Emergency presentation of hernias of the torso: What your surgeon wants to know.

Transcription

1 Emergency presentation of hernias of the torso: What your surgeon wants to know. Ken F Linnau, MD, MS Emergency Radiology UW Medicine Harborview Medical Center klinnau@uw.edu Nordic Forum 2017 Helsinki, Finland

2 No financial disclosure Thanks to: Charles A Rohrmann Jr. Amie Y. Lee and Joel A Gross for lending me cases Lisa K McIntyre for her surgical perspective

3 Hernia Hernia, pl. herniae or hernias.: Protrusion of a part or structure through the tissues normally containing it Etymology: Latin = rupture Stedman s Medical Dictionary, 28 th Ed (2006) Oxford English Dictionary, 2 nd Ed (1989)

4 78yof, epigastric pain, N/V

5 78yof, epigastric pain, N/V

6 Role of radiology Locate and describe hernia Road map for surgery Assess acuity of hernia Timing of surgery Suggest complications, if suspected

7 Complications of herniation Bowel obstruction: Hernia is second most common cause after adhesions (10-15% of cases) Usually small bowel Incarceration Non-reducible Clinical diagnosis: imaging can suggest If incarcerated: Bowel: immediate surgery to prevent necrosis Fat or fluid only: timing less important Strangulation: Ischemia due to decreased blood supply Clinical diagnosis: imaging can suggest

8 Incarceration: findings Narrow neck Free fluid in the hernia sack Bowel wall thickening Luminal dilatation

9 Clinical diagnosis Strangulation Metabolic acidosis: serum lactate (90% sensitivity, 42-87% specificity), WBC Intraoperative assessment of ischemia Direct inspection Wood lamp after fluorescent agent injection Anti-mesenteric intraoperative Doppler

10 Strangulation: radiologic findings Usually closed loop obstruction afferent and efferent limb U or C shaped bowel loops in hernia sack Wall thickening Mural hypo- or hyper enhancement Mesenteric vessel engorgement Fat stranding Ascites

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12 Groin: direct and indirect Indirect groin hernia: Lateral to inferior epigastric artery Most common hernia of the groin, through patent processus vaginalis Direct groin hernia: Medial to inferior epigastric artery Through Hasselbach triangle More common in men Sometimes managed expectantly

13 34 yom, LLQ pain

14 34 yom, LLQ pain

15 Direct and indirect groin hernia

16 Groin: Femoral hernia Occurs through the empty space at the medial femoral canal Medial to femoral vein Posterior to inguinal ligament More common in women (4:1) Only 4% of groin hernias, but 40% present with emergency Always surgical

17 80 year old woman with severe abdominal pain Incarcerated Right Femoral Hernia Causing Small Intestine Obstruction

18 Ventral abdominal hernia Umbilical: linea alba, most common ventral, usually asymptomatic Paraumbilical: linea alba, rectus abdominis diastasis related Hypogastric: line alba, inferior to umbilicus Epigastric: linea alba superior to umbilicus Incisional: usually first year after surgery More common in vertical incisions

19 Ventral abdominal hernia: aside Rectus diastasis Not a hernia Never surgical indication Acquired defect in which the two rectus muscles are separated more than the usual 1-2 cm

20 24 yom abdominal mass and pain, 1 yr after MVC

21 Incisional hernias Measure maximal rectus-to-rectus distance If < 12 cm: Rectus abdominis muscle release surgery possible (6 cm on each side) If > 12 cm: Different surgical approach necessary e.g. mesh repair

22 Uncommon abdominal hernias Parastomal: incisional variant Spigelian hernia: Through posterior layer of transverse fascia Lateral to rectus muscle Prolapse between abdominal wall muscles Richter hernia: Only a portion of the bowel wall is herniated Obturator, sciatic, perineal: rare

23 75yom with abdominal pain (s/p colectomy and AAA):

24 75yom with abdominal pain (s/p colectomy and AAA): Asyptomatic left parastomal hernia contains stomach and ileostomy Incarcerated right paraumbilical

25 83 yof with abdominal pain

26 83 yof with abdominal pain Spigelian hernia containing small bowel: Through posterior layer of transverse fascia lateral to rectus muscle

27 83 yof with abdominal pain: Spigelian

28 66 yof, abdominal pain, BMI = 40

29 66 yof, abdominal pain, BMI = 40 Richter hernia: only a portion of bowel wall in hernia

30 Lumbar hernias Usually due to trauma or surgery Usually repaired Emergent laparotomy

31 Lumbar hernias Superior lumbar triangle (Grynfeltt- Lesshaft): Superior: 12 th rib Anterior: m. obl. internus Medial: m. erector spinae Inferior lumbar triangle (Petit) Anterior: m. obl. externus Posterior: m latissimus dorsi Inferior: iliac crest

32 64 yof, HS MVC, seat belt sign

33 64 yof, HS MVC, seat belt sign Superior lumbar triangle hernia

34 INTERNAL HERNIAS A PARADUODENAL (53%) B PERICECAL (13%) C FORAMEN OF WINSLOW (8%) D TRANSMESENTERIC (8%) E PELVIC (7%) F INTERSIGMOID (6%) OTHER (5%) After Meyers

35 Paraduodenal hernia Entrapment of SB beneath transverse mesocolon Sag Cor Axial

36 PARADUODENAL HERNIA FORAMEN OF LANDZERT From Netter From Meyers

37 24 year old woman with cramping mid abdominal pain: Retroperitoneal or Intraperitoneal Mass?

38 24 year old woman with cramping mid abdominal pain

39 PARADUODENAL HERNIA FORAMEN OF LANDZERT

40 PARADUODENAL HERNIA FORAMEN OF LANDZERT From Netter

41 FORAMEN OF WINSLOW HERNIA

42 Epiploic Foramen of Winslow Deep to pylorus and anterior to pancreas

43 38yof, abdominal pain Case Courtesy of Dr. S. Elojeimy

44 38yof, abdominal pain Cecum and TI: Deep to pylorus and anterior to pancreas Case Courtesy of Dr. S. Elojeimy

45 Hernia surgery Most frequently performed general surgery Very common emergency surgery High complication rate after hernia repair: up to 20 %

46 Complications of hernia repair Testicular ischemia (uncommon) Hematoma and seroma Abscess Recurrence and Mesh dehiscence Bowel obstruction: Adhesions

47 47yom, POD #4 s/p rt inguinal hernia repair: pain, swelling

48 47yom, POD #4 s/p rt inguinal hernia repair: pain, swelling

49 47yom, POD #4 s/p rt inguinal hernia repair: pain, swelling

50 47yom, POD #5: re-exploration: normal mesh, no re-herniation, no incarceration, hematoma only

51 Summary: hernias Hernias are very common: Look for the uncommon hernia types Provide a road map for your surgeon Complications of herniation: Bowel obstruction Incarceration/strangulation Acuity of process is important Complications of hernia surgery: Recurrence Ischemia (bowel or testicular)

52 Selected references: 1. Aguirre DA, Santosa AC, Casola G, Sirlin CB. Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics 2005;25: Takeyama N, Gokan T, Ohgiya Y, et al. CT of internal hernias. Radiographics 2005;25: Meyers MA. Dynamic Radiology of the Abdomen. 4th Ed. Springer (1994)