Diagnostic ultrasound ( PDFDrive )

CHAPTER 13 Dynamic Ultrasound of Hernias of the Groin and Anterior Abdominal Wall 473
oten require sonographic imaging for diagnosis. Hernias can
contain small bowel, colon, or appendix. he Amyand hernia is
a rare inguinal hernia (about 1% of inguinal hernias, <1% of
appendicitis cases) that contains the appendix 10,11 (Fig. 13.6).
Other, much less common hernia contents include ovaries and/
or “bladder ears.”
FIG. 13.4 Fluid-Containing Incarcerated Direct Inguinal Hernia.
Long-axis image of a luid-containing femoral hernia that caused pain
and swelling.
FIG. 13.5 Bowel-Containing Inguinal Hernia. Short-axis view of
the inguinal canal shows an indirect inguinal hernia that contains bowel.
See also Video 13.3 showing peristalsis.
DYNAMIC MANEUVERS
he dynamic maneuvers that are the key to ultrasound’s ability
to depict and evaluate hernias include watching the region during
quiet breathing, the Valsalva maneuver, the compression maneuver,
and upright positioning. Dynamic maneuvers are useful
because many hernias spontaneously reduce when the patient
is supine and breathing quietly. 8 Hernias that contain only fat
are almost isoechoic with surrounding tissues and therefore
relatively inconspicuous. Watching the groin region during quiet
breathing allows for visualization of bowel peristalsis. Assessment
with color Doppler allows for assessment of bowel perfusion
(implying viability). Dynamic maneuvers can cause the fat within
a hernia to move, making the hernia contents more conspicuous.
he direction of movement can be helpful, because movement
of surrounding tissues is almost always in the anteroposterior
(AP) direction, whereas hernia contents oten move horizontally
or obliquely during compression maneuvers (Video 13.4). Hernia
contents may change with dynamic maneuvers. Finally, reducibility
and tenderness can be assessed.
he Valsalva maneuver is most useful when the patient is
supine. It forces hernia contents anteriorly, and oten horizontally
in an inferomedial direction (Fig. 13.7), and at times elicits pain.
Some hernias become visible only during the Valsalva maneuver
(see Fig. 13.2). In other cases, hernia sacs that can be seen in
quiet respiration elongate and widen during the Valsalva maneuver.
Hernias that appear to contain only fat during quiet respiration
may be shown to contain bowel during the Valsalva maneuver
(Video 13.5). In general, hernia sacs should become larger with
the Valsalva maneuver. If they stay the same size, this is worrisome
for incarceration.
A
B
FIG. 13.6 Amyand Hernia. (A) Right lower quadrant sonogram shows a complex cyst in the region of patient’s pain. (B) Magnetic resonance
image shows the appendix (arrow) extending into the hernia.