Surgical Endoscopy

, Volume 27, Issue 1, pp 11–18 | Cite as

A systematic review and meta-analysis of the role of radiology in the diagnosis of occult inguinal hernia

  • Amy Robinson
  • Duncan LightEmail author
  • Adetayo Kasim
  • Colin Nice



Inguinal hernias are a common cause of groin pain. Most hernias are detectable by clinical examination and many patients proceed to hernia repair on the basis of history and examination findings alone. However, a significant proportion of patients with symptoms suggestive of groin hernia are found to have a normal clinical examination. Several radiological techniques have been developed to solve the dilemma posed by occult inguinal hernias. No systematic review or meta-analysis has addressed this common clinical problem.


A systematic review and meta-analysis were undertaken of relevant articles in Medline, Embase, and the Cochrane database. Studies were assessed using the QUADAS tool. Statistical analysis was undertaken.


We have shown in this meta-analysis that ultrasound has a sensitivity of 86 % and a specificity of 77 % in occult inguinal hernias. Computed tomography has a sensitivity of 80 % and a specificity of 65 %. Herniography has a sensitivity of 91 % and a specificity of 83 %.


Based on this systematic review, herniography should be considered as the initial investigation for occult inguinal hernia where available. In centers where this is not available, ultrasound of the groin should be used with good clinical judgment. When there is still diagnostic uncertainty, further investigation with magnetic resonance imaging should be considered to exclude alternative pathology.


Hernia Ultrasonography Occult hernia 



The authors acknowledge the assistance of the Statistics Department at Durham University and the medical library in Gateshead NHS Trust.


Amy Robinson, Duncan Light, Adetayo Kasim, and Colin Nice have no conflicts of interest or financial ties to disclose.


