European Journal of Radiology, 15 (1992) 185-189
185
0 1992 Elsevier Science Publishers B.V. All rights reserved. 0720-048X/92/$05.00
EURRAD
3 12
Prompt diagnosis of ‘acute groin’ conditions in infants I. Erez a, N. Schneider b, E. Glaser b and M. Kovalivker a “Department of Pediattic Surgery and b Department of Radiology, Meir General Hospital, Sapir Medical Center. Kfar Saba and Tel-Aviv University Sackler School of Medicine, Tel-Aviv. Israel
(Received 30 January 1992; accepted after revision 18 April 1992)
Key words: Ultrasound,
infants and children; Ultrasound,
emergency
Abstract Urgent sonographic examination of the groin was performed in 58 patients under the age of two years. Accurate diagnosis was done in conditions such as: incarcerated inguinal hernia, twisted undescended testis, incarcerated ovary in inguinal hernia and others. Ultrasonography facilitated decision-making and differentiation between surgical and non-surgical conditions.
Introduction Prompt diagnosis is particularly important in infantile patients, in whom groin complications are frequent and severe [ 11. Ultrasonography provides accurate visualization of soft tissue structures, elucidates location, size and even consistency of groin masses. Yet, few reports are published concerning its use in detecting complications of the groin [2-51. In situations in which the physical examination is either non-conclusive or difficult because of communication deficiency with the child, the sonographic examination is particularly useful and proved to be readily available, simple and highly accurate in 54/58 cases. Material and methods During a two-year period ultrasonographic examinations were performed in 58 patients (44 males, 14 females) under the age of two years. Fifteen patients were 3 months old or younger, and one baby was born with twisted inguinal testis, which was diagnosed by ultra-
Correspondence
to: N. Schneider, M.D., Department Meir General Hospital, 44281 Kfar Saba, Israel.
of Radiology,
sound of the groin. In all 58 cases the sonographic evaluations were conducted urgently by two experienced radiologists, using B mode system 7.5 MHz high resolution transducers. The sonographic examinations were performed only following non-conclusive physical examinations, done by senior pediatric surgeons. The results were compared with the management and ultimate outcome. Results The ultimate diagnosis of the 58 patients is shown in Table 1. Incarcerated inguinal hernia was the most frequent groin pathology. In seven cases the sonographic results did not correlate with the referring diagnoses (Table 2). In five of these seven cases the sonography proved to be correct. In another two patients both the physical examination and ultrasonography were incorrect in diagnosing ‘incarcerated hernias’, which could not be confirmed at operation (false positive diagnosis). Two cases of false negative results were also obtained. A recurrent hernia was wrongly diagnosed as a hematoma and idiopathic edema was incorrectly diagnosed by ultrasound as a groin abscess. In all other cases the sonographic diagnosis was correct. The accuracy rate of ultrasonographic examination of the groin was therefore 93% (54/58).
186 TABLE
Case reports
1
Ultimate diagnoses of 58 patients Ultimate diagnosis
No. of patients
Incarcerated inguinal hernia Incomplete reduction of hernia Irreducible ovary Early recurrent inguinal hernia Lymphadenopathy of the groin Torsion of undescended testis Postoperative hematoma of the cord Postoperative infected hematoma Lymphangioma of the groin Funiculocele Idiopathic inguino-scrotal edema Strangulated omentum in hernia Normal groin/hydrocele
24 3 4 2 6 2 6 1 1 3 2 1 3
Total
58
Case I. A one-year old female was admitted because of a 24 h history of left groin swelling, fever and vomiting. The differential diagnosis included incarcerated inguinal hernia, strangulated ovary and lymphadenitis. Ultrasonogram (Fig. la) showed multiple hyperechoic irregular structures outside a normal inguinal canal. Lymphadenitis was diagnosed and treated successfully by broad spectrum antibiotics. Case 2. A two-week-old baby was examined in the emergency room for incarcerated right inguinal hernia. The hernia was manually reduced, but the baby remained uncomfortable. An incomplete reduction was suspected and ultrasonography was done (Fig. lb). This showed a right inguinal canal with no bowel pattern. The baby had been fed and relaxed shortly afterwards. Case 3. A one-month-old baby was unwell for 24 h, with two episodes of vomiting. On examination, a ten-
TABLE 2 Comparison
of diagnoses and results between noncorrelated
clinical and sonographic evaluation
Referring diagnosis
U/S Diagnosis
No.
