Abdominalwall hernias

Transcription

1 Abdominalwall hernias Poster No.: C-1120 Congress: ECR 2011 Type: Educational Exhibit Authors: B. Molinares, W. Quiceno, G. Vélez, L. Sanchez; CO Keywords: Abdomen, Abdominal wall, Anatomy, CT, Ultrasound, MR, Hernia DOI: /ecr2011/C-1120 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 32

2 Learning objectives - Recognize the different types of abdominal wall hernias - Make appropriate differential diagnosis - Recognize complications of abdominal wall hernias - Describe the proper technique of abdominal CT for the evaluation of abdominal wall hernias Background The abdominal wall hernias are common. Most are asymptomatic and are carried to an elective surgery. A delay in diagnosis or an incorrect diagnosis can lead to complications that may endanger the lives of patients and will require urgent surgical management. Also after correction of hernias are complications that must be identified and treated appropriately. Clinical diagnosis of abdominal wall hernia can be very difficult especially in obese patients with severe abdominal pain and abdominal wall scars. The different imaging modalities, specifically the ultrasound and CT with the proper technique are very useful to make the correct diagnosis and timely manner. Imaging findings OR Procedure details The most commonly used diagnostic methods to assess abdominal wall hernias are ultrasound and computed tomography. Ultrasound is especially used in pediatric patients. Using high frequency linear transducers. The evaluation is dynamic with the patient at rest and with Valsalva maneuver. In patients with adequate acoustic window, especially those who present with palpable abdominal mass, ultrasound is useful. Fig. 1 However, the valuation of the abdominal wall with ultrasound is limited especially in obese, abdominal scars and gaseous intestinal distention. These are patients who are at increased risk of abdominal wall hernias and their complications. Page 2 of 32

3 Contrast tomography with multiplanar reconstructions is an excellent method for assessing the anatomy of the abdominal wall hernias and their complications. Without limitation in obese patients, abdominal wall scars or distention. It is very useful for assessing the differential diagnosis of abdominal wall masses such as tumors, lymphadenopathy, hematoma, collections and more. When the abdominal wall hernias are reducible, and only present with pain and no presence of mass are more difficult to identify, especially with ultrasound which requires an adequate Valsalva maneuver to identify the hernia sac. Tomography with multiplanar reconstructions demonstrate the advantage of abdominal wall defects with small hernia sacs Technique In our institution we use a multislice CT scanner with 4 rows of detectors, manage positive oral contrast and 100 cc of IV contrast. We conducted the study with the patient supine and perform multiplanar reconstructions of the abdominal wall. In some cases it may require the valsalva but in most patients is sufficient with multiplanar reconstructions. Classification of abdominal wall hernias The abdominal wall hernias are classified according to anatomical region that compromise: groin hernias, anterior o ventral, and posterior or lumbar. Other types of abdominal wall hernias are incisional hernias. Fig. 2 Groin hernias Are the most common hernias of the abdominal wall. Include inguinal (direct and indirect) and femoral. Inguinal hernias are located above the inguinal ligament and femoral below. Approximately 80% of abdominal wall hernias are inguinal and femoral are 5%. To evaluate these hernias and classify them, we must properly identify the anatomy of the region. Multislice CT with multiplanar reconstructions specifically is excellent for evaluating these anatomical landmarks. Three anatomical regions found in the groin: femoral triangle (femoral hernia), heselbach triangle and inguinal cord. Fig 3. And several anatomical references: epigastric vessels, the inguinal canal ring with superficial and deep femoral vessels, the inguinal ligament, pubic tubercle and anterior superior iliac spine. Fig 4 Page 3 of 32

