Medial Groin and Hernia: Sonographic Evaluation. Adam M. Pourcho DO Swedish Sports Medicine

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1 Medial Groin and Hernia: Sonographic Evaluation Adam M. Pourcho DO Swedish Sports Medicine

2 Disclosures

3 Hernia Eval Takes Practice: Fake it till you make it

4 Objectives Understand anatomy of medial hip and hernias Go over inguinal, direct, indirect, Spigelian, and sports hernia Scanning protocols for each

5 Ways to illicit a Hernia 1. Bearing down(valsalva) Try blowing on back of hand 2. Lifting shoulders 3. Bearing down while lifting shoulders 4. Coughing 5. Standing Evaluation

6 Femoral Triangle Anatomy Femoral Canal Femoral artery and vein Femoral Br. Genitofemoral nrv lymph nodes Femoral nerve is separate More common in females Common post-pardum

7 Femoral Canal Scanning n a v RT FC SAX MED

8 Femoral Hernia Valsalva: Normal RT FC SAX MED

9 Femoral Hernia RT FC SAX MED RT FC LAX DIST

10 Inguinal Canal Anatomy Deep and superficial rings Females Round ligament of Uterus Males Spermatic cord Testicular artery and vein Artery to Vas Deferens Pampiniform Plexus Genital br. Genitofemoral Nrv Vas deferens Lymph Processus Vaginalis Autonomic nerves

11 Scanning for Direct/indirect hernias a v RT FC SAX MED

12 Inguinal Canal Males vs Females Female Male a v a v RT FEM IC SAX MED RT MALE IC SAX MED

13 Finding Inferior Epigastric Arteries RA RT IEA SAX MED RT IEA SAX MED

14 Inguinal Canal: Normal SAX to IEA RT IC SAX MED

15 Indirect Inguinal Hernia LAX to IEA SAX to IEA Slides courtesy of Doug Hoffman, MD

16 Direct Inguinal Hernia Slides courtesy of Doug Hoffman, MD

Spigelian Hernia Spigelian hernia (1-2% of all hernias) is the protrusion of preperitoneal fat, peritoneal sac, or organ(s) through a congenital or acquired defect in the spigelian

17 Spigelian Hernia Spigelian hernia (1-2% of all hernias) is the protrusion of preperitoneal fat, peritoneal sac, or organ(s) through a congenital or acquired defect in the spigelian aponeurosis the aponeurosis of the transverse abdominal muscle limited by the linea semilunaris laterally and the lateral edge of the rectus muscle medially Skandalakis, PN. Et al. 2006

18 Scanning for Spigelian Hernia RT ABD SAX MED

19 Spigelian Hernia Slides courtesy of Doug Hoffman, MD

20 Sports Hernia / Athletic Pubalgia Its not athletic pubalgia Its not osteitis pubis/ pubic instability Its not adductor/gracillis tendinopathy Its not rectus abdominus or conjoint tendinopathy Its not a hernia It is tranversalis diastasis with deformation of the spermatic cord or round ligament

21 Scanning for Sports Hernia Pubic symphysis Adductor tendons Esp adductor longus Gracilis Rectus abdominus aponeurosis/tendon Conjoint tendon Direct region Laxity of transversalis fascia-valsalva

22 Transversalis Fascia Insufficiency/ Direct region

23 Transversalis Fascia Insufficiency

24 Transversalis Fascia Insufficiency Slides courtesy of Doug Hoffman, MD

25 Scanning for Medial Groin B L P R M RT MED HIP LAX PROX

26 Adductor Longus Tear With Calcification RT MED HIP LAX DIST

27 Adductor Longus and PF, and ICH Add Magnus tears Obey, 2016

28 Distal and Proximal Adductor Longus Tear RT MED HIP LAX DIST

29 Pubic Symphysis RT LT

30 Pubic Symphysis RT LT

31 Distal Rectus Abdominus RT RA LAX DIST

32 Questions?

33 References The Athletic Hernia-A Systemic Review; Swan and Wolcott:Clinical Orthopaedics and Related Research; :78-87 Sportsmen s Groin-Diagnostic Approach and Treatment With the Minimal Repair Technique: A Single-Center Uncontrolled Clinical Review; Muschaweck /Berger: Sports Health : Santilli, O. L., et al. (2015). "Sports hernias: experience in a sports medicine center."hernia. Steele, P., et al. (2004). "Surgery for posterior inguinal wall deficiency in athletes." J Sci Med Sport 7(4): ; discussion Orchard, J. W., et al. (1998). "Groin pain associated with ultrasound finding of inguinal canal posterior wall deficiency in Australian Rules footballers." Br J Sports Med 32(2): Hackney, R. G. (1993). "The sports hernia: a cause of chronic groin pain." Br J Sports Med 27(1): Obey MR 1, Broski SM 2, Spinner RJ 3, Collins MS 2, Krych AJ 4. Anatomy of the Adductor Magnus Origin: Implications for Proximal Hamstring Injuries. Orthop J Sports Med Jan 11;4(1): doi: / ecollection 2016 Jan.

GI anatomy Lecture: 2 د. عصام طارق

GI anatomy Lecture: 2 د. عصام طارق Objectives: To define rectus sheath. To describe anatomy of inguinal canal. To relates types of inguinal hernia to the region. To explore spermatic cord. Rectus Abdominis