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Ultrasonography in diagnosing clinically occult groin hernia: systematic review and meta-analysis

  • Ultrasound
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Abstract

Objectives

To provide an updated systematic review on the performance of ultrasonography (US) in diagnosing clinically occult groin hernia.

Methods

A systematic search was performed in MEDLINE and Embase. Methodological quality of included studies was assessed. Accuracy data of US in detecting clinically occult groin hernia were extracted. Positive predictive value (PPV) was pooled with a random effects model. For studies investigating the performance of US in hernia type classification (inguinal vs femoral), correctly classified proportion was assessed.

Results

Sixteen studies were included. In the two studies without verification bias, sensitivities were 29.4% [95% confidence interval (CI), 15.1-47.5%] and 90.9% (95% CI, 70.8-98.9%); specificities were 90.0% (95% CI, 80.5-95.9%) and 90.6% (95% CI, 83.0-95.6%). Verification bias or a variation of it (i.e. study limited to only subjects with definitive proof of disease status) was present in all other studies. Sensitivity, specificity, and negative predictive value (NPV) were not pooled. PPV ranged from 58.8 to 100%. Pooled PPV, based on data from ten studies with low risk of bias and no applicability concerns with respect to patient selection, was 85.6% (95% CI, 76.5-92.7%). Proportion of correctly classified hernias, based on data from four studies, ranged between 94.4% and 99.1%.

Conclusions

Sensitivity, specificity and NPV of US in detecting clinically occult groin hernia cannot reliably be determined based on current evidence. Further studies are necessary. Accuracy may strongly depend on the examiner's skills. PPV is high. Inguinal and femoral hernias can reliably be differentiated by US.

Key Points

• Sensitivity, specificity and NPV of ultrasound in detecting clinically occult groin hernia cannot reliably be determined based on current evidence.

• Accuracy may strongly depend on the examiner's skills.

• PPV of US in detection of clinically occult groin hernia is high [pooled PPV of 85.6% (95% confidence interval, 76.5-92.7%)].

• US has very high performance in correctly differentiating between clinically occult inguinal and femoral hernia (correctness of 94.4- 99.1%).

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Abbreviations

FN:

False negative

FP:

False positive

TN:

True negative

References

  1. Kingsnorth A, LeBlanc K (2003) Hernias: inguinal and incisional. Lancet 362:1561–1571

    Article  Google Scholar 

  2. Primatesta P, Goldacre MJ (1996) Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol 25:835–839

    Article  CAS  Google Scholar 

  3. HerniaSurge Group (2018) International guidelines for groin hernia management. Hernia 22:1–165

    Article  Google Scholar 

  4. Jenkins JT, O'Dwyer PJ (2008) Inguinal hernias. BMJ 336:269–272

    Article  Google Scholar 

  5. Niebuhr H, König A, Pawlak M, Sailer M, Köckerling F, Reinpold W (2017) Groin hernia diagnostics: dynamic inguinal ultrasound (DIUS). Langenbeck's Arch Surg 402:1039–1045

    Article  Google Scholar 

  6. LeBlanc KE, LeBlanc LL, LeBlanc KA (2013) Inguinal hernias: diagnosis and management. Am Fam Physician 87:844–848

    PubMed  Google Scholar 

  7. Robinson A, Light D, Kasim A, Nice C (2013) A systematic review and meta-analysis of the role of radiology in the diagnosis of occult inguinal hernia. Surg Endosc 27:11–18

    Article  Google Scholar 

  8. Lilly MC, Arregui ME (2002) Ultrasound of the inguinal floor for evaluation of hernias. Surg Endosc 16:659–662

    Article  CAS  Google Scholar 

  9. Light D, Ratnasingham K, Banerjee A, Cadwallader R, Uzzaman MM, Gopinath B (2011) The role of ultrasound scan in the diagnosis of occult inguinal hernias. Int J Surg 9:169–172

    Article  CAS  Google Scholar 

  10. 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 64:608–614

    Article  CAS  Google Scholar 

  11. McGrath TA, McInnes MD, Korevaar DA, Bossuyt PM (2016) Meta-analyses of diagnostic accuracy in imaging journals: analysis of pooling techniques and their effect on summary estimates of diagnostic accuracy. Radiology 281:78–85

