Sonography of Hernias

Transcription

1 Sonography of Hernias Cindy Rapp BS, RDMS, FAIUM, FSDMS Sr. Clinical Marketing Manager Toshiba America Medical Systems Tustin, California What is a hernia? A hernia is a protrusion of an organ or tissue through an abnormal opening in the body. not all hernias contain bowel loops fat is the most common sonographic hernia content Where do hernias occur? Areas of natural weaknesses in our abdominal wall canals where plumbing goes through Internal inguinal ring and inguinal canal Femoral canal fetal canals - umbilical ring aponeroses direct inguinal, Spigelian, linea alba surgical scar Causes of hernias Increase in the intra-abdominal pressure obesity chronic coughing lifting heavy objects straining constipation pregnancy ascites Sonography can determine location (type) of hernia contents reducibility (dynamic maneuvers) strangulation Sonography of Hernias Abdominal Wall Hernias inguinal hernia direct indirect umbilical hernia femoral hernia spigelian hernia epigastric hypogastric Zarvan et al. 8 6 = linea alba epigastric 7 = linea alba hypogastric 8 = incisional 7 6 1

2 Sonography of Hernias Hernia contents: intraperitoneal fat fluid bowel vessels membranes properitoneal fat only incarceration bowel obstruction strangulation fat Hernia contents intraperitoneal fluid and bowel vessels and membranes hernia contents hernia contents shadowing gas within bowel peristalsing bowel hernia contents Hernia contents properitoneal / preperitoneal fat peritoneal membrane linea alba 2

3 Sonography of Hernias Indirect - long axis valsalva Dynamic maneuvers valsalva compression upright position some hernias present only during Valsalva indirect inguinal hernia compression dynamic maneuver upright Fat containing hernia - Supine Fat and fluid - upright Inguinal Hernia key to identifying internal inguinal ring = inferior epigastric vessels Key to diagnosis of inguinal hernias identify inferior epigastric vessels follow them to origin from EIA inferior epigastric origin marks the Internal Inguinal Ring long axis and short axis not longitudinal and transverse 3 3

4 Inferior Epigastric Vessels Inguinal Hernias Indirect inguinal hernia up and over (superficial) the inferior epigastric artery anterior to the spermatic cord (round ligament) may communicate with scrotum Direct inguinal hernia inferior to the internal inguinal ring through the conjoined tendon posterior to the spermatic cord trans left inguinal canal direct vs. indirect - spermatic cord short axis lt inguinal canal indirect indirect direct direct inguinal hernia indirect indirect inguinal hernia arises in the internal inguinal ring, superior, lateral, and passes anterior to the inferior epigastric artery adapted from Skandalakis et al. 4

5 indirect inguinal hernia long axis up and over inferior epigastric vessels indirect inguinal hernia short axis A A TRV RT ING CAN indirect inguinal hernias lie anterior to spermatic cord indirect inguinal hernia Not all are anterior to the SC in short axis compression of cord can cause pain radiating into scrotum indirect inguinal hernia indirect inguinal hernias wide neck configuration often has intraperitoneal contents narrow neck configuration often has only fat (may be called lipoma of spermatic cord) containing - fat and bowel 5

6 indirect inguinal hernias indirect inguinal hernia wide-neck indirect inguinal hernia containing - fat indirect inguinal hernias small fat-containing indirect inguinal hernia long axis - Valslava indirect inguinal hernia short axis - compression long indirect inguinal hernia containing bowel trans indirect inguinal hernia containing bowel 6

7 indirect inguinal hernia indirect inguinal hernia extending into scrotum inguinal hernia direct direct inguinal hernia A arises inferior and medial to and never passes anterior to the inferior epigastric artery adapted from Skandalakis et al. direct inguinal hernia -- short axis In many cases......thinning & bulging of conjoined tendon... thinning of the conjoined tendon SC...not an actual hole in tendon transverse left long valsalva long QR 7

8 direct inguinal hernia -- long axis direct inguinal hernia -- short axis A IEA sp cord hernia A sc direct inguinal hernias lie post. and med. to spermatic cord direct inguinal hernia compression of cord can cause pain radiating into scrotum arises inferior and medial to, and does not drape over inferior epigastic artery trans direct inguinal hernia long direct inguinal hernia 8

9 femoral hernias femoral hernia femoral hernia femoral hernia adapted from Skandalakis et al. femoral hernia femoral hernia 9

10 femoral hernia bilateral fat-containing spigelian hernias right femoral canal left femoral canal spigelian hernia spigelian hernia adapted from Skandalakis et al. tear of transversus abdominus sometimes internal oblique aponeurosis, external oblique intact left spigelian hernia fat containing partially reducible Ext obliq Int obliq Transv abd Rectus 10

11 left spigelian hernia fat & bowel containing partially reducible Spigelian vs. indirect inguinal hernias ventral hernias epigastric hypogastric linea alba hernia epigastric or hypogastric adapted from Skandalakis et al. linea alba hernia properitoneal Epigastric - linea alba hernia non-reducible, non-strangulated properitoneal fat only 11

12 epigastric hernia properitoneal fat non-reducible multiple epigastric hernia s mesh epigastric hernia reducible umbilical hernias umbilical hernia umbilical hernia supine valsalva 12

13 umbilical hernia umbilical hernia bowel, fat and fluid partially reducible Strangulated fat Normal fat recurrent or residual pain after surgical hernia repair occurs more commonly than thought many causes recurrent hernia seroma, hematoma, abscess repair too tight reaction to mesh tender spiral clips scar ilioinguinal nerve entrapment (default dx) acute & subacute herniorraphy complications hematoma compression of spermatic cord and testicular ischemia seroma stitch abscess acute post-herniorraphy hematoma acute post-herniorraphy seroma 13

14 subacute post herniorrhpahy stitch abscess herniorrhaphy mesh hernia occurs from edges of mesh most likely detached edge most often infero-medial edge all this means that we must try to identify the mesh sonographically recurrent hernias after repair with mesh Hernia repair mesh not classified as direct or indirect arise from edge of mesh -interrogate entire margin of mesh dynamically most frequently from infero-lateral edge of mesh typically clip has come loose and mesh has retracted superiorly lower edge of mesh often appears too high well above internal inguinal ring and conjoined tendon can arise from any edge tender during compression Trans LLQ Long LLQ many different types of mesh sonographic appearance varies recurrent inguinal hernia at inferior edge of mesh 14

15 recurrent hernias arise from edge of mesh Recurrent hernia edge of mesh mesh can bulge normally eccentric bulge to this degree typically is associated with recurrent hernia spiral clips post herniorrhaphy tender spiral clip at edge of mesh 15

16 Palpable Diastasis Recti Hernia sonography 43 year old female, left groin pain. R/O hernia long left inguinal canal long left inguinal canal IEA Valsalva Compression long left inguinal canal Bilateral round ligament varices supine upright LEFT round ligament varices 16

17 significance of incidence of multiple hernias to diagnostic imagers How a report reads exam type, indications, and technique if a hernia detected: look for additional hernias of other types ipsilaterally look for mirror image hernias contralaterally some types of hernias are frequently bilateral femoral direct inguinal > indirect inguinal Spigelian look for additional hernias aponeurosis multiple epigastric hernias exam: dynamic ultrasound of bilateral groin indication: right groin pain / lump procedure: bilateral dynamic sonographic evaluation of the groin was performed with the patient in both supine and upright positions and with and without compression and Valsalva maneuvers how a report reads: (primary findings) There is a small right fat containing non-reducible indirect inguinal hernia that is... tender when compressed. (size) (side) (contents) (reducibility) (type) (tenderness) The End 17