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Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 70-75

Dynamic Inguinal Ultrasound (DIUS) in diagnosing groin hernias: Technique, examples and results

1 Hamburg Hernia Center, Hamburg, Germany
2 Hamburg Hernia Center, Hamburg, Germany; University of Tabuk, Faculty of Medicine, Department of Surgery, Tabuk, Saudi Arabia
3 Vivantes Klinikum Spandau, Klinik F. Chirurgie - Visceral- and Gefäßchirurgie, Berlin, Germany

Date of Submission02-Jan-2021
Date of Decision13-Feb-2021
Date of Acceptance19-Feb-2021
Date of Web Publication31-May-2021

Correspondence Address:
Prof. Henning Niebuhr
Hamburger Hernien Centrum, Eppendorfer Baum 8, 20249 Hamburg
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_13_21

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Groin hernia is one of the most common surgical conditions worldwide. Clinical examination can reveal the majority of inguinal hernias. Small inguinal and femoral hernias (in women) may be missed. Dynamic inguinal ultrasound (DIUS) can fill this diagnostic gap. A standardized technique of DIUS is, therefore, important and will be described. The results show high specificity (0.9980) and sensitivity (0.9758), demonstrating the value of the method (which is known to be highly examiner dependent).

Keywords: Inguinal hernia, Femoral hernia, Ultrasound, Diagnosis, Imaging, Clinical examination, Dynamic, Sonography

How to cite this article:
Niebuhr H, Malaibari Z, Dag H, Reinpold W, Köckerling F. Dynamic Inguinal Ultrasound (DIUS) in diagnosing groin hernias: Technique, examples and results. Int J Abdom Wall Hernia Surg 2021;4:70-5

How to cite this URL:
Niebuhr H, Malaibari Z, Dag H, Reinpold W, Köckerling F. Dynamic Inguinal Ultrasound (DIUS) in diagnosing groin hernias: Technique, examples and results. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2021 Oct 19];4:70-5. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/2/70/317317

  Introduction Top

Pain in the groin region is not always caused by herniation and may be triggered by a variety of different causes [Table 1].
Table 1: Different causes of inguinal pain

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The current practice of conducting only a clinical examination (CE) 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]

  Standardized Technique of Ultrasound Examination of the Groin Top

In this study, CE 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 through the external inguinal ring.

Ultrasound (US) examination followed the CE. It was carried out using a BK Medical Profocus Ultraview color duplex system with a multifrequency 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.

For this purpose, the small part linear transducer (frequency 9 MHz) is first placed vertically over the symphysis in such a way that the total reflection of the cortical bone of the symphysis is visible as a white, curved contour on the (right) lower edge of the US image.

Apically, in the longitudinal section, the rectus abdominis muscle is visible as a hypoechoic structure with a thin echo-dense rim (fascia) with its attachment tendon (strong echo line) to the symphysis. Ventrally, subcutaneous fat tissue of medium-echo density is visible, dorsally the peritoneum as a likewise echo-dense line.

Step 2: Diagonal t. p.(apical-lateral and caudal-medial).

The transducer is then gradually moved laterally and positioned slightly diagonally (apical-lateral and caudal-medial) in order to visualize the spermatic cord (hypoechoic), the spermatic cord vessels (hypoechoic), and the enveloping tissues (strong echo line) in the longitudinal section [Figure 1]. 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.
Figure 1: (a) Longitudinal section (slightly diagonal transducer position) over inguinal canal depicting the funiculus and the spermatic cord. (b) Longitudinal section (slightly diagonal transducer position) over inguinal canal de1icting the funiculus (marked by blue line) and the spermatic cord

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The hernial sac itself is recognizable as a thin echo-dense lamella, the hernial contents, depending on the quality, of medium echo density (fat, greater omentum) or partly echo-poor partly Echo-dense with characteristic cocards (intestinal loops) [Figure 2].
Figure 2: (a) Longitudinal section over a medium size inguinal hernia while employing a Valsalva maneuver. (b) Longitudinal section over a medium size inguinal hernia while employing a Valsalva maneuver (marked by blue line)

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Subsequently, the transducer will be rotated 90° to receive a cross-section view. At this angle, the epigastric vessels are easily identified. With this identification, it would be possible to distinguish between lateral (indirect) and medial (direct) hernias by letting the patient repeat a Valsalva maneuver.

In women, the (more difficult) visualization of the hypoechoic, not always clearly delineable round ligament (Lg. rotundum uteri) is performed. A possible inguinal hernia sac can be visualized by a Valsalva maneuver analogously to the procedure described above. A special feature is the varicosis of the ligamentous veins, which can be observed, especially during pregnancy and may appear in the B image as an echo-poor, clinically quite painful protrusion. Therefore, color duplex examination is essential in these cases to differentiate hernia/varicosis [Figure 3].[3],[4],[5],[6]
Figure 3: Color duplex ultrasound: Varicosis of round ligament

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Now, the transducer is rotated 90° to receive a cross-sectional view. At this angle, the epigastric vessels are easily identified.