4 Indirect inguinal hernia They are relate to the persistence or re-channeling of the peritoneum vaginal process, which is a continuation of the peritoneum in the inguinal canal. This leads to output intraabdominal structures lateral to the inferior epigastric vessels, into the scrotum or the labia. They are more common in men. Fig. 5 Direct inguinal hernia Are acquired, secondary to a weakness of the transversalis fascia. Hernia sac is out of the abdominal cavity through a defect that is medial to the inferior epigastric vessels, above the inguinal ligament and lateral to the rectus muscles (heselbach triangle). It occurs more often in men and is often bilateral. Fig. 6 Femoral hernia Are less frequent. Rare in children and occur most frequently in women and on the right side. Attributed to a defect in the insertion of the transversalis fascia with the pubis. The hernia defect is posterior and inferior to the inguinal ligament and medial to the femoral vessels. Have high tendency to incarceration. Often accompanied by a compressive effect on the femoral vein. Fig. 7 Ventral hernias They are divided into midline defects, which include: umbilical, paraumbilical, hypogastric and epigastric and lateral defects or spiguel hernia. Umbilical hernia These hernias are second in frequency. In children seen by a congenital incomplete closure of the umbilical defect through which the gut contents back into the abdominal cavity at 10 weeks of gestation. Physiological closure of this defect may be incomplete at birth but most close spontaneously in childhood. If a fault occurs in the closure of this defect, umbilical hernias occur. In adults are acquired and the main risk factors are pregnancy, asicitis, obesity and abdominal masses. Fig 8 and 9. Epigastric hernia Are less frequent. Occur in the linea alba between the xiphoid and umbilicus. They are more common in obese patients and their symptoms can be mistaken with acid peptic disease or biliary colic. Fig. 10 Hypogastric hernias Below the umbilicus. Are more prone to incarceration and strangulation. Fig. 11 Page 4 of 32

5 Lateral defects of the abdominal wall Spiguel hernia Lateral wall defect in the semilunar line. Fig. 2. Between the rectus muscle and the fascia of the oblique and transverse muscles. High risk of incarceration and strangulation. Fig. 12 Back or lumbar hernias Are hernias that occur in the posterior abdominal wall between the ribs 12 and the iliac crest. Fig. 2. These hernias usually occur in patients with traumatic or surgical history of the posterior abdominal wall In 1783 Petit describes the lower lumbar triangle hernias. Fig. 13 In 1866 Grinfelt Lesshaft describes the superior lumbar triangle hernias. Fig. 14 Other hernias Incisional They come in 0.5 to 14% of the surgeries that affect the abdominal wall. Symptoms usually occur within the first 4 months after surgery. Fig 14 and 16. Parostomales hernias are a subtype of incisional, which are very difficult to assess clinically or with ultrasound. Explained by the output of abdominal contents through the defect of an ostomy. Fig. 17 Traumatic hernia Related to high energy trauma. Usually require surgical correction and have other associated intra-abdominal injuries. Fig. 18 Richter hernia The hernia sac contains only part of the intestinal wall. Fig. 19 Amyand hernia: Contains the appendix. Fig. 20 Hernia of Littre: Meckel diverticulum containing. Differential Diagnosis Page 5 of 32

6 The differential diagnosis of abdominal wall hernias is very broad. Includes all adominal wall masses as hematomas, collections, lymphadenopathy and tumor implantation. Fig. 21 Ultrasound is useful when there is mainly a palpable mass. However, contrast CT with multiplanar reconstructions is superior especially in patients with obesity and abdominal wall scars and allows an adequate characterization of the majority of abdominal wall lesions that are part of differential diagnosis. Complications of abdominal wall hernias Complications of abdominal wall hernias are strangulation and intestinal obstruction. The strangulation means the commitment of irrigation for the content of the sac and ischemia. Both require urgent surgical management. The imaging signs that suggest complication of hernias are free fluid in the sac, fluid within the loops herniated, bowel wall thickening and increased attenuation of fat within the hernia sac. Fig. 22, 23. Images for this section: Page 6 of 32

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30 Conclusion The aim of imaging methods to assess abdominal wall hernia is to confirm their diagnosis and assess the presence of complications. It is necessary an adequate description of the relevant anatomical references to properly classify the type of hernia. This classification may have implications for management. Especially when complications are identified as intestinal obstruction and strangulation. Computed tomography with proper technique, using intravenous contrast medium to identify vascular anatomical references and multiplanar reconstructions allows an adequate diagnosis of abdominal wall hernias, the presence of complications and make appropriate differential diagnosis Personal Information Beatriz Molinares. Radiology Deparment. Pablo Tobon Uribe Hospital. Chief of Radiology postgrade. CES University. Medellin. Colombia William Quiceno. Radiology Deparment. Pablo Tobón Uribe Hospital. Professor of Radiology. CES University. Medellín. Colombia. Luisa Sánchez. Radiology Resident. CES University. Medellín. Colombia References 1. Jamadar D, Jacobson J, Morag Y, Girish1 G, Dong G, Al-Hawary M, Franz M, Characteristic Locations of Inguinal Region and Anterior Abdominal Wall Hernias: Sonographic Appearances and Identification of Clinical Pitfalls. AJR. 2007; 188: Page 30 of 32

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