Best way to determine a direct or indirect Inguinal hernia???

[drtowfigh]

[USER=”3125″]Alephy[/USER] check out the Pinned post on this

[Casimir]

[USER=”935″]drtowfigh[/USER] This is exactly the type of information to have as a resource here, IMO.

I was recently speaking with a surgeon from Munich, and he said he was giving a presentation to a large group of hernia surgeons here in the US, and he asked by a show of hands how many perform ultrasound before surgery to know as best as possible what is going on prior to cutting — he said he was shocked when NONE raised their hands. Not a single one — and there were hundreds he was speaking to. He said they always do and would not consider otherwise.

It seems knowing what type you have is the critical first step (and how to find out).
And then, understanding the types of treatments available for that type – with pros and cons.
And lastly, knowing who does them.

I tried before my surgery to get a lot of info, and was literally unable to from various surgeons locally, other than yeah, you got yourself a hernia, time to do laparoscopy with mesh, so when do you want to schedule.

I didn’t know, what I didn’t know.

Therefore, I thought I did the right thing by getting a desarda on what was a quite small, indirect hernia. Which failed — and led to a huge incisional hernia. My story is posted elsewhere here, but suffice to say, it’s literally devastated us — far too many tears to count. It was a needless solution to my problem. And the aftercare was literally nonexistent when I did need it.

I always wondered why it never hurt lifting anything heavy, never ever hurt hiking, biking, running, and nothing ever happened when I coughed. Only now, only after reading through this forum, it’s all starting to make sense. Yet, not one single surgeon here took that as a hint, whatsoever. Not one suggested ultrasound to find out. I was close to understanding something wasn’t adding up — I sensed it, I was almost going to back out day of surgery, but, I was not close enough.

A resource here to help people understand the critical aspects in choosing a path forward would literally save some peoples lives, and their families. A life in pain is a life gone, and harms far more than that one. I can’t imagine how many others are in the same situation, needlessly. I so wish to God I had known a general outline in making a plan. Please consider it.

Thanks again for sharing your expertise and time on this resource.

[Alephy]

Can one point to some core exercises videos one cam do/try?

[drtowfigh]

Indirect hernia.

[Alephy]

I would also like to know…

[Jeremy B]

Which type of hernia (Direct or Indirect) is more likely to respond to a core based regime as far as symptom improvement and or management?
Thanks in advance for your input drtowfigh.

-Jeremy

[drtowfigh]

Interesting post. Just to add some clarity:

– sometimes indirect bs direct can be diagnosed in physical examination. That is not always accurate.
– direct hernias are more of a weakness of the transversalos fascia. Indirect hernias are an enlarging if a natural hole
– the type of repair (direct vs indirect) does not always determine the repair type (open vs lap vs non-mesh). I do tailor the approach to the needs of the patient (Eg, size of hernia, size of patient, their lifestyle, their medical history, etc).
– it is not a good idea to treat one hernia and not the other. Eg, if you have an indirect hernia, we also include the direct space in your repair. The reverse is also true, especially in adult men. The reason is because the entire myopectineal orifice is at risk, so repairing only on May result in having a recurrence in the other, and redo surgery to address the other has higher risk than repairing both direct and indirect spaces at the same time.
– ultrasound is preferred over CT scan. In the US, you are right that a good Hernia ultrasound is not as easy to get.

Hope thats helpful.

[Jeremy B]

So I had an ultrasound done and the results show a Direct Inguinal hernia with bowel (protrusion medial to the vessels) upon Valsalva.
I’m saddened by this news as It seems like the repair will be more invasive (repair of the floor) vs high ligation and a couple of stitches.
The only good thing is that the direct type is less susceptible to strangulation.

#Dr. Towfigh, have you had any luck with a core based regime in people with a direct hernia?
or would it only benefit someone with an Indirect defect?

[Jeremy B]

Thanks everyone for the suggestions, and thanks for the try at home test Dr. Kang; I will give this a go.
At many times in the morning It will stay mostly reduced, It gets more pronounced after a long period of standing, during mental or physical stress.
I acquired this from straining extremely hard on the toilet and felt something quickly pop out and back in. It wasn’t noticeable at first but if I strained or coughed I would get the same popping out and back in sensation. The bulge became apparent over time, with some burning sensations and is closer to my pubic bone than my leg crease. Do any of these symptoms suggest one type over the other? Any thoughts appreciated.
Thanks!
-Jeremy

[drkang]

quote Jeremy B:

Good Intentions, thank you for your response.

I am a 37yo male, 170lb thin, 6’2″ diagnosed with a right side inguinal hernia by two local surgeons (both hernia specialists);
Neither of them were able to determine subtype upon examination.

The reason I would like to know the subtype is to develop a plan with a very conscious surgeon who can perform a quality no-mesh repair with minimal trauma. Please chime in with any thoughts or opinions.

