Cont. Chest Anat, HERNIAS

Diastasis Recti

Increased distance between the rectus abdominus muscles caused by weakness in anterior abdominal wall

Linea alba is normally a narrow fibrous band in the midline abdomen that separates the two rectus abdominus muscles

Muscle weakness and thinning/stretching of the linea alba

This distance between the 2 muscles can increase with pregnancy, obesity and in newborns

It can be differentiated from ventral hernia b/c there is no fascial defect

Diastasis Recti presents as

A midline bulge that increases with increased abdominal pressure

Diastasis Recti

Abdominal wall lipoma

Fatty tumor localized within the abdominal wall

Usually hypoechoic to isoechoic with surrounding tissues

Soft, compressible, movable

Usually removed for cosmetic purposes

Abdominal wall lipoma

Other abdominal wall masses

Desmoid tumors

Endometriomas

Sarcoma

Mets

Desmoid tumors

Benign neoplasm

Usually found in the abdominal wall but can be intra- or extra-abdominal

Most commonly seen in women age 25-40yrs

Associated with pregnancy and previous abdominal surgery

Homogenous, isoechoic to hypoechoic mass

Endometriomas

Associated with cesarean section or laparotomies

Commonly mistaken for incisional hernia

Variable sonographic appearance

Important to determine if the mass has invaded the abdominal fascia

Hernia sac -

Has a neck, body, fundus and contents

Neck of hernia is in the _____

Orifice

A narrow, rigid or angled neck increases risk for:

Strangulation

Most hernias contain

Intraperitoneal or preperitoneal fat, but bowel can also protrude into sac

Pts with one hernia, usually have ________ and should be evaluated for other types of ipsilateral and contralateral groin

Multiple

Incarcerated hernias

Hernias that are nonreducible

Obstructed hernias

Contain incarcerated bowel loops that have become mechanically obstructed

Strangulated hernias

Contain incarcerated contents with compromised vascularity

Most significant complication of a hernia

Strangulation

Signs of hernia strangulation

Hyperechoic fat, thickened hernia sac, fluid in the sac, thickened bowel loops in the sac

Use color

Most common surgical procedures in the US

Herniorrhaphy

Hernia repair is usually performed using:

Mesh material

Abdominal wall or Ventral hernia are caused by

Chronically increased intraabdominal pressure or connective tissue weakness

• Allows for protrusion of intestines → can cause intestine to continuously enter in and out

Linea abla hernias

Anterior abdominal wall hernias that penetrate through lina alba

Superior to umbilicus = epigastric

Inferior to umbilicus = hypogastric

Found fecentieters of the umbilicus

Linea alba

Thick layer of aponeurosis that separates the rectus abdominus muscles

Most common type of ventral hernia

Umbilical

Most common reason for missing an epigastric linea alba hernia

Examination for abdominal pain was performed with a low frequency transducer

Epigastric hernias usually have…

A narrow neck, are NOT reducible with increased risk for strangulation

Hypogastric hernias are usually found

Within a few centimeters of the umbilicus and have narrow necks, NOT reducible and are at increased risk for strangulation

Spigelian hernia

Nearly all these occur inferior to arcuate line, where spigelian fascia is penetrated by the inferior epigastric vessels

Associated with conditions that increase intraabdominal pressure

Spigelian hernia USA

Complex mass within the anterolateral aspect of the abdominal wall, could contain fluid or bowel loops or fluid

Mushroom or anvil shaped

Groin

Region of the ilioinguinal crease at the junction of the abdomen and the thigh and the adjacent areas immediately above and below

Groin hernia maneuvers

Quiet breathing - demonstrates bowel peristalsis

Valsalva maneuver (pt in supine position, hernia should increase in size with this)

Compression maneuver (assesses reducibility and tenderness in pts)

Upright position (demonstrates pooling of related peritoneal fluid)

Groin hernia with a broad fundus and narrow neck =

Usually NONreducible

A hernia with a broad neck and more narrow fundus =

Usually reducible

Inferior epigastric artery

Key landmark in distinguishing among the direct, indirect and spigelian hernias

The artery originates at the external iliac artery

Courses superiomedially, across the spigelian fascia and semilunar line

Distally it courses along the mid-posterior aspect of the rectus abdominus

Direct inguinal hernia =

Herniated structures medial to inferior epigastric artery

Indirect inguinal hernia =

Herniated structures lateral to the inferior epigastric artery

Most common type of hernia overall and most commonly in males

Indirect Inguinal hernia

Inguinal ligament

Extends from the anterior superior iliac spine to the pubic tubercle

Inguinal canal

Runs between the external oblique and the transversalis fascia, superficial to the inguinal ligament