Management
U/S Diagnosis Correct
Irreducible ovary Funiculocele Idiopathic edema Incarcerated hernia Recurrent hernia Recurrent hernia
Lymphadenopathy Incarcerated hernia Groin abscess Strangulated omentum Hematoma Hematoma
2 1 1 1 1 1
Medical Surgery Observation Surgery Observation Surgery
++ + _
a
b
+ + _
C
Fig. 1. (a) Lymphadenitis of the groin. Note the multiple hyperechoic irregular nodes outside a normal inguinal canal. b. Inguinal canal. No bowel pattern is visible. c. Incarcerated inguinal hernia. Bowel pattern is included at the proximal side of the inguinal canal. A normal sized testis is present distally.
187
der mass was palpated at the right groin and no testicle was detected inside the scrotum. Diagnosis of tor-, sion of the right testis was made but sonography, performed just prior to the operation (Fig. lc), revealed an incarcerated bowel in inguinal hernia and an undescended testis. On exploration the bowel was reduced, hemiotomy was performed and a mildly cyanotic testis, which soon recovered, was then pexied. Case 4. An eight-mont-old restless baby was admitted with a 12 h history of vomiting. On physical examination a large, unrecorded mass was palpable in the left groin, suspected to be incarcerated hernia. Ultrasonography (Fig. 2a) demonstrated a homogenic, welldefined hypoechoic lesion, compatible with funiculocele. This was followed up in the outpatient clinic. Otitis media was the true source of the baby’s symptoms, which was treated conservatively. Case 5. A one-year-old male with normal past medical history was urgently admitted because of sudden onset of groin swelling and a tender scrotum. A torsion testis was suspected, but incarcerated bowel could not be excluded. The ultrasound showed normal testicular and epididymis structures, surrounded by fluid (Fig. 2b), a dilated inguinal canal and incarceration of a fatty tissue (not bowel). This unusual diagnosis was confirmed at an urgent exploration and a strangulated necrotic segment of omentum was resected. Case 6. A two-year-old infant had a right inguinal herniotomy, performed 3 weeks earlier. The patient was
a
checked for high positioned testis and a non-tender swelling along the inguinal region. Sonography (Fig. 2c) demonstrated irregular, mixed, solid and cystic lesions, with calcification compatible with an old hematoma along the spermatic cord. These findings were confirmed when an orchidopexy was done, electively, two weeks later. Case 7. A two-week-old female was admitted with a right groin lump. The differential diagnosis was between incarcerated inguinal hernia and an irreducible ovary. Ultrasonography (Fig. 3a) showed an homogeneous hypoechoic ovarian structure in the inguinal canal with no bowel pattern. A normal unstressed ovary was reduced at operation and herniotomy was then performed. Case 8. A 14-month-old baby was waiting for elective surgery of the right undescended testis. Sudden groin pain and vomiting occurred and was diagnosed on physical examination as twisted inguinal testis or incarcerated hernia. The ultrasound examination could not demonstrate a bowel pattern inside the canal and a diagnosis of torsion of inguinal testis was confirmed at urgent exploration (Fig. 3b). Discussion The frequency of groin complications is highest during early infancy [ 1,6]. It is a daily experience to examine a distressed baby who presents an ‘acute groin’ condition. Generally the medical history and a careful physical examination enable a straightforward diagno-
C b Fig. 2. (a) Funiculocele. Hypoechoic, homogenic lesion, typical to fluid-filled mass, inside the inguinal canal. b. Strangulated omentum in hernia. Fatty tissue incarcerated in a dilated inguinal canal. The testis and epididymis are normal. c. Postoperative hematoma of the cord. Irregular solid and cystic lesions along the spermatic cord. Note the calcifications typical of an old hematoma.
a Fig. 3. Incarcerated
b ovary in inguinal hernia. The ovary is shown as a homogeneous hypoechoic structure. b. Torsion of inguinal testis. Edematous hypoechoic testis inside the canal. No bowel pattern is present.
