Abdominal wall radiology: A surgeon’s perspective for primary care

Abdominal wall hernias are arguably one of the most common conditions surgeons deal with.
 
Medicare figures show more than 60,000 repairs are performed annually in the private healthcare system.
 
With surgeons frequently seeing patients coming with imaging that was either unnecessary or incorrect, the health dollars spent on radiology could be much better utilised.
 
In response, and as President of the Australia and New Zealand Hernia Society, I am calling on my primary care colleagues to refrain from routinely ordering groin ultrasounds and temper patient expectations when a sonographic hernia is diagnosed. Explain they may not have a hernia, that it may not be the cause of their pain and surgery is unlikely to be a solution.
 
Thoughtful collaboration between primary care, radiology and surgery will prevent unnecessary operations, reduce healthcare costs and most importantly, improve patient outcomes.
 
Over the past decade, significant advances have transformed our understanding of hernia pathophysiology and repair, revolutionising management strategies.
 
Smoking cessation and weight loss have improved results, use of botulinum toxin A has increased abdominal wall compliance, robotics have advanced minimally invasive approaches, artificial intelligence has assisted in predicting complications, and multiple repair options are now available.
 
Moreover, not every hernia needs surgical repair and not every surgeon has the skillset to deal with complex abdominal wall pathology.
 
This has led to new centres of excellence and dedicated abdominal wall reconstruction surgeons. In Australia, the peak body for this group is the Australia and New Zealand Hernia Society (ANZHS).
 
High-resolution imaging now allows for more accurate assessment of abdominal wall muscles and viscera, helping surgeons select the optimal approach.
 
Nevertheless, many radiology reports are suboptimal, and the reporting of groin ultrasounds proves even more problematic.
 
Typically, the ultrasound is requested for a patient with groin pain – a symptom with a wide differential diagnosis. Importantly, inguinal or femoral hernias are uncommon causes of such pain.
 
In groin ultrasound, the improved acuity has paradoxically resulted in reporting small defects (< 5mm) and/or the presence of fat within the inguinal canal as a hernia.
 
Inguinal canal fat (cord lipoma) is common (present in up to 70% of people) and is frequently misinterpreted as either omentum or described as a fat containing, incarcerated hernia. While these cord lipomata can be symptomatic and may be associated with a true hernia, they rarely require an operation.
 
Imaging always needs to be interpreted in the appropriate clinical context, but patients return to their GP with an ultrasound report diagnosing a hernia and are often referred to a general surgeon based solely on this. Many of them do not have a hernia, and those who do are likely to have another cause for their pain.
 
Experienced and informed general surgeons recognise that sonographically detected hernias without a clinical correlate are seldom the cause of pain. But the patient has come with an explicit (radiological) diagnosis and the expectation of surgery. Then often ensues a difficult discussion with a disgruntled and dissatisfied patient still looking for a solution to their problem.
 
Evidence shows that patients who undergo surgery for non-clinically evident (sonographic-only) hernias face a significantly higher risk of chronic postoperative pain. This underscores the need for caution when considering surgery for this group, though not all surgeons are equally aware.
 
Furthermore, once these sonographic defects are labelled as hernias the diagnosis can significantly impact preemployment checks and work-related investigations of groin pain, sometimes precluding employment or return to work until the hernia is repaired.
 
If a patient has a clear history (a groin or abdominal wall bulge that comes and goes or used to but no longer does) or examination findings of a hernia, radiology is rarely necessary.
 
The economics and time constraints of general practice do not always allow for comprehensive patient evaluation but very few patients appear to have been examined before being referred for a scan and then to a surgeon if the ultrasound is positive.
 
If the symptoms do suggest a hernia but none is clinically evident, we urge GPs to refrain from ordering groin ultrasounds. As well as being misleading, they are costly.
 
In 2018 approximately $39.8 million in rebates were paid for groin ultrasounds in Australia – a 13-fold increase since 2000.
 
There was a concomitant decline in unilateral inguinal hernia repair with an increase in bilateral repairs, many for asymptomatic ‘occult’ ultrasound detected hernias – that is money that could have been better spent providing healthcare for Australians.
 
Surgeons recognise that easy access to a surgical opinion is often difficult and slow. However, imaging decisions (ultrasound, CT or MRI) for suspected hernia or groin pain are best made by the clinician responsible for treatment.
 
Currently many public hospitals will not accept hernia referrals without radiology. ANZHS is working to educate hospital administrations that this is wasteful and unnecessary. We are also engaging with the Royal Australian and New Zealand College of Radiologists to revise their descriptors in reporting groin ultrasounds, recognising that most so-called ‘irreducible fat-containing hernias’ are cord lipomas.
 
Dr Rod Jacobs is a general surgeon in Melbourne and inaugural President of the Australia and New Zealand Hernia Society.

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