Structured Report Format for Inguinal Hernia
A comprehensive structured report for inguinal hernia should include administrative information, patient demographics, hernia characteristics, anatomical details, and management recommendations to ensure standardized documentation and facilitate optimal patient care.
Administrative Information
- Date and time of examination
- Name and credentials of the examining physician
- Facility information
- Study identifier or accession number
- Report generation date and time
Patient Demographics and Clinical Information
- Patient's full name, medical record number, date of birth, gender
- Relevant medical history (previous hernias, surgeries)
- Current symptoms (pain, swelling, functional limitations)
- Risk factors (family history, collagen disorders, prostatectomy history)
- Medication history and allergies
Hernia Characteristics
- Type of hernia (direct, indirect, femoral, or combined)
- Laterality (right, left, or bilateral)
- Size measurements (in centimeters)
- Maximum length
- Maximum width
- Defect size
- Reducibility status (reducible, partially reducible, or irreducible)
- Presence of incarceration or strangulation
- Content of hernia sac (if identifiable)
Anatomical Details
- Relationship to anatomical landmarks:
- Distance from pubic tubercle
- Relationship to inguinal ligament
- Involvement of the spermatic cord (in males)
- Relationship to round ligament (in females)
- Integrity of the inguinal canal
- Status of internal and external rings
- Condition of surrounding tissues
Imaging Findings (if applicable)
- Modality used (ultrasound, CT, MRI)
- Technical specifications of image acquisition
- Visualization of hernia defect and contents
- Associated findings (fluid collections, inflammation)
- Vascular assessment (if relevant)
Classification
- European Hernia Society (EHS) classification 1
- Lateral (L)/Medial (M)/Femoral (F)
- Size: 1 (<1.5 cm), 2 (1.5-3 cm), 3 (>3 cm)
- Recurrent status (primary or recurrent)
Assessment and Recommendations
- Diagnosis summary
- Recommended management approach
- Surgical technique considerations
- Risk assessment for complications
- Follow-up recommendations
Additional Considerations
- Comparison with previous examinations (if available)
- Documentation of any limitations in the examination
- Quality of examination (optimal, limited, etc.)
Documentation of Communication
- Documentation of findings discussed with patient
- Documentation of management options discussed
- Documentation of any critical findings communicated to referring physician
By implementing this structured format, clinicians can ensure comprehensive documentation of inguinal hernias, facilitating standardized care, quality assessment, and improved patient outcomes 2. The structured approach also enables better comparison between examinations and supports research and audit activities 3.
Common Pitfalls to Avoid
- Failing to distinguish between direct and indirect hernias
- Overlooking femoral hernias, especially in female patients
- Incomplete documentation of hernia size and reducibility
- Inadequate description of anatomical relationships
- Missing bilateral hernias (particularly during unilateral examinations)
- Incomplete documentation of risk factors for recurrence
Using ultrasonography as an adjunct to physical examination can improve diagnostic accuracy, particularly in challenging cases such as obese patients, women, and suspected recurrent hernias 3, 4.