sis. However, examination of a tender mass in a restricted area may be difhcult, even to an experienced clinician, in the absence of good communication with the patient, in view of a previous operation, or when other common symptoms and signs (e.g. fever, vomiting) mislead the diagnosis. Conditions such as incarcerated inguinal hernia, torsion of undescended testis, irreducible ovary in inguinal hernia should immediately be differentiated from nonsurgical conditions as hematomas, lymphadenitis, retractile testis and others. Ultrasonographic investigation of the groin provides non-invasive, high resolution qualities [ 3,4]. A typical fluid-filled mass of funiculocele can be easily distinguished from other lesions by its homogenous hypo- or an-echoic appearance, as in case no. 4. A hematoma of the groin following trauma or inadequate hemostasis during an operation is detected as mixed echogenicity [ 7-91. A long-standing hematoma develops thickening of the wall, calcifications and septations visible on the ultrasound screen [lo] (Fig. 2~). Infection may present fluid-debris levels [ 91 and an inflammatory process of the groin can be differentiated from surgical emergency by the appearance of mixed hyperechogenic structures of enlarged lymph nodes outside a normal inguinal canal (Fig. la). Incarcerated inguinal hernia was, as expected, the most common groin pathology in this study. Over 40% of incarcerations occur in the infantile age group [ 11,121. In children, unlike the approach in adults, an attempt at non-surgical reduction of an early incarceration is safe [ 1,111. An elective operation of inguinal hernia is always preferable, as the rate of complications in urgent operative reduction is high [ 131. This includes
testicular infarction [ 121, lung complications [ 141 and a relatively high recurrence rate in babies [ 61. The differential diagnosis of an incarcerated hernia, in which a manual reduction is preferable, and a torsion of inguinal testis is extremely important, but seldom straightforward. The salvage of the testis and future fertility depend on early diagnosis and immediate exploration in conditions of torsion of undescended testes. Ultrasonography (Fig. 3b) offered correct distinction of these two conditions. Correct diagnosis was obtained in 54 of 58 infants (93 %) who presented with ‘acute groin’ conditions. The diagnoses were confirmed either by operative findings or by successful medical and observational management. These results are similar to the accurate results of others [3,4,15,16], who reported 91-100% reliability in delineating hernias, hematomas, abscesses, tumors and other pathologies in the inguinal region. Our data support a more routine use of this simple, non-invasive, accurate mode of investigation, particularly in urgent conditions of the groin in infants.
References Rowe WI, Lloyd DA. Inguinal hernia. In Welch KJ, Randolph JG et al. (eds): Pediatric Surgery (4th ed). Chicago, IL, Year Book, 1986; pp 779-193. Deitch EA, Soncrant MC. The value of ultrasound in the diagnosis of nonpalpable femoral hernias. Arch Surg 1981; 116: 185187. Deitch EA, Soncrant MC. Ultrasonic diagnosis off surgical disease of the inguinal-femoral region. Surg Gynecol Obstet 1981; 152: 3 19-322. Lineaweaver W, Vlasak M, Muyshoudt E. Ultrasonic examina-
189
5
6
7 8
9
tion of abdominal wall and groin masses. South Med J 1983; 76: 590-592. Subramanya BR, Balthazar EJ, Raghavendra BN, Horii SC, Hilton S. Sonographic diagnosis of scrotal hernia. AJR 1982; 139: 535-538. Grosfeld JL, Minnick K, Shedd F, West KW, Rescorla FJ, Vane DW. Inguinal hernia in children: Factors affecting recurrence in 62 cases. J Ped Surg 1991; 26: 283-287. Wicks JD, Silver TM, Bree RL. Gray scale features of hematocele: An ultrasonic spectrum. AJR 1978; 131: 977-980. Cunningham J. Sonographic findings is clinically unsuspected acute and chronic scrotal hematocele. AJR 1983; 140: 749752. Archer A, Choyke PL, O’Brien W, Maxted WC, Grant EG. Scrotal enlargement following inguinal herniography: Ultrasound evaluation. Urol Radio1 1988; 9: 249-252.
10 Hricak H. Jeffrey RB. Sonography of acute scrotal abnormalities. Radio1 Clin N Am 1983; 21: 595-603. 11 Puri P, Guiney EJ, O’Donnell B. Inguinal hernia in infants: The fate of the testis following incarceration. J Pediatr Surg 1984; 19: 44-46. 12 Friedman D. Schwartzbard A, Velcek FT. Klotz DH, Kottmeier PK. The government and the inguinal hernia. J Pediatr Surg 1979; 14: 356-359. 13 Rowe MI, Clatworthy HW. Incarcerated and strangulated hernias in children. Arch Surg 1970; 101: 136-138. 14 Kauffman HN Jr, O’Brien DP. Selective reduction of incarcerated inguinal hernia. Am J Surg 1970; 119: 660-673. 15 Engel JM, Deitch EA. Sonography of the anterior abdominal wall. AJR 1981; 137: 73-77. 16 Shawker TH. B-mode ultrasonic evaluation of scrotal swellings. Radiology 1976; 118: 417-419.
