Diagnostic ultrasound ( PDFDrive )

474 PART II Abdominal and Pelvic Sonography
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B
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D
FIG. 13.7 Value of Valsalva Maneuver. Indirect Inguinal Hernias. (A) and (B) Split-screen long-axis views of a fat-containing indirect inguinal
hernia during quiet respiration and Valsalva maneuvers. The left image shows the hernia during quiet respiration (arrows). The right image, obtained
during a Valsalva maneuver, shows the hernia contents being forced distally in a horizontal direction within the inguinal canal (arrows and dotted
arrows). (C) and (D) Split-screen views in another patient show the more obvious hernia with Valsalva maneuver.
he compression maneuver is essential to assess reducibility
and tenderness in patients who have sonographically detectable
hernias, regardless of whether the patient is upright or supine.
Compression maneuvers are also useful in supine patients in
whom the Valsalva maneuver is inefective. Compression helps
assess reducibility of a hernia. Hernias may be completely
reducible (Video 13.6), partially reducible (Video 13.7), or
nonreducible (Video 13.8). he shape of hernias correlates with
reducibility. A hernia with a broad fundus and narrow neck is
likely to be nonreducible, whereas a hernia with a broad neck
compared with the fundus is more likely to be reducible (Fig.
13.8). Assessing tenderness is very important because dynamic
sonography is so sensitive that it can detect many asymptomatic
and clinically unimportant hernias. Furthermore, in some patients
the pain is caused by other etiologies.
Upright positioning is essential in all patients being sonographically
evaluated for groin hernia. Many patients are
symptomatic only in the upright position, or they are more
symptomatic in the upright position. Fluid is oten best demonstrated
with the patient in the upright position. It may take
minutes for the free luid to “puddle” in the inferior end of the
hernia sac once the patient has been standing. herefore delayed
imaging in the upright position may be helpful in demonstrating
peritoneal luid. Other hernias contain bowel only in the upright
position. Some hernias are either only visible in the upright
position 6 or are much better demonstrated in the upright position
(direct inguinal and femoral). he reducibility of a hernia may
vary between supine and upright position, so it is important to
assess reducibility in both positions. In most patients, groin
hernias are more reducible in the supine than in the upright
position, whereas in others the opposite is true.
KEY SONOGRAPHIC LANDMARKS
Ultrasound shows characteristic features of groin hernias that
lie above the inguinal ligament. Four types of hernias occur