Faroes Lectures 2019

1. POCUS of the groin
Hernia, hip and lymph nodes
Dr. Bjørn Skjoldbye M.D. B.Sc.
Dept. of Radiology
Aleris-Hamlet Privathospitals
Denmark

2. • Sonoscopy (Ultrasound Viewing)
– POCUS; point-of-care ultrasound
– FAST, FATE
– FUS (Fokuseret Ultralydskanning)
• Sonography (Ultrasound scanning)
– Imaging specialist
• Sonologist or sonographer
– Clinical specialist

3. Pain in the groin
• Lower abdomen & pelvic
– Uro-genitial
– Bowel
– Lymphadenitis
• Abdominal Wall
– Hernias
– Masses, fluid
• Musculo-Sceletal
– Intra-articular
– Pubalgia

4. Equipment and settings
• Linear array 7-12 MHz
• Virtual Convex
• Preset: Abdominal Wall
• Colour Doppler
• Dual Image
• Clip & Image storage

5. Hernia
• Hernia:- protrusion of a structure
through a wall that normally
contains it
• Abdominal hernia: - contains
peritoneal sac and may contain
viscera, usually small bowel, and
omentum.
• ULTRASOUND:
• Surpine & Upright position
• Repeated Valslava
• ½ Sit-up

6. Imaging of Inguinal Hernia
• Ultrasonography
– Clinical
– Dynamic
– Non-ionizing
– High PPV
– Fast and Cheap
MRI (T1) peritoneal fat
Herniography
CT
US
Sensitivity 92,7 - 100
Specificity 22 - 100
PPV 83,3 - 100
NPV 40 - 100
Amy Robinson et al—Meta-analysis of Sonography in the Diagnosis of Inguinal Hernias
J Ultrasound Med 2013; 32:339–346

7. Features of a hernia
• Reponibelt (Reponable)
– Spontant
– Reponerbart
• Irreponibelt
– Obstrueret
– Incarcereret
– Stranguleret
• Broksæk (hernia sac)
– Indhold (contain)
• Brokport/Broktype (type)
Spina illiaca sup. Ant.
Tuberculum pub.
Inguinal Canal

8. Most frequent surgical procedure, in DK.
10.000 inguinale, 400 femoral- opr. /yr
5.000 umbilical or ventral hernia opr /yr
Acute operations: < 1%.
Net-mesh: 98 %.
Laparoskopic opr: 97 %
Reccurence rate DK: 1%.
Inguinal hernia : Most frequent males.
-Indirekt hernia: Children/younger
-Direct hernia: increase by age
Femoral, umbilical: most frequent females
Hernia database in DK
7% of all surgical outpatient visits.
- Male:female ratio is 8:1.
- Affects 1-3% children.
Male incidence
- 11 per 10,000 person-years, (16-24 yr)
- 200 per 10,000 person-years, (>75 yr)
Risk factors
Infants: prematurity, male sex.
Adults: male sex, obesity, constipation,
chronic cough, heavy lifting.

9. Femoral and Inguinal Hernias

10. a. & v. epigastrica inf.

11. The inguinal canal; Normal
Tub. Pub.
+ Valsalva

12. Lateral Inguinal Hernia

13. Indirect Hernia (Lateral Hernia)

14. Lateral inguinal hernia

15. Incarcerated hernia

16. Direct hernia (Medial hernia)

17. Femoral Hernia

18. Spigelian Hernia
Lateral Ventral Hernia
≈1% of all hernia

19. Linea Alba –
diastasis & hernias

20. Para-umbilical hernia

21. Net-mesh
Tags, glue, peritoneum

22. Net mesh in-situ - normal

23. Netmesh
with post-operative fluid collections

24. Netmesh complication

25. Pain from tag fixation of a netmesh

26. Post-operative lump in the groin
Seroma punctured (21 G Chiba)

27. Solid lesions in the abdominal wall
Dynamic evaluation
• Subcutaneous ?
• Invasive/adherent ?
• Irregular ?
• Hypervascular ?

28. Post operative pain in the groin after Lap-hernia opr. : 5%
• New hernia
• Hernia recurrence
• Net mesh
• Tags/glue/adherences
• Fluid collections
• Muculo-skeletal
– Co-exsiting disorder
– Iatrogenic

29. The Hip Joint

30. Ultrasonography of the hip
• Anterior
– Ileo-psoas tendons
– Anterior labrum, acetabular rim, joint
capsule Normal/Abnormal?
– Hydarthron, extra-articular fluid
• Latreral
– Illiac crest, Tractus ileo-tibialis
– Per-trocanteric insersitions & bursa
• Posterior approach (Prone position)
– Tuber ischii (Semimembranosus,
semitendinosus)
– Gluteus region
– Piriformis
• Comparison (yes/no)
• Direct pain (yes/no)
• Fluid (yes/no)
• Masses (yes/no)
• Structure (thickness, layers, borders, surface)
• Hypervascular (Color Doppler) (yes/no)

31. Anterior hip; longtudinal view
Left-right comparision

32. Anterior Labrum, Synovial thicknes, Hydarthron?
Other abnormal issues?
acetabulum caput

33. US-guided intraarticular injection

34. The greater trocanter, Trocanter maj.

35. Trocanter maj, Bursitis

36. The Doha Agreement 2014
Groin Pain (GrP)
• Excluding Lower Abd. & Uro-Gynaecological causes
• Excluding hernias
• Excluding intra-articular disorders
– Adductor related GrP
– Ileopsoas related GrP
– Inguinal related GrP
• No inguinal hernia is present
• Aggravated pain during ”sit-up” test or Valsalva
– Pubic related GrP
• Pain in the symphysis or adjacent bone

37. Pubalgia athletica - sports hernia

38. Adductor femoris

39. ”Sports hernia”
R
F
R
F
- Bugpres
+ Bugpres

40. ”Bulging”
No clinical significance if not
simultaneusly pain

41. POCUS-features of normal lymphnodes
• Size < 1 cm (L-axis)
• Shape (L/S axis < 0,5)
• Cortex/hilus (visual)
• Not hypervascular

42. Lymph adenitis
• Benign (reactive)
– Inflammation
• Auto immune reaction
• Infection
• Local irritative causes
• Sacoidosis, tuberculosis…

43. POCUS Follow up on lymphadenitis
• Normal (no follow-up)
• Additional imaging or tests
• Test of time (4-6w)
• Referal:
• Surgical removal (in-toto)
• US-guided Biopsy
– FNAC (21 G Chiba)
– Coarse needle (16 G Tru-Cut)

45. Dansk Ultralyddiagnostisk Selskab
DUDS
• Bliv medlem og:
• Følg med i forskning og uddannelse indenfor ultralyd
• Få medlemskab af den europæiske sammenslutning af
ultralydselskaber EFSUMB (og adgang til betalingstjenester)
• Få nedsat kongresafgift til EUROSON kongresser
• Modtag det europæiske tidsskrift European Journal of
Ultrasound (impact factor 4,645) og DUDS medlemsblad
• Få mulighed for at søge legat til aktiv kongresdeltagelse og
relevant studieophold
Pris: 450 kr
Kontakt: sekretaer@duds.dk

46. UL morfologi
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