185
0 1992 Elsevier Science Publishers B.V. All rights reserved. 0720-048X/92/$05.00
EURRAD
3 12
Prompt diagnosis of ‘acute groin’ conditions in infants I. Erez a, N. Schneider b, E. Glaser b and M. Kovalivker a “Department of Pediattic Surgery and b Department of Radiology, Meir General Hospital, Sapir Medical Center. Kfar Saba and Tel-Aviv University Sackler School of Medicine, Tel-Aviv. Israel
(Received 30 January 1992; accepted after revision 18 April 1992)
Key words: Ultrasound,
infants and children; Ultrasound,
emergency
Abstract Urgent sonographic examination of the groin was performed in 58 patients under the age of two years. Accurate diagnosis was done in conditions such as: incarcerated inguinal hernia, twisted undescended testis, incarcerated ovary in inguinal hernia and others. Ultrasonography facilitated decision-making and differentiation between surgical and non-surgical conditions.
Introduction Prompt diagnosis is particularly important in infantile patients, in whom groin complications are frequent and severe [ 11. Ultrasonography provides accurate visualization of soft tissue structures, elucidates location, size and even consistency of groin masses. Yet, few reports are published concerning its use in detecting complications of the groin [2-51. In situations in which the physical examination is either non-conclusive or difficult because of communication deficiency with the child, the sonographic examination is particularly useful and proved to be readily available, simple and highly accurate in 54/58 cases. Material and methods During a two-year period ultrasonographic examinations were performed in 58 patients (44 males, 14 females) under the age of two years. Fifteen patients were 3 months old or younger, and one baby was born with twisted inguinal testis, which was diagnosed by ultra-
Correspondence
to: N. Schneider, M.D., Department Meir General Hospital, 44281 Kfar Saba, Israel.
of Radiology,
sound of the groin. In all 58 cases the sonographic evaluations were conducted urgently by two experienced radiologists, using B mode system 7.5 MHz high resolution transducers. The sonographic examinations were performed only following non-conclusive physical examinations, done by senior pediatric surgeons. The results were compared with the management and ultimate outcome. Results The ultimate diagnosis of the 58 patients is shown in Table 1. Incarcerated inguinal hernia was the most frequent groin pathology. In seven cases the sonographic results did not correlate with the referring diagnoses (Table 2). In five of these seven cases the sonography proved to be correct. In another two patients both the physical examination and ultrasonography were incorrect in diagnosing ‘incarcerated hernias’, which could not be confirmed at operation (false positive diagnosis). Two cases of false negative results were also obtained. A recurrent hernia was wrongly diagnosed as a hematoma and idiopathic edema was incorrectly diagnosed by ultrasound as a groin abscess. In all other cases the sonographic diagnosis was correct. The accuracy rate of ultrasonographic examination of the groin was therefore 93% (54/58).
186 TABLE
Case reports
1
Ultimate diagnoses of 58 patients Ultimate diagnosis
No. of patients
Incarcerated inguinal hernia Incomplete reduction of hernia Irreducible ovary Early recurrent inguinal hernia Lymphadenopathy of the groin Torsion of undescended testis Postoperative hematoma of the cord Postoperative infected hematoma Lymphangioma of the groin Funiculocele Idiopathic inguino-scrotal edema Strangulated omentum in hernia Normal groin/hydrocele
24 3 4 2 6 2 6 1 1 3 2 1 3
Total
58
Case I. A one-year old female was admitted because of a 24 h history of left groin swelling, fever and vomiting. The differential diagnosis included incarcerated inguinal hernia, strangulated ovary and lymphadenitis. Ultrasonogram (Fig. la) showed multiple hyperechoic irregular structures outside a normal inguinal canal. Lymphadenitis was diagnosed and treated successfully by broad spectrum antibiotics. Case 2. A two-week-old baby was examined in the emergency room for incarcerated right inguinal hernia. The hernia was manually reduced, but the baby remained uncomfortable. An incomplete reduction was suspected and ultrasonography was done (Fig. lb). This showed a right inguinal canal with no bowel pattern. The baby had been fed and relaxed shortly afterwards. Case 3. A one-month-old baby was unwell for 24 h, with two episodes of vomiting. On examination, a ten-
TABLE 2 Comparison
of diagnoses and results between noncorrelated
clinical and sonographic evaluation
Referring diagnosis
U/S Diagnosis
No.
