16-9 Naz Hernias LE 2021

3/11/21

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US of Abdominal Wall Hernias

Levon N. Nazarian, MDWilliam E. Conrady, MD Professor of Radiology

Sidney Kimmel Medical College of Thomas Jefferson University

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Disclosures

• None relevant to this presentation

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Educational Objectives

• Following the presentation, participant should be able to:–Describe the ultrasound technique

for identifying hernias–Discuss normal and pathologic

anatomy for hernias

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Hernia Terminology• Reducible or non-reducible

(incarcerated)• Strangulated• Obstructed

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Normal Abdominal Wall

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Umbilical Hernia

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Umbilical Hernia

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Epigastric Hernia

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Epigastric Hernia

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Epigastric Hernia

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Epigastric Hernia: Valsalva

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Epigastric Hernia: Reducible

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Umbilical Hernia Supine

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Umbilical Hernia Standing

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Spigelian Hernia

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Spigelian Hernia

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Spigelian Hernia

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Spigelian Hernia Seen Only With Standing

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60-Year-Old Man With RLQ Abdominal Wall Bulge

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60-Year-Old Man With RLQ Abdominal Wall Bulge

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Diastasis Recti(Divarication)

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Diastasis Rectus

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Diastasis Recti

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Diastasis Recti

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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

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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 men37

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

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Ultrasound Method• Identify inferior epigastric

vessels in cross-section

Left Lower Quadrant

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Ultrasound Method• Follow them down to the

confluence with femoral vessels

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Ultrasound Method• Slide above inguinal ligament

and find the internal inguinal ring

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Ultrasound Method• Re-find vessels in long axis

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Ultrasound Method• Put probe lateral to vessels

aligned with inguinal canal–Supine–Valsalva–Standing if needed

• Repeat medial to vessels43

Ultrasound Method

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Indirect Inguinal Hernia

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Indirect Inguinal HerniaTransverse View

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Bowel Containing Inguinal Hernia: Reducible

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Bowel Containing Inguinal Hernia: Not Reducible

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Indirect Inguinal hernia: Importance of Standing

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Direct Inguinal HerniaLong Axis

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Direct Inguinal HerniaShort Axis

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Clinically Occult Direct Hernia 60-year-old Man

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Clinically Occult Direct Hernia 60-year-old Man

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Direct Inguinal Hernia: Short Axis (Standing)

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“Pantaloon” Hernia

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Recurrent Inguinal Hernia3 Surgeons Said No

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27-Year-Old Man With Pelvic PainScheduled for Orchiectomy

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75-Year-Old Woman With 2 Years of Groin Pain

• X-ray showed hip arthritis• Tried to tell MD this felt

“different” from her hip pain• He scheduled her for THR

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Femoral hernias

• 3% of all hernias• Originate below inguinal

ligament, whereas inguinal hernias originate above

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Normal Femoral Canal

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Femoral hernia: 37 y.o. Woman

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Femoral hernia: 63 y.o. Man

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Inguinal and Femoral Hernia91-Year-Old Man

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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.

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16-9 Naz Hernias LE 2021