If it is a Direct hernia I will try to live with it as long as possible as the surgery is more traumatic and involved.
If it is Indirect then I will travel anywhere to have one of the all time masters repair it:

1. If It is a very small opening in the internal ring, Dr Ponsky has what seems to be the least invasive approach (High ligation Laparoscopic) Yet limited data is concerning.

2. If it is a defect that is larger in size, than Dr Kang and Dr William Brown have methods to isolate just the Indirect defect by high ligation and narrowing of the ring.

3. I wish I knew more details of what Dr. Towfigh offers as I would consider her as well.

I would also be open to documenting (video) the surgery so that others may see and benefit. @Dr. Kang I know that many people would like to see your technique, I’d be honored if you used me as an example.

Thanks!
Jeremy

I totally agree with Chaunce1234’s opinion on ultrasonography and CT scan regarding the diagnosis of the inguinal hernia. If possible, you would better check with ultrasound.
But there is one way you can identify yourself. In many cases the hernia type can be distinguished if you try to cough strongly after lying flat in bed. That is, if bulging is easy when a big coughing is done, it is likely to be a direct type. If bulging is not done well, it is more likely to be an indirect type. Of course, when the size of the hernia is not large enough, it will not be easy to distinguish that way.

I have tried to make a video recording on my surgical procedure, but the skin incision and the operative field is so small that the procedure inside seems not clearly visible and understandable.
So, I will take several important cuts with a fine camera and make them into illustrates and will show them to you soon or later.
And one more thing I want to say. Even with direct inguinal hernia, surgery is not much larger or much more traumatic than indirect type. In fact, the recovery process after surgery is similar. Therefore, even if you have a direct type, it is better to get it fixed soon.

[dog]

quote Jeremy B:

Thank you Chaunce1234, I will keep up the search for a radiologist that can confidently perform an ultrasound with valsava.

It is so frustrating that the majority of doctors or radiologists here don’t do this or have an interest outside of just opening me up and stapling down some plastic; This sounds terrifying to me.

I guess in America we are quick to slap a bandage on the issue and hope for the best. my apologies for the rant, I’m just so frustrated.
Right now my thoughts are, Try to live with this thing or travel to Dr. Brown,Dr. Towfigh, Dr Ponsky or Dr. Kang.

-Jeremy

Totally Agree !!! But who is Dr Ponsky ?

[UhOh!]

quote Good intentions:

I know that my hernia had what seem to be the classic signs of a direct hernia – a peaked bump medial to the groin when standing, that disappears when lying down. I haven’t see a clear explanation of what, exactly, is stretching or tearing and/or why a bump forms there. I assume though that the “tear” extends across or in to the inguinal canal. The image of a round hole is probably incorrect, it’s probably a longitudinal or oblong defect. Some of the omentum and intestine is pressing directly outward, visibly, and some is pressing in to the canal, where the spermatic cord is. While I was trying to live with my hernia, at times my right testicle would get pretty screwed up as the spermatic cord got pinched.

The diagrams I’ve seen, which I think are pretty overgeneralized, seem to suggest that a hole forms in the posterior part of the canal, something (fat or bowel) then pushes into the canal from the back side, and then sort of slides down and out the external ring.

The diagrams I’ve seen are always depicted with intestine in them, but I thought that a significant percentage were just fat, though I cannot seem to find a reliable stat on that.

I don’t really get testicular pain, just some muscle cramping above the defect, closer to my hip joint. Feels like a minor muscle ache, which I’m assuming is because there’s some kind of tear along that muscle and the discomfort is referring upwards.

[miner]

You might try calling some places that do ultrasounds for pregnancies and host those ridiculous parties where you invite your friends and they look at the baby on the ultrasound. That was what I did and the person who ran the business was more then happy to do it without any type of referral and was quite knowledgeable. They actually taught ultrasound technicians. It was like $100.

A CT isnt really dependent on the technician you strain and the machine does the rest that is why most doctors prefer them. Plus they increase your risk of cancer which means more business.

The surgeon I went to would not order a ultrasound he didnt like them. My primary care doctor played dumb and would not order one. Call some places.

[Good intentions]

quote UhOh!:

Not to hijack this thread, but a related question: Is it true that ease of manual reducibility and tendency to spontaneous self-reduce upon lying supine can determine the type (between direct and indirect) and if so, how accurate are these indicators?

I know that my hernia had what seem to be the classic signs of a direct hernia – a peaked bump medial to the groin when standing, that disappears when lying down. I haven’t see a clear explanation of what, exactly, is stretching or tearing and/or why a bump forms there. I assume though that the “tear” extends across or in to the inguinal canal. The image of a round hole is probably incorrect, it’s probably a longitudinal or oblong defect. Some of the omentum and intestine is pressing directly outward, visibly, and some is pressing in to the canal, where the spermatic cord is. While I was trying to live with my hernia, at times my right testicle would get pretty screwed up as the spermatic cord got pinched.

[Good intentions]

quote Jeremy B:

Good Intentions, thank you for your response.