    Article  Google Scholar 

  12. Sica GT (2006) Bias in research studies. Radiology 238:780–789

    Article  Google Scholar 

  13. McInnes MD, Bossuyt PM (2015) Pitfalls of systematic reviews and meta-analyses in imaging research. Radiology 277:13–21

    Article  Google Scholar 

  14. Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MM, Sterne JA, Bossuyt PM, QUADAS-2 Group (2011) QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 155:529–536

    Article  Google Scholar 

  15. Alam A, Nice C, Uberoi R (2005) The accuracy of ultrasound in the diagnosis of clinically occult groin hernias in adults. Eur Radiol 15:2457–2561

    Article  Google Scholar 

  16. Freeman MF, Tukey JW (1950) Transformations related to the angular and the square root. Ann Math Stat 21:607–611

    Article  Google Scholar 

  17. DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7:177–188

    Article  CAS  Google Scholar 

  18. Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327:557–560

    Article  Google Scholar 

  19. Deitch EA, Soncrant MC (1981) Ultrasonic diagnosis of surgical disease of the inguinal-femoral region. Surg Gynecol Obstet 152:319–322

    CAS  PubMed  Google Scholar 

  20. Kervancioglu R, Bayram MM, Ertaskin I, Ozkur A (2000) Ultrasonographic evaluation of bilateral groins in children with unilateral inguinal hernia. Acta Radiol 41:653–657

    Article  CAS  Google Scholar 

  21. Chen KC, Chu CC, Chou TY, Wu CJ (1998) Ultrasonography for inguinal hernias in boys. J Pediatr Surg 33:1784–1787

    Article  CAS  Google Scholar 

  22. Kraft BM, Kolb H, Kuckuk B et al (2003) Diagnosis and classification of inguinal hernias. Surg Endosc 17:2021–2024

    Article  CAS  Google Scholar 

  23. Dattola P, Alberti A, Dattola A, Giannetto G, Basile G, Basile M (2002) Inguino-crural hernias: preoperative diagnosis and post-operative follow-up by high-resolution ultrasonography. A personal experience. Ann Ital Chir 73:65–68

    CAS  PubMed  Google Scholar 

  24. Korenkov M, Paul A, Troidl H (1999) Color duplex sonography: diagnostic tool in the differentiation of inguinal hernias. J Ultrasound Med 18:565–568

    Article  CAS  Google Scholar 

  25. Djuric-Stefanovic A, Saranovic D, Ivanovic A et al (2008) The accuracy of ultrasonography in classification of groin hernias according to the criteria of the unified classification system. Hernia 12:395–400

    Article  CAS  Google Scholar 

  26. Yeh HC, Lehr-Janus C, Cohen BA, Rabinowitz JG (1984) Ultrasonography and CT of abdominal and inguinal hernias. J Clin Ultrasound 12:479–486

    Article  CAS  Google Scholar 

  27. Malouf PA, Descallar J, Berney CR (2018) Bilateral totally extraperitoneal (TEP) repair of the ultrasound-diagnosed asymptomatic contralateral inguinal hernia. Surg Endosc 32:955–962

    Article  Google Scholar 

  28. Bradley M, Morgan J, Pentlow B, Roe A (2006) The positive predictive value of diagnostic ultrasound for occult herniae. Ann R Coll Surg Engl 88:165–167

    Article  CAS  Google Scholar 

  29. 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 187:1168–1178

    Article  Google Scholar 

  30. Vasileff WK, Nekhline M, Kolowich PA, Talpos GB, Eyler WR, van Holsbeeck M (2017) Inguinal hernia in athletes: role of dynamic ultrasound. Sports Health 9:414–421

    Article  Google Scholar 

  31. Gupta H, Subedi N, Robinson P (2016) Effectiveness of sonography in detecting clinically occult femoral hernias. J Ultrasound Med 35:1675–1679

    Article  Google Scholar 

  32. Roshanaei A, Tahmasebi M, Gharibvand MM, Askari M (2016) The accuracy of ultrasound in detecting occult inguinal hernia in patients with inconclusive clinical findings, compared with surgical results. Int J Pharm Technol 8:1

    Google Scholar 

  33. Brandel DW, Girish G, Brandon CJ, Dong Q, Yablon C, Jamadar DA (2016) Role of sonography in clinically occult femoral hernias. J Ultrasound Med 35:121–128

