Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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Abdominal Wall Hernia (Left) Transverse ultrasound at rest shows a medium-sized traumatic right spigelian hernia ſt bulging through the linea semilunaris/transversus abdominis aponeurosis . The rectus abdominis muscle st is shown. (Right) Transverse ultrasound during Valsalva shows the same posttraumatic right spigelian hernia , which has enlarged. The intact rectus abdominis muscle st is shown. The change with Valsalva is more evident on real-time imaging. Diagnoses: Abdominal Wall/Peritoneal Cavity (Left) Axial CT obtained after a traumatic right hip fracture shows a spigelian hernia st containing colon. The hernia defect lies between the rectus and oblique muscles . (Right) Axial NECT shows a fat-containing superior lumbar hernia (Grynfeltt hernia). (Left) Graphic shows a superior lumbar hernia (Grynfeltt hernia) arising from the superior lumbar triangle bounded by the erector spinae muscle medially , the 12th rib superiorly , and the internal oblique muscle laterally . (Right) Graphic shows an inferior lumbar hernia (Petit hernia) arising from the inferior lumbar triangle bounded by the latissimus dorsi muscle medially , the iliac crest inferiorly st, and the external oblique muscle laterally ſt. 617

Groin Hernia Diagnoses: Abdominal Wall/Peritoneal Cavity TERMINOLOGY • Hernia: Weakness or defect in fibromuscular wall with protrusion of organ or part of organ through defect • Reducible hernia: Decrease in hernia size with decreased intraabdominal pressure or application of external pressure • Incarcerated: Nonreducible • Strangulated: Compromised vascular supply of hernia contents IMAGING • Indirect inguinal hernia passes through deep inguinal ring, extends along inguinal canal, and emerges at superficial inguinal ring • Direct inguinal hernia passes through transversalis fascial defect in Hesselbach triangle • Femoral hernia passes through femoral canal into superomedial thigh • Ultrasound accurate at detecting hernia sac and contents as well as fascial defect at rest or with provocative maneuvers KEY FACTS ○ Increase in hernia size during cough, Valsalva maneuver, or standing • Color Doppler helps identify inferior epigastric artery and its relationship to hernia neckfor inguinal hernias • CT or MR: Useful if ultrasound is equivocal, better for detecting alternative causes of symptoms TOP DIFFERENTIAL DIAGNOSES • Lipoma of spermatic cord • Encysted hydrocele canal of Nück • Inguinal canal lesions CLINICAL ISSUES • Obstruction or strangulation more common with femoral hernias due to narrow neck (Left) Graphic shows 3 types of groin hernia: Direct ſt and indirect inguinal hernias arise above the inguinal ligament , medial and lateral to the inferior epigastric vessels st respectively; femoral hernias arise below the inguinal ligament medial to femoral vessels . (Right) Transverse ultrasound of the right groin shows a direct inguinal hernia containing small bowel ſt. The hernia neck was medial to the inferior epigastric vessels st. The small bowel was only seen during Valsalva or while standing. (Left) Transverse ultrasound shows a left direct-type inguinal hernia ſt containing bowel. The neck of the hernia lies medial to the inferior epigastric vessels st. (Right) Transverse color Doppler ultrasound of the same left direct inguinal hernia ſt during Valsalva maneuver is shown. The hernia sac is larger. The hernia neck is medial to the inferior epigastric vessels st. Direct inguinal hernias rarely obstruct. 618

Abdominal Wall Hernia<br />

(Left) Transverse ultrasound at<br />

rest shows a medium-sized<br />

traumatic right spigelian<br />

hernia ſt bulging through the<br />

linea semilunaris/transversus<br />

abdominis aponeurosis .<br />

The rectus abdominis muscle<br />

st is shown. (Right)<br />

Transverse ultrasound during<br />

Valsalva shows the same posttraumatic<br />

right spigelian<br />

hernia , which has enlarged.<br />

The intact rectus abdominis<br />

muscle st is shown. The<br />

change with Valsalva is more<br />

evident on real-time imaging.<br />

Diagnoses: Abdominal Wall/Peritoneal Cavity<br />

(Left) Axial CT obtained after<br />

a traumatic right hip fracture<br />

shows a spigelian hernia st<br />

containing colon. The hernia<br />

defect lies between the rectus<br />

<strong>and</strong> oblique muscles .<br />

(Right) Axial NECT shows a<br />

fat-containing superior lumbar<br />

hernia (Grynfeltt hernia).<br />

(Left) Graphic shows a<br />

superior lumbar hernia<br />

(Grynfeltt hernia) arising from<br />

the superior lumbar triangle<br />

bounded by the erector spinae<br />

muscle medially , the 12th<br />

rib superiorly , <strong>and</strong> the<br />

internal oblique muscle<br />

laterally . (Right) Graphic<br />

shows an inferior lumbar<br />

hernia (Petit hernia) arising<br />

from the inferior lumbar<br />

triangle bounded by the<br />

latissimus dorsi muscle<br />

medially , the iliac crest<br />

inferiorly st, <strong>and</strong> the external<br />

oblique muscle laterally ſt.<br />

617

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