I am a 37yo male, 170lb thin, 6’2″ diagnosed with a right side inguinal hernia by two local surgeons (both hernia specialists);
Neither of them were able to determine subtype upon examination.

I see. You must be early in the hernia development process, with pain and/or pressure but no significant physical signs. There have been a few others on the forum with that problem.

I think that Dr. Kang has a mesh-free solution for direct and indirect hernias. I would imagine that Dr. Brown does also. I think that the open surgical method starts the same way for both so in the end the result might feel the same. I think that repairing a direct hernia soon, before the tissue gets stretched and/or torn, is important. I think that one of the reasons that mesh became popular was because it works well for large defects. If you wait too long on a direct hernia, you might just wait yourself in to mesh, or a high recurrence probability.

Good luck.

[UhOh!]

Not to hijack this thread, but a related question: Is it true that ease of manual reducibility and tendency to spontaneous self-reduce upon lying supine can determine the type (between direct and indirect) and if so, how accurate are these indicators?

I, too, am curious about this, and have a similar “plan” to the OP (as far as whether/when to seek repair), though it has more to do with the propensity of indirect hernias to eventually become incarcerated.

[Jeremy B]

Good Intentions, thank you for your response.

I am a 37yo male, 170lb thin, 6’2″ diagnosed with a right side inguinal hernia by two local surgeons (both hernia specialists);
Neither of them were able to determine subtype upon examination.

The reason I would like to know the subtype is to develop a plan with a very conscious surgeon who can perform a quality no-mesh repair with minimal trauma. Please chime in with any thoughts or opinions.

If it is a Direct hernia I will try to live with it as long as possible as the surgery is more traumatic and involved.
If it is Indirect then I will travel anywhere to have one of the all time masters repair it:

1. If It is a very small opening in the internal ring, Dr Ponsky has what seems to be the least invasive approach (High ligation Laparoscopic) Yet limited data is concerning.

2. If it is a defect that is larger in size, than Dr Kang and Dr William Brown have methods to isolate just the Indirect defect by high ligation and narrowing of the ring.

3. I wish I knew more details of what Dr. Towfigh offers as I would consider her as well.

I would also be open to documenting (video) the surgery so that others may see and benefit. @Dr. Kang I know that many people would like to see your technique, I’d be honored if you used me as an example.

Thanks!
Jeremy

[Good intentions]

I’ve been under the impression that the physical exam will determine direct versus indirect. Can you give more detail on what your situation is? It’s a bit confusing. It’s sounding like you’ve been diagnosed with a hernia and mesh implantation was suggested as a repair method.

https://www.ncbi.nlm.nih.gov/books/NBK423/

[Jeremy B]

Thank you Chaunce1234, I will keep up the search for a radiologist that can confidently perform an ultrasound with valsava.

It is so frustrating that the majority of doctors or radiologists here don’t do this or have an interest outside of just opening me up and stapling down some plastic; This sounds terrifying to me.

I guess in America we are quick to slap a bandage on the issue and hope for the best. my apologies for the rant, I’m just so frustrated.
Right now my thoughts are, Try to live with this thing or travel to Dr. Brown,Dr. Towfigh, Dr Ponsky or Dr. Kang.

-Jeremy

[Chaunce1234]

A standard ultrasound of the groin with valsava should be able to determine if a hernia is direct, indirect, or femoral. But it may be operator/radiologist dependent. This is fairly well studied too: https://www.ncbi.nlm.nih.gov/pubmed/12831490

You may just want to request an ultrasound with valsava of the groin, that should give you a good idea. Sometimes the reports don’t specify what type of hernia but instead they will say something like “protrusion medial to vessels” or “lateral to the vessels”, which a surgeon (or google) can help decipher for you.

This should be helpful in that regard:

“indirect inguinal hernia
– more common
– herniates lateral to the inferior epigastric artery 2
– anterior to the spermatic cord in males 8
– follows the round ligament in females 8

direct inguinal hernia
– less common
– a weakness in the fascial floor of the inguinal canal 10
– herniates medial to the inferior epigastric artery 2
– often through a defect in the Hesselbach triangle

Femoral hernias protrude inferior to the course of the inferior epigastric vessels and medial to the common femoral vein. They often have a narrow funnel-shaped neck and may compress the femoral vein, causing engorgement of distal collateral veins.”

from: https://radiopaedia.org/articles/inguinal-hernia and https://radiopaedia.org/articles/femoral-hernia

CT and MRI will certainly be radiologist dependent, as Dr Towfigh has shown repeatedly that many scans are misread or misinterpreted. It’s also possible the hernia could slide back into the abdominal cavity where it belongs and then not show up on any sort of imaging, simply because you’re laying down.

Given that a CT has radiation and an ultrasound does not, it might be good to start with ultrasound first. It’s also a lot cheaper.

Anyway, keep us updated on what you decide.

[B. Bell]

Looking for the mysterious missing Pinned post…