Management
U/S Diagnosis Correct
Irreducible ovary Funiculocele Idiopathic edema Incarcerated hernia Recurrent hernia Recurrent hernia
Lymphadenopathy Incarcerated hernia Groin abscess Strangulated omentum Hematoma Hematoma
2 1 1 1 1 1
Medical Surgery Observation Surgery Observation Surgery
++ + _
a
b
+ + _
C
Fig. 1. (a) Lymphadenitis of the groin. Note the multiple hyperechoic irregular nodes outside a normal inguinal canal. b. Inguinal canal. No bowel pattern is visible. c. Incarcerated inguinal hernia. Bowel pattern is included at the proximal side of the inguinal canal. A normal sized testis is present distally.
187
der mass was palpated at the right groin and no testicle was detected inside the scrotum. Diagnosis of tor-, sion of the right testis was made but sonography, performed just prior to the operation (Fig. lc), revealed an incarcerated bowel in inguinal hernia and an undescended testis. On exploration the bowel was reduced, hemiotomy was performed and a mildly cyanotic testis, which soon recovered, was then pexied. Case 4. An eight-mont-old restless baby was admitted with a 12 h history of vomiting. On physical examination a large, unrecorded mass was palpable in the left groin, suspected to be incarcerated hernia. Ultrasonography (Fig. 2a) demonstrated a homogenic, welldefined hypoechoic lesion, compatible with funiculocele. This was followed up in the outpatient clinic. Otitis media was the true source of the baby’s symptoms, which was treated conservatively. Case 5. A one-year-old male with normal past medical history was urgently admitted because of sudden onset of groin swelling and a tender scrotum. A torsion testis was suspected, but incarcerated bowel could not be excluded. The ultrasound showed normal testicular and epididymis structures, surrounded by fluid (Fig. 2b), a dilated inguinal canal and incarceration of a fatty tissue (not bowel). This unusual diagnosis was confirmed at an urgent exploration and a strangulated necrotic segment of omentum was resected. Case 6. A two-year-old infant had a right inguinal herniotomy, performed 3 weeks earlier. The patient was
a
checked for high positioned testis and a non-tender swelling along the inguinal region. Sonography (Fig. 2c) demonstrated irregular, mixed, solid and cystic lesions, with calcification compatible with an old hematoma along the spermatic cord. These findings were confirmed when an orchidopexy was done, electively, two weeks later. Case 7. A two-week-old female was admitted with a right groin lump. The differential diagnosis was between incarcerated inguinal hernia and an irreducible ovary. Ultrasonography (Fig. 3a) showed an homogeneous hypoechoic ovarian structure in the inguinal canal with no bowel pattern. A normal unstressed ovary was reduced at operation and herniotomy was then performed. Case 8. A 14-month-old baby was waiting for elective surgery of the right undescended testis. Sudden groin pain and vomiting occurred and was diagnosed on physical examination as twisted inguinal testis or incarcerated hernia. The ultrasound examination could not demonstrate a bowel pattern inside the canal and a diagnosis of torsion of inguinal testis was confirmed at urgent exploration (Fig. 3b). Discussion The frequency of groin complications is highest during early infancy [ 1,6]. It is a daily experience to examine a distressed baby who presents an ‘acute groin’ condition. Generally the medical history and a careful physical examination enable a straightforward diagno-
C b Fig. 2. (a) Funiculocele. Hypoechoic, homogenic lesion, typical to fluid-filled mass, inside the inguinal canal. b. Strangulated omentum in hernia. Fatty tissue incarcerated in a dilated inguinal canal. The testis and epididymis are normal. c. Postoperative hematoma of the cord. Irregular solid and cystic lesions along the spermatic cord. Note the calcifications typical of an old hematoma.
a Fig. 3. Incarcerated
b ovary in inguinal hernia. The ovary is shown as a homogeneous hypoechoic structure. b. Torsion of inguinal testis. Edematous hypoechoic testis inside the canal. No bowel pattern is present.
