Diagnostic ultrasound ( PDFDrive )

CHAPTER 13 Dynamic Ultrasound of Hernias of the Groin and Anterior Abdominal Wall 483
A
B
FIG. 13.22 Direct Inguinal Hernia. (A) Short-axis view of direct inguinal hernia shows a thinned and bulging conjoined tendon, consisting of
the internal oblique aponeurosis (supericial arrows) and transverse abdominis aponeurosis (arrowhead), and underlying transversalis fascia (horizontal
arrow) and peritoneum (*). SC and oval dotted lines indicate spermatic cord. (B) Long-axis view shows the conjoined tendon (among three vertical
arrows and arrowhead), underlying transversalis fascia (oblique arrow), and peritoneum (*).
1
2
3
4
FIG. 13.23 Conjoined Tendon: Two Views. Upper illustration,
Relationship of the conjoined tendon to the spermatic cord in quiet
respiration in the supine position. The layers are separated by loose
connective tissues or fat. Lower illustration, Bulging of the conjoined
tendon during Valsalva maneuver or in the upright position. The layers
tend to be pushed together and are more dificult to distinguish from
one another. When the aponeuroses of the internal oblique (1) and
transverse abdominis (2) muscles are pushed together, the conjoined
tendon appears as a more discrete structure. 3, Transversalis fascia; 4,
peritoneum. The anterior bulging of the conjoined tendon pushes the
spermatic cord laterally and rotates it from a “wider-than-tall” orientation
to a “taller-than-wider” orientation.
he femoral canal lies deeper than the inguinal canal and
may be more diicult to assess with a high-frequency linear
array transducer. Small and even moderate-sized femoral hernias
frequently reduce completely in the supine position during quiet
respiration and are most readily demonstrated during the Valsalva
maneuver or in the upright position during compression maneuvers.
Femoral hernias are oten bilateral (see Fig. 13.2C).
Spigelian Hernias
Spigelian hernias are usually considered anterior abdominal wall
hernias rather than groin hernias. hey can occur anywhere
along the course of the spigelian fascia, the complex aponeurotic
tendon that lies between the oblique muscles laterally and the
rectus muscles medially. However, almost all spigelian hernias
occur at the inferior end of the semicircular line, inferior to
the arcuate line, where the posterior rectus sheath is absent, and
where the spigelian fascia is penetrated and weakened by the
inferior epigastric vessels (Fig. 13.31). In many patients, this
location is within 2 cm of the internal inguinal ring. Furthermore,
when symptomatic, the pain caused by spigelian hernias can be
diicult to distinguish from that caused by indirect inguinal
hernias. herefore we are including spigelian hernias in our
discussion of groin hernias, because sonographic diagnosis of
these patients is possible when they are referred for lower
quandrant pain. 32
Spigelian hernias are associated with conditions that increase
intraabdominal pressure. 33,34 he spigelian fascia is composed
of several diferent layers of loosely apposed aponeurotic tendons.
From external to internal lie the aponeuroses of the external
oblique, internal oblique, and transverse abdominis muscles.
Internal to the aponeuroses lie the transversalis fascia and
peritoneum. In spigelian hernias the transverse abdominis tendon