Inguinal hernia

Weakness in pelvic floor muscles allows pelvic contents to drop into scrotal area

Hernia sac - composed of peritoneum

Indirect inguinal hernia

Due to migration of testis, spermatic cord, or round ligament penetration of the pelvis floor

Neck is SUPERIOR to IEA origin

Fundus is oriented horizontally and expands inferior and medial, passing superficial to the IEA origin

Anterior lateral to the spermatic cord

Indirect inguinal hernia is associated with

Abnormal movement of fat, bowel, or both through the deep inguinal ring and inguinal canal

Sliding inguinal hernia -

Wide neck, usually reproducible

Non-sliding hernia -

Narrow neck, usually Nonreproducible

Direct inguinal hernia

Intra-abdominal structures move anteriorly through the aponeurosis at the Hesselbach triangle

Neck lies inferior and medial to the IEA origin

Inguinal hernia sac lies posterior and medial to the spermatic cord in males, round ligament in females

Aponeuroses

Layers of fibrous tissue that connect sheet-like muscles needing a wide area of attachment

Hesselbach triangle

Bordered inferiorly by the inguinal ligament, medially by the lateral aspect of the rectus abdominus muscle, and superolaterally by the IEA

Amyand hernia

Rare inguinal hernia that contains appendix

Incisional hernia

Delayed complication of abdominal surgery

Occurs in first few months of surgery

More common with vertical incisions than with transverse incisions

Elderly, obese and malnourished pts have increased risk of an incisional hernia

Incisional hernia is associated with

Transverse rectus abdominus myocutaneous (TRAM) flap breast reconstruction surgery

Femoral hernia

Occur in areas where vessels penetrate the abdominal wall

Located below the inguinal ligament

Abnormal intraabdominal contents move inferiorly through the femoral canal

MORE COMMON IN WOMEN ON RIGHT
Hernia sac usually lies medial to the common femoral vein

Abdominal wall hernia

Spigelian hernia

Umbilical hernia

Epigastric hernia

Inguinal hernia

Femoral hernia

M-mode is commonly used to eval a pt for

Pneumothorax

What causes the diaphragm to appear highly echogenic on US evaluation?

Specular reflection

In cases of pneumothorax, what sign is identified on US evaluation?

Barcode sign

Transudate pleural effusion is related to:

CHF

Exudate pleural effusion is related to

Malignancy

Signs of pleural effusion

Diaphragm sign, displaced crus sign, bare area sign

Lactate dehydrogenase concentration can be used to differentiate:

Transudate from exudate effusion

US is used to eval the __________ for hernia formation

Anterior parietal peritoneum

The ___________ is called the foramen of Winslow and the __________ is called the morsion pouch

Right subhepatic space; Hepatorenal space

Liver disease causes a reduction in ________ levels which are associated with ascites formation

Albumin

The retroperitoneum is located between the:

Parietal peritoneum and the transversalis fascia

An enlarged, rounded lymph node with loss of hilar definition = _________

An enlarged oval lymph node with normal hilar characteristics = ___________

Malignancy; Infection

Which of the following can cause hydro, pedal edema, and scrotal swelling in a male pt?

Ormond disease

Which of the following are required when evaluating a pt with a suspected anterior wall hernia?

Ask them to perform the Valsalva

Scan them standing up

Obtain comparison views of unaffected side

All of the above

All of the above

Injury to the _________ is the most common cause of hematoma formation in the anterior abdominal wall

Inferior epigastric artery

Stretching of the linea alba during pregnancy results in what chronic disease

Diastasis recti

How can you differentiate diastasis recti from a ventral hernia?

Presence of a fascial defect

A narrow, rigid or angled hernia neck increases the risk of:

Strangulation

An incarcerated hernia cannot be:

Reduced

When reporting findings from an US eval for a hernia, what should be included?

Dynamic maneuvers used in exam, hernia contents, reducibility of hernia

Key landmark in distinguishing among direct and indirect Spigelian hernias?

Inferior epigastric artery

If a hernia does not increase in size with Valsalva strain, ______________ should be suspected

Strangulation, incarceration, or ischemia