us of abdominal wall disclosures hernias none...
TRANSCRIPT
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US of Abdominal Wall
HerniasLevon N. Nazarian, MD
Professor of Radiology
Thomas Jefferson University Hospital
Disclosures
• None relevant to this
presentation
Educational Objectives
• Following the presentation, participant should be able to:
–Discuss normal and pathologic anatomy for abdominal wall hernias
–Describe the ultrasound criteria for evaluating these hernias
Normal Abdominal Wall
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Normal Abdominal Wall Normal Abdominal Wall
Normal Abdominal Wall Normal Abdominal Wall
Normal Abdominal Wall Umbilical Hernia
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Umbilical Hernia Epigastric Hernia
Epigastric Hernia Epigastric Hernia
Epigastric Hernia: Valsalva Epigastric Hernia: Reducible
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Diastasis Recti
(Divarication)
Diastasis Rectus
Diastasis Recti Diastasis Recti
Spigelian Hernia Spigelian Hernia
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Spigelian HerniaSpigelian Hernia
Weakened Linea Semilunaris Weakened Linea Semilunaris
Normal Linea Semilunaris Inguinal Hernia
Epidemiology
• Most common hernia type
• More than 1 million hernias
repaired each year in US: 75%
are inguinal
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Identification of the inferior
epigastric vessels is critical to
localizing an inguinal hernia
Types of Inguinal Hernias
• Indirect: lateral to vessels, goes
through internal inguinal ring
–Occur at any age
–Most common (2/3)
• Direct: Medial to vessels
–Most common in middle aged and
elderly men
Ultrasound Method
• Identify inferior epigastric vessels in
cross-section
• Follow them down to the confluence
with femoral vessels
• Slide above inguinal ligament and
find the internal inguinal ring
• Re-find vessels in long axis
Ultrasound Method
• Put probe lateral to vessels
aligned with inguinal canal
–Supine
–Valsalva
–Standing if needed
• Repeat medial to vessels
Left Indirect Inguinal Hernia
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Indirect Inguinal Hernia Indirect Inguinal Hernia
Indirect Inguinal HerniaInguinal Hernia: Reducible
Inguinal Hernia: Not Reducible Indirect Inguinal hernia:
Importance of Standing
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Direct Inguinal Hernia:
Short Axis (Standing)
Direct Inguinal Hernia
Long Axis “Pantaloon” Hernia
“Pantaloon” Hernia “Pantaloon” Hernia
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Recurrent Inguinal Hernia
3 Surgeons Said No
27-Year-Old Man With Pelvic Pain
Scheduled for Orchiectomy
Spermatic Cord Lipoma Normal Motion of Spermatic Cord
Normal Motion of Spermatic Cord Femoral hernias
• 3% of all hernias
• Originate below inguinal
ligament, whereas inguinal
hernias originate above
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Normal Femoral Canal
Femoral hernia: 37 y.o. WomanInguinal and Femoral Hernia
91-Year-Old Man
Inguinal and Femoral Hernia
91-Year-Old Man
Inguinal and Femoral Hernia
91-Year-Old Man
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Inguinal and Femoral Hernia
91-Year-Old ManCyst of Canal of Nuck
“Female Hydrocele”
Cyst of Canal of Nuck Cyst of Canal of Nuck
“Sports Hernia”
• Posterior inguinal wall deficiency
• Koulouris G. AJR 2008; 191:962.
• Also sometimes used to refer to
groin pain in athletes: prefer
“athletic pubalgia”
“Sports Hernia”
• DDx:
– True hernias
–Rectus abdominis pathology
–Adductor tendon pathology
–Osteitis pubis
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• The conjoint tendon forms when the
medial fibers of the internal oblique
aponeurosis unite with the deeper
fibers of the transversus abdominis
aponeurosis
• The conjoint tendon turns inferiorly
and attaches to the pubis, forming
part of the posterior wall of the
inguinal canal
Conjoint TendonConjoint Tendon
“Sports Hernia” “Sports Hernia”
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“Sports Hernia” Direct Inguinal Hernia
Short Axis
References
• Jamadar DA, et al. Sonography of inguinal region
hernias. AJR 2006; 187: 185-190
• Jamadar DA, et al. Characteristic locations of
inguinal region and anterior abdominal wall
hernias: sonographic appearances and
identification of clinical pitfalls. AJR 2007;
188:1356-1364
• Koulouris G. Imaging review of groin pain in elite
athletes: an anatomic approach to imaging
findings. AJR 2008; 191:962-972.