia on clinical examination were referred for outpatient evaluation by peritoneography. Twenty-nine patients had prior inguinal surgery in the region of their current pain. Peritoneography was performed using a midline or paraumbilical approach. Radiographs were obtained with patients in prone and prone oblique positions with the head elevated 20 degrees to 25 degrees, both with and without provocative maneuvers. All available records were retrospectively reviewed for radiographic findings and outcome.

Results: Of the 80 patients undergoing peritoneography, 36 (45%) were diagnosed radiographically to have inguinal hernias that were not detectable clinically. Twenty-seven of these patients subsequently underwent inguinal exploration, and a hernia was confirmed in 24 (89%). Of the patients having prior inguinal surgery in the region of their pain, 12/29 (41%) were diagnosed by peritoneography with a hernia. Two complications (2.5%), both colon perforations that did not require significant intervention, occurred as a result of peritoneography.

Conclusions: Peritoneography is highly reliable for detecting clinically occult inguinal hernia and has a low complication rate. Its usefulness is shown in a prospective consecutive series for detection of occult hernias in patients with chronic inguinal pain. The authors conclude that peritoneography is a safe and useful diagnostic test in the setting of persistent inguinal pain and a negative clinical examination.

Figure 1. (A) Normal study on a standard peritoneogram. In contrast, a positive study reveals an obvious indirect inguinal hernia on both the posteroanterior (B) and oblique (C) images (arrows).

Figure 2. Importance of a provocative maneuver. (A) Normal study with the patient at rest. (B) The same patient performs a Valsalva maneuver, revealing an obvious indirect occult inguinal hernia (arrow).