Diagnostic ultrasound ( PDFDrive )

CHAPTER
13
Dynamic Ultrasound of Hernias of
the Groin and Anterior
Abdominal Wall
Deborah Levine, Lisa Napolitano, and A. Thomas Stavros
SUMMARY OF KEY POINTS
• Dynamic ultrasound is the key examination for assessing
the groin or anterior abdominal wall pain. Dynamic
components of the examination include Valsalva and
compression maneuvers and scanning in both supine and
upright positions. Dynamic sonography enables clinicians
to determine hernia type, size, contents, reducibility, and
tenderness.
• Evaluation of groin pain in athletes is frequently more
complex than in nonathletes because of associated
tendinosis and osteitis pubis. Adding magnetic resonance
imaging to dynamic ultrasound is usually necessary to
identify underlying pathologic processes and to decide the
best combination of surgical and nonsurgical treatments.
• Patients with one hernia frequently have multiple hernias,
so in any patient in whom a hernia is sonographically
demonstrable, the examination should be continued,
looking for other types of ipsilateral and contralateral groin
or anterior abdominal hernias. Even when no additional
hernias are found, it is important to the surgeon to
speciically mention in the report that a complete search of
both groin areas was made and no additional hernias were
found.
• Strangulation is the most dreaded complication of groin
hernias. Gray-scale indings of strangulation—hyperechoic
fat, isoechoic thickening of the hernia sac, luid within
the sac, and thickening of the walls of bowel loops—
are all more sensitive for strangulation than is Doppler
ultrasound.
• Recurrent pain after herniorrhaphy is a relatively common
problem. Dynamic sonography can be helpful in assessing
both acute and chronic recurrences of groin pain. Most
hernia repairs now use mesh. The key to sonographic
identiication of recurrent hernias is to assess the edges of
the mesh with dynamic maneuvers, because recurrent
hernias arise from the edges of the mesh.
• Many pathologic processes, both rare and nonspeciic, can
simulate hernia, but cysts or hydroceles of the processus
vaginalis (or canal of Nuck) and round ligament varices are
relatively common and have virtually pathognomonic
sonographic appearances.
CHAPTER OUTLINE
TECHNICAL REQUIREMENTS
THE REPORT FOR DYNAMIC
ULTRASOUND OF GROIN
HERNIAS
HERNIA CONTENTS
DYNAMIC MANEUVERS
KEY SONOGRAPHIC LANDMARKS
INGUINAL AND INGUINAL REGION
HERNIAS
Indirect Inguinal Hernias
Direct Inguinal Hernias
Femoral Hernias
Spigelian Hernias
Sports Hernias
ABDOMINAL WALL OR VENTRAL
HERNIAS
Linea Alba Hernias
Umbilical Hernias
Paraumbilical or Periumbilical Hernias
Incisional Hernias
Multiple Hernias
ADDITIONAL ISSUES REGARDING
HERNIAS
Recurrent Groin Hernias
Hernia Complications
Entities That Simulate Groin Hernias
Entities That Simulate Anterior
Abdominal Wall Hernias
SUMMARY
Patients with groin pain may have a variety of conditions
including, but not limited to, hip abnormalities, tendonitis,
lymphadenopathy, or hernia. 1 Groin pain is a common presenting
symptom in adult patients. Herniorrhaphy is the most common
surgical procedure in the United States, with more than 800,000
operations performed annually. 2 An estimated 2.3 million inpatient
abdominal hernia repairs were performed from 2001 to 2010,
of which an estimated 567,000 were performed emergently. A
general increase in the rate of total emergent hernias was observed
from 16.0 to 19.2 emergent hernia repairs per 100,000
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