Diagnostic ultrasound ( PDFDrive )

CHAPTER 13 Dynamic Ultrasound of Hernias of the Groin and Anterior Abdominal Wall 477
Hernia type−groin−coronal CT reformat
Semilunar line
Inferior epigastric
vessels
Spigelian
Internal inguinal
ring (indirect)
Conjoined tendon
(direct)
Femoral canal
(femoral)
Groin = ilioinguinal crease
FIG. 13.10 Locations of Four Types of “Groin” Hernias. Abdominal and pelvic computed tomography (CT) image, reformatted in coronal
plane. Indirect inguinal hernias arise within the internal or deep inguinal ring, which lies in the crotch between the external iliac artery and the
proximal inferior epigastric artery. Direct inguinal hernias arise through the “conjoined tendon,” which lies inferior and medial to the origin of the
inferior epigastric artery. Spigelian hernias arise through the spigelian fascia just lateral to the inferior epigastric artery, where it reaches the lateral
margin of the rectus muscle. Femoral hernias lie within the femoral canal, inferior to the inguinal canal and inguinal ligament.
or incomplete closure of the inguinal canal. hus indirect inguinal
hernias are more common in males. However, delayed or
incomplete closure of the canal of Nuck can occur in females.
he neck of an indirect inguinal hernia is the segment that lies
within the internal inguinal ring, and the fundus lies within the
inguinal canal (Fig. 13.11). he neck (internal inguinal ring) lies
just superior and lateral to the IEA’s origin and tends to be oriented
in an AP direction, whereas the fundus (inguinal canal) is oriented
horizontally and courses inferiorly and medially, passing supericial
to the IEA’s origin he fundus of an indirect inguinal hernia
lies anterior and lateral to the spermatic cord in males and the
round ligament in females (Fig. 13.12). In the short axis, the
internal inguinal ring and the neck of the indirect inguinal hernia
lie between the external iliac artery along its lateral side and the
IEA along its medial side.
In the long axis, indirect inguinal hernias can have two
appearances: sliding and nonsliding. he sliding type of indirect
inguinal hernia has a relatively wide neck compared with the
fundus, with loss of the angle between the neck and fundus. It
is usually reducible and is more likely to contain bowel and other
intraperitoneal contents. he nonsliding type has a relatively
narrower neck compared with the fundus and maintains the
almost 90-degree angle between the neck and fundus (Fig. 13.13).
Nonsliding hernias usually contain only properitoneal fat and
are nonreducible, and may be misclassiied as “spermatic cord
lipoma” or “inguinal canal lipoma” at surgery. True spermatic
Epigastric vessels
Internal inguinal ring
Hesselbach triangle
FIG. 13.11 Indirect Inguinal Hernia. Diagram of the deep aspect
of the anterior abdominal wall depicting a left indirect inguinal hernia.
The hernia sac protrudes through the internal inguinal ring, located lateral
to the epigastric vessels. Note the Hesselbach triangle, located medial
and inferior to the epigastric vessels. (Reproduced with permission from
Granja M, Rivero O, Aguirre D. Abdominal wall hernias. In: Sahani DV,
Samir AE, editors. Abdominal imaging. 2nd ed. Philadelphia: Elsevier;
2017:1014-1025. 43 )