Ultrasound of the abdominal wall hernias

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  • Subcostal incision skinincisionshorter than deeper incision with extension along line of incision both medially and laterally. There is potential for hernia (ovals).Midline vertical incisionSuture perforations (circles) site for incisional hernias (curved arrow).Lower abdominal Pfannenstiel incision (bikini cut)Bikini cut is curvilinear cutaneous and subcutaneous incision (A), but vertical component of incision is between rectus abdominis muscles, with potential for incisional hernia (vertical rectangle).
  • Sonogram of inguinal region parallel and cranial to inguinal ligament Spermatic cord (C), external iliac artery (A), inferior epigastric artery (E), femoral vein (V), and superior pubic ramus (curved arrow).
  • Pre-Valsalva maneuver sonogramHernia not visible, external iliac artery (A), inferior epigastric artery (E), and superior pubic ramus (curved arrow).Post-Valsalva maneuver sonogram External iliac artery (A), inferior epigastric artery (E), dilated external iliac vein (V), superior pubic ramus (curved arrow), and indirect inguinal hernia (H) originating from lateral to external iliac artery (arrowhead) and traversing inguinal canal from lateral to medial. (Left = lateral)
  • Pre-Valsalva maneuver sonogram Hernia not visible, peritoneal fat stripe (straight arrows) medial to inferior epigastric artery (curved arrow).Post-Valsalva maneuver sonogramDirect inguinal hernia deforming peritoneal reflection (straight arrows) medial to inferior epigastric artery (curved arrow). Left is lateral, right is medial.
  • Pre-Valsalva maneuver sonogram Hernia not visible, femoral artery (A), femoral vein (V), and superior pubic ramus (curved arrow).Post-Valsalva maneuver sonogram Dilated femoral vein (V) lateral to femoral hernia (arrows). Superior pubic ramus (curved arrow) is also seen.
  • Subcostal incision skinincisionshorter than deeper incision with extension along line of incision both medially and laterally. There is potential for hernia (ovals).Midline vertical incisionSuture perforations (circles) site for incisional hernias (curved arrow).Lower abdominal Pfannenstiel incision (bikini cut)Bikini cut is curvilinear cutaneous and subcutaneous incision (A), but vertical component of incision is between rectus abdominis muscles, with potential for incisional hernia (vertical rectangle).
  • Ultrasound of the abdominal wall hernias