sis. However, examination of a tender mass in a restricted area may be difhcult, even to an experienced clinician, in the absence of good communication with the patient, in view of a previous operation, or when other common symptoms and signs (e.g. fever, vomiting) mislead the diagnosis. Conditions such as incarcerated inguinal hernia, torsion of undescended testis, irreducible ovary in inguinal hernia should immediately be differentiated from nonsurgical conditions as hematomas, lymphadenitis, retractile testis and others. Ultrasonographic investigation of the groin provides non-invasive, high resolution qualities [ 3,4]. A typical fluid-filled mass of funiculocele can be easily distinguished from other lesions by its homogenous hypo- or an-echoic appearance, as in case no. 4. A hematoma of the groin following trauma or inadequate hemostasis during an operation is detected as mixed echogenicity [ 7-91. A long-standing hematoma develops thickening of the wall, calcifications and septations visible on the ultrasound screen [lo] (Fig. 2~). Infection may present fluid-debris levels [ 91 and an inflammatory process of the groin can be differentiated from surgical emergency by the appearance of mixed hyperechogenic structures of enlarged lymph nodes outside a normal inguinal canal (Fig. la). Incarcerated inguinal hernia was, as expected, the most common groin pathology in this study. Over 40% of incarcerations occur in the infantile age group [ 11,121. In children, unlike the approach in adults, an attempt at non-surgical reduction of an early incarceration is safe [ 1,111. An elective operation of inguinal hernia is always preferable, as the rate of complications in urgent operative reduction is high [ 131. This includes
testicular infarction [ 121, lung complications [ 141 and a relatively high recurrence rate in babies [ 61. The differential diagnosis of an incarcerated hernia, in which a manual reduction is preferable, and a torsion of inguinal testis is extremely important, but seldom straightforward. The salvage of the testis and future fertility depend on early diagnosis and immediate exploration in conditions of torsion of undescended testes. Ultrasonography (Fig. 3b) offered correct distinction of these two conditions. Correct diagnosis was obtained in 54 of 58 infants (93 %) who presented with ‘acute groin’ conditions. The diagnoses were confirmed either by operative findings or by successful medical and observational management. These results are similar to the accurate results of others [3,4,15,16], who reported 91-100% reliability in delineating hernias, hematomas, abscesses, tumors and other pathologies in the inguinal region. Our data support a more routine use of this simple, non-invasive, accurate mode of investigation, particularly in urgent conditions of the groin in infants.
References Rowe WI, Lloyd DA. Inguinal hernia. In Welch KJ, Randolph JG et al. (eds): Pediatric Surgery (4th ed). Chicago, IL, Year Book, 1986; pp 779-193. Deitch EA, Soncrant MC. The value of ultrasound in the diagnosis of nonpalpable femoral hernias. Arch Surg 1981; 116: 185187. Deitch EA, Soncrant MC. Ultrasonic diagnosis off surgical disease of the inguinal-femoral region. Surg Gynecol Obstet 1981; 152: 3 19-322. Lineaweaver W, Vlasak M, Muyshoudt E. Ultrasonic examina-
189
5
6
7 8
9
tion of abdominal wall and groin masses. South Med J 1983; 76: 590-592. Subramanya BR, Balthazar EJ, Raghavendra BN, Horii SC, Hilton S. Sonographic diagnosis of scrotal hernia. AJR 1982; 139: 535-538. Grosfeld JL, Minnick K, Shedd F, West KW, Rescorla FJ, Vane DW. Inguinal hernia in children: Factors affecting recurrence in 62 cases. J Ped Surg 1991; 26: 283-287. Wicks JD, Silver TM, Bree RL. Gray scale features of hematocele: An ultrasonic spectrum. AJR 1978; 131: 977-980. Cunningham J. Sonographic findings is clinically unsuspected acute and chronic scrotal hematocele. AJR 1983; 140: 749752. Archer A, Choyke PL, O’Brien W, Maxted WC, Grant EG. Scrotal enlargement following inguinal herniography: Ultrasound evaluation. Urol Radio1 1988; 9: 249-252.
10 Hricak H. Jeffrey RB. Sonography of acute scrotal abnormalities. Radio1 Clin N Am 1983; 21: 595-603. 11 Puri P, Guiney EJ, O’Donnell B. Inguinal hernia in infants: The fate of the testis following incarceration. J Pediatr Surg 1984; 19: 44-46. 12 Friedman D. Schwartzbard A, Velcek FT. Klotz DH, Kottmeier PK. The government and the inguinal hernia. J Pediatr Surg 1979; 14: 356-359. 13 Rowe MI, Clatworthy HW. Incarcerated and strangulated hernias in children. Arch Surg 1970; 101: 136-138. 14 Kauffman HN Jr, O’Brien DP. Selective reduction of incarcerated inguinal hernia. Am J Surg 1970; 119: 660-673. 15 Engel JM, Deitch EA. Sonography of the anterior abdominal wall. AJR 1981; 137: 73-77. 16 Shawker TH. B-mode ultrasonic evaluation of scrotal swellings. Radiology 1976; 118: 417-419.
