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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.