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Surgeon challenging Radiologist’s CT scan
Hi,
I had inguinal hernia repair, left side middle of June. Around same time I felt similar pains on right side. Surgeon looked during surgery and saw nothing. Had follow up appt in July and he felt for hernia on right side and said no hernia. Left side was healing well. I go back in August complaining about right side and he still says no hernia, but orders an ultrasound.Had US in Sept which was neg, but there was presence of small fluid buildup in right inguinal canal which explains the small bulge I see time to time on right side with occasional dragging and pressure sensation. Surgeon then refers me to urologist. Went to see him and everything was fine with testicles and he also feels no hernia.
Frustrated, I go back to surgeon who then orders pelvic CT scan. Results seem to clearly indicate small hernia. The report states:
“Just superior to the marker, there is discontinuity of the abdominal wall with herniation of fat. The hernia content is quite small measuring 2.7 cm transversely, 0.8 cm anterior to posterior, and 1.7 cm
caudocranially. The abdominal wall defect is just lateral to the inferior aspect of the right abdominal rectus muscle, and there may be a small focus of fluid along the inferior aspect of this herniated fat.”So, I feel like I was right all along and the surgeon was wrong, but then he calls yesterday and says he spoke to radiologist and he doesn’t really think it’s a hernia? I’m like, “huh?” Isn’t the report conclusive? He states he agrees that there is “something there”, but doesn’t think it’s a hernia. Maybe cyst. He suggests lapro saying that if hernia is in fact present, he’ll fix it. If he can’t see hernia, then he’ll switch to open exploratory. I’m not in favor of this. He says he’s seen many CT scans of hernias and it sounds like because he can’t feel the hernia which is the preffered diagnosis, then there likely can’t be one.
I told him to schedule the surgery which is 6-8 weeks out, but in the meantime, I’m getting 2nd opinion from another surgeon and possibly radiologist. While my problem hasn’t gotten worse, it’s persistent and bothersome, but I am not letting someone open me up and fish around for something. Thoughts?
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19 Replies
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Surgeon challenging Radiologist’s CT scan
Hard to determine if there is a hernia based on these new images. The entire set of images needs to be seen.
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Surgeon challenging Radiologist’s CT scan
Dr. T, could you provide any more comments on my last two images? thanks again.
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Surgeon challenging Radiologist’s CT scan
Dr. T,
I’ve attached one more CT image and recent US image of this fluid sac. Three different surgeons, including Dr. G said there is no hernia. The radiologist said there was small fat hernia. You had previously agreed with this. Do these added images support your original conclusion? Thank you.
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Surgeon challenging Radiologist’s CT scan
Saw Dr. Goodyear today, prepared for surgery, but he concluded while there is weakening of abdominal wall on right side, there is no hernia. Left side pain, in area of recent hernia repair likely post op pain. Nice doctor, but bitter sweet since I was hoping to resolve my issue. He recommended waiting and seeing what happens.
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Surgeon challenging Radiologist’s CT scan
Dr Goodyear may have done more hernia surgeries than any other surgeon in the US and does corrective procedures also. Did you review his website and forum?
I would trust Dr Goodyear.
If it is a Lipoma not sure if that is a GS surgery or Urology. I would want a true specialist when working in that area. I know in hernia surgery they remove Lipoma’s but if it was just for that I thinking Urologist, maybe I am wrong.
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Surgeon challenging Radiologist’s CT scan
So I got one more surgeon opinion before heading to Dr. Goodyear. Saw a local Dr. yesterday and like everyone else so far did not feel any hernia. He did feel an asymmetry in the spermatic cords, with the one on the right being larger in the area of the fluid buildup. He says it’s likely a lipoma and he suggested I wait it out unless it’s really bothering me (it is).
I’m just more frustrated as ever since everyone so far as a different opinion, which I somewhat understand given there appears to be no definitive result, either physical or imaging. He thought it was a good idea to get a 3rd opinion from Dr. Goodyear, but was hesitant about doing “same day surgery”. I think this was more about not knowing who Dr. Goodyear is and possibly thinking this is some fly by night surgery.
In any case, I’ll see Dr. G on the 29th. I have a feeling there will be no surgery since he likely won’t feel the hernia either. Which leads me to the next question, which is whether he would operate to at least remove the lipoma. Maybe while he’s doing that he will see the hernia that apparently can’t be felt.
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Surgeon challenging Radiologist’s CT scan
1. Hydroceles may be associated with a small inguinal hernia. Most often they are two separate entities, but they can coexist.
2. Unpredictable if fat or intestinal content hernia is painful. Everyone is different.
3. Likely not referred pain from the other side. The rest are complex situations which require a physical examination and complete history. -
Surgeon challenging Radiologist’s CT scan
quote :Agree with Ct reading.How did your appointment with Dr Goodyear go?
My appt is in two weeks. I did speak with Dr. Goodyear on the phone and he said the CT was inconclusive. I guess I should expect Dr’s to have different interpretations on image results. I am somewhat confused about something he said about hydrocoels. He said those are only found in the scrotum and the buldge I am seeing is the hernia. I found it difficult to understand since the buldge, which comes and goes can be pretty noticeable and yet the ultrasound was neg, the CT scan depending on the doctor is pos or neg for a hernia and nobody has yet to physically feel the hernia. It was quite painful today. A couple questions:
1. do hernias cause hydrocoel formation or vice versa? Or are they totally two separate things?