Pathological protrusion of the transversalis fascia with the displacement of the spermatic cord and accompanying nerves as a sign of a painful “soft groin,” “sportsmans groin/hernia” is also best recognized in cross-section.

Step 3: In the next step (again slightly diagonal longitudinal position), the transducer is moved further laterally to above the femoral/iliac vessels to visualize a hyperechoic bulge (femoral herniation) below the inguinal ligament (recognizable as a strong echo line in slender individuals) in the lacuna vasorum in projection onto the femoral vein under Valsalva maneuver. Here, the longitudinal section is the preferred plane because the extent of the echo-dense hernial sac can be measured very well on the background of the anechoic femoral vein [Figure 4].
Figure 4: (a) Femoral hernia (echoic) in front of the femoral vein (background, unechoic) while employing a Valsalva maneuver. (b) Femoral hernia (echoic) in front of the femoral vein (background, unechoic) while employing a Valsalva maneuver (marked by blue line)

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At the same time, perivascular lymph nodes are best visualized in this sectional plane. However, these can also be found relatively far lateral to the vessels. Attentive screening for possible lymph nodes in all planes is therefore essential.

Step 4: Finally, the 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.(differential diagnosis: E.g., coxarthrosis/impingement).

In men, a testicular imaging with qualitative visualization of the testicular blood flow in color duplex mode is obligatory.

After inguinal surgery with mesh placement, the mesh position can be easily controlled sonographically. In the standard positions described above, the mesh can be seen behind the rectus muscle and in front of the transversalis fascia as a delicate echo-dense interrupted line.

A postoperative spermatic cord hematoma (so-called “Pseudo-recurrence”) can be clearly distinguished from a so-called early recurrence: A true recurrence shows the typical protrusion in the standard planes under Valsalva; the “pseudo-recurrence” can be visualized as a rather echo-poor structure in the spermatic cord region under Valsalva immobile with the mesh in place.

Postoperative testicular perfusion can be easily visualized by color duplex US examination [Figure 5] and [Figure 6].
Figure 5: Correct postoperative testicular circulation

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Figure 6: Testicular necrosis

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  Dynamic Magnetic Resonance Imaging Examination of Pelvic Wall and Groin Top

An MRI examination of the groin or pelvic wall is not the first-choice examination. In fact, it is only necessary for the detection of rare hernias such as an obturator hernia that cannot be reached by US.

It should be performed like a normal MRI examination of the pelvic wall or groin. Of crucial importance is the Valsalva maneuver, which has so far often not been routinely performed. Only with this technique is the dynamic of the examination and thus the real-time representation of a herniation possible.

  Results Top

All consecutive patients with groin complaints who presented for regular hernia consultation at Hanse-Hernia Center in Hamburg were included in the study [Table 2] and [Figure 7].
Figure 7: Patients flow

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Table 2: Baseline characteristics of the group

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In 3,659 (73.9%) cases, a hernia was diagnosed with both the clinical and US examinations. In those patients, surgery was indicated.

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.

In 292 (5.9%) cases, the CE 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 US 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 admitted to surgery, including 91 (31.1%) of the 292 hernias diagnosed only clinically and 22 of 25 hernias diagnosed only sonographically (n = 3,772), and consisted of both inguinal hernias (n = 3,546 [94%]) and femoral hernias (n = 226 [6%]).

The transabdominal preperitoneal procedure (TAPP) was performed in 3546 (94%) cases. 3291 (92.8%) were inguinal and 255 (7.2%) were femoral hernias. Open surgery was the method of choice in 226 (6%) patients. Lichtenstein procedure was performed on 223 patients with inguinal hernia (98.7%), and a direct suture technique was performed on three patients diagnosed with a femoral hernia (1.3%).

All diagnoses made by both examinations were intraoperatively confirmed.

Of the 292 cases with only clinical suspicion of a hernia and without sonographical confirmation of a small hernia in the Valsalva maneuver, 189 patients were scheduled for watchful waiting and 103 underwent diagnostic laparoscopy after further specialized diagnostics because of severe complaints.

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 operation. These patients were also scheduled for further watchful waiting.

The 204 (189 + 12 + 3) cases that did not receive surgical treatment were subjected to further observation. To date, none of the cases has undergone any type of surgery (mean observation time: 27 months).