    1. 1. US of anterior abdominal wall hernias Samir Haffar M.D. Assistant Professor of Gastroenterology
    2. 2. Anterior abdominal wall hernias • Types: Anterior abdominal wall hernias Incisional hernias • Pitfalls in hernia evaluation
    3. 3. Anterior abdominal wall hernias -1 Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Epigastric hernia Periumbilical hernia Umbilical hernia Infraumbilical divarication
    4. 4. Anterior abdominal wall hernias -2 Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Inferior epigastric artery & inguinal ligament Direct inguinal hernia Indirect inguinal hernia Femoral hernia Spigelian hernia
    5. 5. Incisional hernias Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Midline vertical incision Lower abdominal Pfannenstiel incision (bikini cut) Subcostal incision
    6. 6. Abdominal wall hernia  Epigastric hernia  Periumbilical hernia  Umbilical hernia  Infraumbilical divarication  Spigelian hernia  Indirect inguinal hernia  Direct inguinal hernia  Femoral hernia  Incisional hernia
    7. 7. Anterior abdominal wall hernias – 1 Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Epigastric hernia Periumbilical hernia Umbilical hernia Infraumbilical divarication
    8. 8.  Epigastric hernia
    9. 9. Epigastric hernia Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Longitudinal sonogram along linea alba No movement during Valsalva maneuver Not unusual for these hernias when small Defect in linea alba Herniated extraperitoneal fat
    10. 10.  Periumbilical hernia
    11. 11. Paraumbilical hernia Rectus abdominis muscle Rectus abdominis muscle Transverse sonogram Defect in linea alba Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Herniated extraperitoneal fat
    12. 12.  Umbilical hernia
    13. 13. Umbilical hernia Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. 4-month-old boy with umbilical hernia Transverse sonogram at umbilicus Umbilical hernia Medial margin of of rectus abdominis Medial margin of of rectus abdominis
    14. 14.  Infraumbilical divarication
    15. 15. Infraumbilical divarication of rectus abdominis Pre-Valsalva sonogram Both rectus abdominus muscles closely approximated to midline Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Pre-Valsalva sonogram Separation of rectus abdominis muscles
    16. 16. Anterior abdominal wall hernias – 2 Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Direct inguinal hernia Indirect inguinal hernia Femoral hernia Inferior epigastric artery
    17. 17. Anterior abdominal wall hernias – 2 Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Inferior epigastric artery & inguinal ligament Direct inguinal hernia Indirect inguinal hernia Femoral hernia Spigelian hernia
    18. 18. Man’s right inguinal region viewed from within abdomen Jamadar DA et al. AJR 2006; 187:185–190 Inferior epigatric artery Rectus abdominal Inguinal ligamentDeep ring Vas deferens Direct inguinal hernia Femoral hernia Spigelian hernia Indirect inguinal hernia
    19. 19. Transducer position to evaluate abdominal wall hernias Jamadar DA et al. AJR 2006; 187:185–190 1- Spigelian hernia 4- Femoral hernia 3- Direct inguinal hernia 2- Indirect inguinal hernia
    20. 20.  Spigelian hernia
    21. 21. Right spigelian hernia Jamadar DA et al. AJR 2006; 187:185–190 Rectus abdominis M Lateral abdominal M Inferior epigastric artery Peritoneal fat stripe Post-Valsalva sonogram Rectus abdominis M Lateral abdominal M Peritoneal fat stripe Pre-Valsalva sonogram
    22. 22. Left spigelian hernia Transverse sonogram along linea semilunaris Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Bowel Rectus abdominis Flank muscle Extraperitoneal fat
    23. 23.  Indirect inguinal hernia
    24. 24. Normal inguinal anatomy Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364. Rt inguinal region – Parallel to & cranial to inguinal ligament Superior pubic ramus
    25. 25. Indirect inguinal hernia Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Rt inguinal region – Parallel & cranial to inguinal ligament Pre-Valsalva maneuver Superior pubic ramus Post-Valsalva maneuver Superior pubic ramus
    26. 26.  Direct inguinal hernia
    27. 27. Direct inguinal hernia Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Rt inguinal region – Parallel & cranial to inguinal ligament Inferior epigastric artery Pre-Valsalva maneuver Fat stripe Post-Valsalva maneuver Inferior epigastric artery
    28. 28.  Femoral hernia
    29. 29. Femoral hernia Superior pubic ramus Pre-Valsalva maneuver Superior pubic ramus Post-Valsalva maneuver Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Rt inguinal region – Parallel & caudad to inguinal ligament
    30. 30. Incisional hernias Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Midline vertical incision Lower abdominal Pfannenstiel incision (bikini cut) Subcostal incision
    31. 31.  Incisional hernia
    32. 32. Incisional hernia Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. 39-year-old woman with right upper quadrant discomfort medial to cholecystectomy incision (hernia) (extraperitoneal fat) (posterior rectus abdominis) Transverse oblique sonogram
    33. 33. Pitfalls in hernia evaluation
    34. 34. Pitfalls in hernia evaluation • Atrophy of anterior abdominal wall muscles • Focal spasm in an abdominal wall muscle • Xiphoid process noticeable after weight loss • Enlarged lymph nodes • Saphenous varix • Hematoma • Focal fluid collection • Subcutaneous endometrioma Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364.
    35. 35. Atrophy of anterior abdominal wall muscles Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364. Appreciated by close proximity of underlying bowel to abdominal wall Centimeter scale to right of image
    36. 36. Prominent xiphoid process Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364. Sagittal midline epigastric sonogram Hypoechoic cartilaginous xiphoid process (X) with ventral curve Tip (arrow) closest to overlying skin & under palpable abnormality
    37. 37. Inguinal lymph nodes Lymph node with fatty hilum Medial to femoral artery (A) & femoral vein (V) Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Sonogram caudad & parallel to inguinal ligament
    38. 38. Saphenous varix Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364. Focal variceal dilation (V) along proximal LSV Just before it traverses cribriform fascia to anastomose with FV V FV LSV Sonogram over proximal LSV
    39. 39. Groin hematoma Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. 25-year-old woman with right groin hematoma Transverse sonogram Heterogeneous, predominantly hypoechoic mass in superficial tissues
    40. 40. Wound abscess Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Longitudinal sonogram Tubular structure Hypoechoic contents Thick & irregular walls Wavy echogenic structure Abdominal wall mesh Prior incisional hernia repair
    41. 41. Subcutaneous endometrioma 34-year-old woman after caesarian section Ill-defined heterogeneous mass with indistinct margins & minimal vascularity superficial to rectus abdominis muscle Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364. Longitudinal sonogram over scar
    42. 42. Thank You

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