Diagnostic ultrasound ( PDFDrive )

CHAPTER 13 Dynamic Ultrasound of Hernias of the Groin and Anterior Abdominal Wall 479
Ind
Dir
A
Short-axis view
B
FIG. 13.14 Hernia Sacs Relative to Spermatic Cord. (A) Direct (Dir) and indirect (Ind) hernia sacs relative to the spermatic cord (SC). Left,
Drawing shows that indirect inguinal hernia sac tends to lie anterior to spermatic cord, whereas direct inguinal hernia sac lies posterior to the cord.
Center, Short-axis view shows fat-containing direct inguinal hernia (H) posterior and medial to the spermatic cord (SC). Right, Short-axis view shows
fat-containing indirect inguinal hernia (H) lying anterior and lateral to the spermatic cord (SC). (B) Long-axis views of right direct and left indirect
inguinal hernias in the same patient. Left, Image shows the right direct inguinal hernia sac lying posterior to the spermatic cord (SC). Right, Image
shows the left indirect inguinal hernia sac lying anterior to the spermatic cord (SC).
along the anterolateral aspect of the spermatic cord, whereas
direct inguinal hernia sacs tend to lie posteromedial to the
cord (Fig. 13.14). In females, indirect inguinal hernias lie
anterior to the round ligament (Fig. 13.15). Large indirect inguinal
hernias can latten and splay the spermatic cord (Figs. 13.16 and
13.17), causing pain that radiates into the scrotum. Indirect
inguinal hernias are much more likely than direct inguinal
hernias to extend into the scrotum or labium majus (Fig. 13.18,
Video 13.9).
Direct Inguinal Hernias
he characteristic inding of a direct inguinal hernia is focal
intraabdominal tissue moving anteriorly through the Hesselbach
triangle. 1,8,22,23 On ultrasound, this tissue of variable
echogenicity will move characteristically in a posterior-to-anterior
direction. 1
Direct inguinal hernias are the second most common type
of groin hernia and are acquired. he incidence increases with
age, as this type of hernia results from a weakening of the
tranversalis fascia in the Hesselbach triangle. 27 he Hesselbach
triangle is anatomically bounded inferiorly by the inguinal ligament,
medially by the lateral margin of the rectus abdominis,
and superolaterally by the IEA.
Direct hernias arise in two ways: either a passing through a
defect in the “conjoined tendon” (Fig. 13.19) or by greatly stretching
the tendon into the inguinal canal (Fig. 13.20). During open
hernia repair, direct inguinal hernias protrude “directly” into
the opened inguinal canal from a posterior direction. Indirect