    Article  Google Scholar 

  34. Lee RK, Griffith JF, Ng WH (2015) High accuracy of ultrasound in diagnosing the presence and type of groin hernia. J Clin Ultrasound 43:538–547

    Article  Google Scholar 

  35. Kim B, Robinson P, Modi H, Gupta H, Horgan K, Achuthan R (2015) Evaluation of the usage and influence of groin ultrasound in primary and secondary healthcare settings. Hernia 19:367–371

    Article  CAS  Google Scholar 

  36. Palumbo VD, Tomasello G, Bruno A et al (2014) The value of diagnostic ultrasound for detecting occult inguinal hernia in patients with groin pain. Acta Med Mediterr 30:2

    Google Scholar 

  37. Miller J, Cho J, Michael MJ, Saouaf R, Towfigh S (2014) Role of imaging in the diagnosis of occult hernias. JAMA Surg 149:1077–1080

    Article  Google Scholar 

  38. Alabraba E, Psarelli E, Meakin K et al (2014) The role of ultrasound in the management of patients with occult groin hernias. Int J Surg 12:918–922

    Article  CAS  Google Scholar 

  39. Grant T, Neuschler E, Hartz W 3rd (2011) Groin pain in women: use of sonography to detect occult hernias. J Ultrasound Med 30:1701–1707

    Article  Google Scholar 

  40. Højer AM, Rygaard H, Jess P (1997) CT in the diagnosis of abdominal wall hernias: a preliminary study. Eur Radiol 7:1416–1418

    Article  Google Scholar 

  41. Jaffe TA, O'Connell MJ, Harris JP, Paulson EK, Delong DM (2005) MDCT of abdominal wall hernias: is there a role for Valsalva's maneuver? AJR Am J Roentgenol 184:847–851

    Article  Google Scholar 

  42. Ng TT, Hamlin JA, Kahn AM (2009) Herniography: analysis of its role and limitations. Hernia 13:7–11

    Article  CAS  Google Scholar 

  43. Jacobson JA, Khoury V, Brandon CJ (2015) ultrasound of the groin: techniques, pathology, and pitfalls. AJR Am J Roentgenol 205:513–523

    Article  Google Scholar 

  44. Gallegos NC, Dawson J, Jarvis M, Hobsley M (1991) Risk of strangulation in groin hernias. Br J Surg 78:1171–1173

    Article  CAS  Google Scholar 

  45. Burkhardt JH, Arshanskiy Y, Munson JL, Scholz FJ (2011) Diagnosis of inguinal region hernias with axial CT: the lateral crescent sign and other key findings. Radiographics 31:E1–E12

    Article  Google Scholar 

  46. de Groot JA, Dendukuri N, Janssen KJ et al (2012) Adjusting for partial verification or workup bias in meta-analyses of diagnostic accuracy studies. Am J Epidemiol 175:847–853

    Article  Google Scholar 

  47. Vecchio TJ (1966) Predictive value of a single diagnostic test in unselected populations. N Engl J Med 274:1171–1173

    Article  CAS  Google Scholar 

  48. Terrin N, Schmid CH, Lau J (2005) In an empirical evaluation of the funnel plot, researchers could not visually identify publication bias. J Clin Epidemiol 58:894–901

    Article  Google Scholar 

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The authors state that this work has not received any funding.

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Authors and Affiliations

  1. Department of Radiology, Zuyderland Medical Centre, Henri Dunantstraat 5, 6419 PC, Heerlen, The Netherlands

    Robert M. Kwee

  2. Department of Radiology, University Medical Centre Groningen, Groningen, The Netherlands

    Thomas C. Kwee

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  1. Robert M. Kwee
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  2. Thomas C. Kwee
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Correspondence to Robert M. Kwee.

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The scientific guarantor of this publication is Robert M. Kwee

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The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise.

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Written informed consent was waived by the Institutional Review Board.

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Institutional Review Board approval was not required because this study was a meta-analysis.

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Kwee, R.M., Kwee, T.C. Ultrasonography in diagnosing clinically occult groin hernia: systematic review and meta-analysis. Eur Radiol 28, 4550–4560 (2018). https://doi.org/10.1007/s00330-018-5489-9

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  • DOI: https://doi.org/10.1007/s00330-018-5489-9

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