What is the appropriate workup for a suspected hernia (hernia diagnosis and treatment)?

From the Guidelines

A hernia workup should typically start with a thorough physical examination and a chest X-ray, with a CT scan being the gold standard for diagnosing diaphragmatic hernia, especially when complications are suspected or the diagnosis is unclear 1. The initial assessment should include a detailed history focusing on symptoms like pain, bulging, and any aggravating factors.

• Physical examination should be performed both standing and lying down, with the patient performing Valsalva maneuver to better visualize the hernia.
• For most hernias, ultrasound is the first-line imaging modality due to its accessibility, lack of radiation, and good sensitivity.
• CT scans may be ordered when complications like strangulation are suspected or when the diagnosis remains unclear after ultrasound, as they have a high sensitivity and specificity for diagnosing diaphragmatic hernia 1.
• Laboratory tests, such as complete blood count and basic metabolic panel, may be ordered to assess for signs of infection or bowel obstruction, especially if complications are suspected 1.
• The workup should also include assessment of comorbidities that might affect surgical candidacy, as surgery remains the definitive treatment for most hernias.
• Watchful waiting may be appropriate for asymptomatic hernias, but patients should be educated about warning signs of complications requiring urgent medical attention, including severe pain, nausea, vomiting, or inability to reduce a previously reducible hernia. Some key findings on CT scans that may indicate diaphragmatic hernia include:
• Diaphragmatic discontinuity
• Segmental non-recognition of the diaphragm
• “Dangling diaphragm” sign
• “Dependent viscera” sign
• Intrathoracic herniation of abdominal contents
• “Collar sign”
• Contiguous injuries of both sides of the diaphragm
• Elevated abdominal organs
• Thickened diaphragm
• Thoracic fluid
• Abutting intra-abdominal viscera
• Hypo-attenuated hemidiaphragm and associated fractured ribs 1.

From the Research

Hernia Workup

• The diagnosis of hernias is typically made through a combination of medical history and physical examination 2, 3, 4.
• Physical examination involves feeling for a bulge or impulse while the patient coughs or strains, and is usually sufficient to make the diagnosis 2, 3.
• Imaging studies such as ultrasonography or magnetic resonance imaging (MRI) may be used to diagnose a hernia in certain cases, such as:
  • Athletes without a palpable impulse or bulge on physical examination 2.
  • Recurrent hernia or suspected hydrocele 2, 4.
  • Uncertain diagnosis or surgical complications 2, 3.
• Computed tomography (CT) scanning can be used to exclude recurrence after laparoscopic ventral hernia repair in doubtful cases 5.

Diagnostic Challenges

• Physical examination may be insufficient to diagnose the exact type of hernia in more than 50% of cases 3.
• Diagnosis can be difficult in cases with pain syndrome without physical examination anomalies, and other diagnoses must be considered before surgical exploration 3.
• Ultrasonography or MRI may be helpful in these cases to confirm the diagnosis or rule out other causes of groin pain 3, 4.

Surgical Intervention

• Surgical repair is not always necessary, such as in cases of small, minimally symptomatic hernias 2.
• Laparoscopic repair is associated with shorter recovery time, earlier resumption of activities of daily living, less pain, and lower recurrence rates than open repair 4, 6.
• Watchful waiting is a reasonable and safe option in men with asymptomatic or minimally symptomatic inguinal hernias, but not recommended in patients with symptomatic hernias or in nonpregnant women 4.