After diagnostic laparoscopy, 22 of the 25 cases with ultrasonographic, but no clinical, suspicion underwent surgical treatment. Nineteen patients were diagnosed intraoperatively with a femoral hernia, three with a small inguinal hernia, and three with no hernia.

  Discussion/Conclusions Top

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 “risk” of inguinal hernia repair is high: 27% for men and 3% for women.[7] Of groin hernia repairs, 10% are performed in emergency settings. Therefore, appropriate diagnostics and timely treatment are important.

It is indisputable that CE alone can reveal the vast majority of groin hernias.[8] However, it can miss a number of hernias, especially small inguinal hernias in the early stages and femoral hernias in women.[9] To close this diagnostic gap, it is important to have additional tools, such as US, MRI, CT, and herniography [Table 3].[10],[11] Accurate knowledge of the anatomy of the groin region is a prerequisite for a reliable US or other imaging examination.[12]
Table 3: International guidelines for groin hernia management

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The described results demonstrate that standardized ultrasonography of the groin with high-frequency small part linear transducers can accurately visualize even small occult hernias. The high specificity (0.9980) and sensitivity (0.9758) demonstrate the value of the procedure (which is known to be highly examiner dependent).[1],[2],[3],[4],[9],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22]

In 1999, van den Berg[1] had calculated a specificity of 0.945 and a sensitivity of 0.815 for ultrasonography and therefore preferred MRI examination[23] with a specificity of 0.963 and a sensitivity of 0.945. Our own values show that the technical development of US equipment with high-frequency transducers can significantly improve these results.[22]

Whether the use of routine ultrasonography can visualize different hernia forms (”bulge, tube, hourglass”) and draw conclusions that so-called “watchful waiting” can be recommended for certain forms as an alternative to planned, timely surgery, cannot be proven from our results at present.[13],[18]

To ensure high-quality diagnosis and treatment in hernia centers, the following items are recommended:

  • Regular use of standardized US examinations in combination with clinical pre- and postoperative examinations
  • Performance of the indicated operations in a high number of cases (high-volume surgeons), as well as the
  • Registration and prospective tracking of all operations in cross-center registries (Herniamed).

Declaration of ethical approval and patient consent

Ethics committee approval was not applicable as this is a “teaching article” on how to do and how to improve ultrasonography in clinical routine. Ultrasonography is a routine diagnostic procedure and a special informed consent is not requested, but the patient agrees with his signature to all diagnostic and therapeutic procedures which are necessary for his optimal treatment.

Financial support and sponsorship


Conflicts of interest

Dr. Ferdinand Köckerling is an Associate Editor, Dr. Henning Niebuhr and Dr. Wolfgang Reinpold are Editorial Board members of International Journal of Abdominal Wall and Hernia Surgery. The article was subject to the journal's standard procedures, with peer review handled independently of the Editorial Board members and their research groups.

  References Top

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Daigeler A, Belyaev O, Pennekamp WH, Morrosch S, Köster O, Uhl W, et al. MRI findings do not correlate with outcome in athletes with chronic groin pain. J Sports Sci Med 2007;6:71-6.  Back to cited text no. 2
Light D, Ratnasingham K, Banerjee A, Cadwallader R, Uzzaman MM, Gopinath B. The role of ultrasound scan in the diagnosis of occult inguinal hernias. Int J Surg 2011;9:169-72.  Back to cited text no. 3
Bradley M, Morgan J, Pentlow B, Roe A. The positive predictive value of diagnostic ultrasound for occult herniae. Ann R Coll Surg Engl 2006;88:165-7.  Back to cited text no. 4
Lechner M, Fortelny R, Ofner D, Mayer F. “Suspected inguinal hernias in pregnancy—handle with care!” Hernia 18 (2013): 375-379.  Back to cited text no. 5
Pilkington SA, Rees M, Jones O, Green I. Ultrasound diagnosis of round ligament varicosities mimicking inguinal hernias in pregnancy. Ann R Coll Surg Engl 2004;86:400-1.  Back to cited text no. 6
Primatesta P , Goldacre MJ. Inguinal hernia repair: Incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol 1996;25:835-9.  Back to cited text no. 7
Bittner R, Bingener-Casey-J, Dietz-U, Fabian M, Ferzli GS, Fortelny RH, et al. Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)-part 1. Surg Endosc 2014;28:2-29.  Back to cited text no. 8
Whalen HR, Kidd GA, O'Dwyer PJ. Femoral hernias. BMJ. 2011;343:d7668. doi: 10.1136/bmj.d7668.  Back to cited text no. 9
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HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018 Feb;22(1):1-165. P. 10, doi: 10.1007/s10029-017-1668-x.  Back to cited text no. 11
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

  [Table 1], [Table 2], [Table 3]


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