2. are fat hernias vs intestinal more or less painful and is one more difficult to repair?
3. I have been having pain on the left sided repair which was fixed 4 months ago. Could I be feeling referred pain from the right side? Could it be scar tissue formation or possible recurrent? The patch size on that side is 10x15cm. Many thanks.
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Surgeon challenging Radiologist’s CT scan
Agree with Ct reading.
How did your appointment with Dr Goodyear go?
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Surgeon challenging Radiologist’s CT scan
Dr. T,
I have an appt to see Dr. Goodyear end of the month. I am still concerned that if he doens’t feel anything, like my surgeon didn’t, then he may not operate despite the CT report. I have attached one of a few CT images pointing out the area flagged by the radiologist indicating herniated fat. Not sure if the resolution is good enough, but what it your interpretation? Many thanks.
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Surgeon challenging Radiologist’s CT scan
Thank you very much. I just visited your website and it looks like a lot of good info. If the docs here in Maine can’t figure it out, I’ll be sure to contact your office. My inlaws are from LA. 🙂
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Surgeon challenging Radiologist’s CT scan
If you have symptoms and there is an inguinal hernia on imaging supporting that and there is a bulge, I don’t see where the non concordance is.
If you would like me to re-read the imaging or review your case, let me know. Or call my office and talk to Sheila. 310-358-5020.
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Surgeon challenging Radiologist’s CT scan
All hydroceles start at the inguinal canal and work their way down to the testicle. Yours is reall an inguinal hernia and early communicating hydrocele.
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Surgeon challenging Radiologist’s CT scan
Hi Dr. But isn’t a hydrocele typically fluid around the testicle? This was ruled out. thank you. So I assume you would not be in favor of exploratory surgery as it seems like my current surgeon doesn’t want to admit he is wrong.
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Surgeon challenging Radiologist’s CT scan
Sounds like your CT scan is showing a communicating hydrocele with inguinal hernia, which is basically a hernia but smaller. The treatment is similar.
I usually perform these in open fashion, as the hydroceletomy portion is better performed in this fashion.There is a spectrum in hernia disease.
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Surgeon challenging Radiologist’s CT scan
quote :jzinckgra, indeed I am only a patient as well, but to me your CT report seems very detailed and specific. I personally have never had a report even close to that detailed but it probably depends on the radiologist and how much they feel like investigating and reporting.With that said I do know it is a very common belief of many doctors and clinics to think that if you do not have the big bulge than you do not have a hernia. On the other hand there is a lot of evidence on this forum and elsewhere to suggest that is not always the case.
Interestingly, I do have a bulge, but it is one of fluid, not fat or intestine. It comes and goes depending on body position. Earlier US report said possible communication between peritoneum and scrotum or vice versa. Nobody seems to know where the fluid is coming from, but seems obvious and likely it has something to do with herniated fat.
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Surgeon challenging Radiologist’s CT scan
jzinckgra, indeed I am only a patient as well, but to me your CT report seems very detailed and specific. I personally have never had a report even close to that detailed but it probably depends on the radiologist and how much they feel like investigating and reporting.
With that said I do know it is a very common belief of many doctors and clinics to think that if you do not have the big bulge than you do not have a hernia. On the other hand there is a lot of evidence on this forum and elsewhere to suggest that is not always the case.
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Surgeon challenging Radiologist’s CT scan
quote :jzinckgra, I don’t think it is uncommon to have interpretive disagreements between radiology and doctors, I have personally encountered this as well and as a patient it can be very frustrating to be on the receiving end.You might want to consider getting a second look at the images, and also find out if the surgeon themselves looks at the images. Many doctors go based on the written report alone which is fine in many cases but with some of the more obscure situations it may not be as helpful, particularly if you do not have the traditional palpable hernia bulge. Find a hernia expert if possible, or at least a doctor with a lot of experience with hernias.
I think Dr Towfigh of these forums used to offer an online consultation service where she would personally review images, perhaps that could offer some insight as well.
thank you. I am waiting for a referral to another surgeon. My current surgeon did look at the images and came away with a different interpretation. My frustration in part has to do with the physical dimensions that the radiologist was able to make. If she had just stated there was an “discontinuity of the abdominal wall” and nothing more I could see how that may be open to interpretation. However, the report states dimensions plus “herniation of fat”. Seems conclusive to me, but what do I know.
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Surgeon challenging Radiologist’s CT scan
jzinckgra, I don’t think it is uncommon to have interpretive disagreements between radiology and doctors, I have personally encountered this as well and as a patient it can be very frustrating to be on the receiving end.
You might want to consider getting a second look at the images, and also find out if the surgeon themselves looks at the images. Many doctors go based on the written report alone which is fine in many cases but with some of the more obscure situations it may not be as helpful, particularly if you do not have the traditional palpable hernia bulge. Find a hernia expert if possible, or at least a doctor with a lot of experience with hernias.
I think Dr Towfigh of these forums used to offer an online consultation service where she would personally review images, perhaps that could offer some insight as well.
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