  1. 1.
    Kark A, Kurzer M, Waters KJ (1994) Accuracy of clinical diagnosis of direct and indirect inguinal hernia. Br J Surg 81:1081–1082PubMedCrossRefGoogle Scholar
  2. 2.
    Sternhill V, Schwartz S (1960) Effect of hypaque on mouse peritoneum. Radiology 75:811Google Scholar
  3. 3.
    Birzle H (1961) Is peritoneography possible and useful as a roentgenological method of examination? Fortschr Geb Rontgenstr Nuklearmed 95:824–829PubMedCrossRefGoogle Scholar
  4. 4.
    Ekberg O, Fork F, Aspelin P (1985) Herniography in anterior abdominal wall hernia. RoFo 143(5):562–568PubMedCrossRefGoogle Scholar
  5. 5.
    Van Ginderachter P, Steyaert L, Pattyn G, Meeus L, Vandevoorde P, Devos V, Casselman J (1990) Herniography in adults: review and personal studies. J Belge Radiol 73(3):181–188PubMedGoogle Scholar
  6. 6.
    Ekberg O (1983) Complications after herniography in adults. AJR Am J Roentgenol 140(3):490–495Google Scholar
  7. 7.
    Light DR, Banarjee A, Cadwallader R, Uzzaman MM, Gopinath B (2011) The role of ultrasound scan in the diagnosis of occult hernias. Int J Surg 9:169–172PubMedCrossRefGoogle Scholar
  8. 8.
    van den Berg JC, de Valois JC, Go PM, Rosenbusch G (1997) Dynamic magnetic resonance imaging in the diagnosis of groin hernia. Invest Radiol 32(10):644–647PubMedCrossRefGoogle Scholar
  9. 9.
    Harrison LA, Keesling CA, Martin NL, Lee KR, Wetzel LH (1995) Abdominal wall hernias: review of herniography and correlation with cross-sectional imaging. Radiographics 15:315–332PubMedGoogle Scholar
  10. 10.
    Whiting PF, Weswood ME, Rutjes AW, Reitsma JB, Bossuyt PN, Kleijnen J (2006) Evaluation of QUADAS, a tool for the quality assessment of diagnostic accuracy studies. BMC Med Res Methodol 6(1):9PubMedCrossRefGoogle Scholar
  11. 11.
    Moses LE, Shapiro D, Littenberg B (1993) Combining independent studies of a diagnostic test into a summary ROC curve: data-analytic approaches and some additional considerations. Stat Med 12:1293–1316PubMedCrossRefGoogle Scholar
  12. 12.
    Lilly MC, Arregui ME (2002) Ultrasound of the inguinal floor for evaluation of hernias. Surg Endosc 16:659–662PubMedCrossRefGoogle Scholar
  13. 13.
    Eames NW, Deans GT, Lawson JT, Irwin ST (1994) Herniography for occult hernia and groin pain. Br J Surg 81:1529–1530PubMedCrossRefGoogle Scholar
  14. 14.
    Estes NC, Childs EW, Cox G, Thomas JH (1991) Role of herniography in the diagnosis of occult hernias. Am J Surg 162:608–610PubMedCrossRefGoogle Scholar
  15. 15.
    Gwanmesia II, Walsh S, Bury R, Bowyer K, Walker S (2001) Unexplained groin pain: safety and reliability of herniography for the diagnosis of occult hernias. Postgrad Med J 77:250–251PubMedCrossRefGoogle Scholar
  16. 16.
    Højer AM, Rygaard H, Jess P (1997) CT in the diagnosis of abdominal wall hernias: a preliminary study. Eur Radiol 7:1416–1418PubMedCrossRefGoogle Scholar
  17. 17.
    Macarthur DC, Grieve DC, Thompson AM, Greig JD, Nixon SJ (1997) Herniography for groin pain of uncertain origin. Br J Surg 84:684–685PubMedCrossRefGoogle Scholar
  18. 18.
    Sutcliffe JR, Taylor OM, Ambrose NS, Chapman AH (1999) The use, value and safety of herniography. Clin Radiol 54:468–472PubMedCrossRefGoogle Scholar
  19. 19.
    Smedberg SG, Broomé AE, Elmér O, Gullmo A (1986) Herniography: a diagnostic tool in groin symptoms following hernial surgery. Acta Chir Scand 152:273–277PubMedGoogle Scholar
  20. 20.
    Hachem MI, Saunders MP, Rix TE, Anderson HJ (2009) Herniography: a reliable investigation avoiding needless groin exploration—a retrospective study. Hernia 3:57–60CrossRefGoogle Scholar
  21. 21.
    Magnusson J, Gustafson T, Gullstrand P, Holmin T (1984) Herniography—a useful diagnostic method in patients with obscure groin pain. Ann Chir Gynaecol 73:91–94PubMedGoogle Scholar
  22. 22.
    Cohen RH, Turkenburg JL, van Dalen A (1990) Herniography in 79 patients with unexplained pain in the groin: a retrospective study. Eur J Radiol 11:184–187PubMedCrossRefGoogle Scholar
  23. 23.
    Depasquale R, Landes C, Doyle G (2009) Audit of ultrasound and decision to operate in groin pain of unknown aetiology with ultrasound technique explained. Clin Radiol 64:608–614PubMedCrossRefGoogle Scholar
  24. 24.
    Heise CP, Sproat IA, Starling JR (2002) Peritoneography (herniography) for detecting occult inguinal hernia in patients with inguinodynia. Ann Surg 235(1):140–144PubMedCrossRefGoogle Scholar
  25. 25.
    Loftus IM, Ubhi SS, Rodgers PM, Watkin DF (1997) A negative herniogram does not exclude the presence of a hernia. Ann R Coll Surg Engl 79:372–375PubMedGoogle Scholar
  26. 26.
    Mäkelä JT, Kiviniemi H, Palm J, Myllylä V (1996) The value of herniography in the diagnosis of unexplained groin pain. Ann Chir Gynaecol 85:300–304PubMedGoogle Scholar
  27. 27.
    Robinson P, Hensor E, Lansdown MJ, Ambrose NS, Chapman AH (2006) Inguinofemoral hernia: accuracy of sonography in patients with indeterminate clinical features. AJR Am J Roentgenol 187(5):1168–1178PubMedCrossRefGoogle Scholar
  28. 28.
    Hureibi KA, McLatchie GR, Kidambi AV (2011) Is herniography useful and safe? Eur J Radiol 80(2):e86–e90PubMedCrossRefGoogle Scholar
  29. 29.
    Smedberg SG, Broomé AE, Elmér O, Gullmo A (1985) Herniography in the diagnosis of obscure groin pain. Acta Chir Scand 151:663–667PubMedGoogle Scholar
  30. 30.
    Alam A, Nice C, Uberoi R (2005) The accuracy of ultrasound in the diagnosis of clinically occult groin hernias in adults. Eur Radiol 15(12):2457–2461PubMedCrossRefGoogle Scholar
  31. 31.
    Markos V, Brown EF (2005) CT herniography in the diagnosis of occult groin hernias. Clin Radiol 60:251–256PubMedCrossRefGoogle Scholar
  32. 32.
    Hureibi KA, McLatchie GR (2010) Groin pain in athletes. Scott Med J 55(2):8–11PubMedCrossRefGoogle Scholar
  33. 33.
    Bradley M, Morgan D, Pentlow B, Roe A (2003) The groin hernia—an ultrasound diagnosis? Ann R Coll Surg Engl 85:178–180PubMedCrossRefGoogle Scholar
  34. 34.
    Leander P, Ekberg O, Sjöberg S, Kesek P (2000) MR imaging following herniography in patients with unclear groin pain. Eur Radiol 10:1691–1969PubMedCrossRefGoogle Scholar
  35. 35.
    van den Berg JC, de Valois JC, Go PM, Rosenbusch G (1999) Detection of groin hernia with physical examination, ultrasound and MRI compared with laparoscopic findings. Invest Radiol 34(12):739–743PubMedCrossRefGoogle Scholar
  36. 36.
    Fon LJ, Spence RA (2000) Sportsman’s hernia. Br J Surg 87:545–552PubMedCrossRefGoogle Scholar
  37. 37.
    Ekberg O, Persson NH, Abrahamsson PA, Westlin NE, Lilja B (1988) Longstanding groin pain in athletes. A multi-disciplinary approach. Sports Med 5(6):56–61CrossRefGoogle Scholar
  38. 38.
    Kurup V, McLatchie G, Gilmore OJA (1999) Groin pain. In: Harries M, McLatchie G, Williams C, King J (eds) ABC of sports medicine. BMJ Books, Oxford, pp 76–79Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Amy Robinson
    • 1
  • Duncan Light
    • 1
    Email author
  • Adetayo Kasim
    • 2
  • Colin Nice
    • 1
  1. 1.Department of General SurgeryGateshead NHS TrustGatesheadUK
  2. 2.Department of StatisticsDurham UniversityDurham CityUK

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