Diagnostic ultrasound ( PDFDrive )

486 PART II Abdominal and Pelvic Sonography
FIG. 13.30 Nonreducible Femoral Hernia. Short-axis view shows
large, nonreducible femoral hernia that arises within the femoral canal
(*) medial to the common femoral vein (CFV). The long, narrow neck
(arrows) extends directly anteriorly, and the large fundus (arrowheads)
illed with peritoneal luid causes this hernia to be at extremely high
risk for strangulation.
Hernia sac
FIG. 13.31 Spigelian Hernia. Diagrammatic axial view of the abdomen
at the level of the umbilicus depicting a complete Spigelian hernia. The
hernia sac protrudes through the linea semilunaris. In complete spigelian
hernias the hernia sac protrudes through the complete thickness of the
wall musculature. (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 )
with sports pubalgia. 38 In a study of 1450 athletes in a sports
medicine clinic who had long-standing pubalgia but no clear
evidence of hernia, 580 (40%) were felt to have “sport hernia.”
In 573 patients, ultrasound examination detected some protrusion
of the posterior wall with normal or minimally dilated inguinal
rings; 498 of them coincided with areas afected by pain. Compared
with indings of laparoscopy, ultrasound had a sensitivity
of 95.42% and a speciicity of 100%. 38
he underlying pathology is usually tendinosis (degenerative
change in tendons without signs of inlammation) of either the
adductor longus origin or the rectus abdominis insertion. he
tendons of these two muscles interdigitate, making them inseparable
from each other as they insert onto the pubis. Tendinosis
of one tendon usually leads to tendinosis of the other, and
eventually to instability of the pubic symphysis and osteitis pubis.
Tendinosis of the rectus abdominis muscle can also lead to
microtears in which the aponeuroses of the internal oblique and
transverse abdominis muscles (components of conjoined tendon)
insert onto the rectus sheath, causing them to bulge anteriorly
into the inguinal canal (posterior inguinal wall insuiciency or
conjoined tendon insuiciency) and also leading to dilation of
the external (supericial) inguinal ring. he thinned and bulged
conjoined tendon pushes the spermatic cord laterally, rotates it,
and compresses it. Because of the efects on the spermatic cord,
the resulting pain oten radiates into the scrotum.
Posterior inguinal wall insuiciency is usually bilateral, even
though symptoms may be only unilateral. In the short axis,
posterior inguinal wall insuiciency appears indistinguishable
from direct inguinal hernia (see Figs. 13.23 and 13.24). In the
long axis, however, posterior inguinal wall insuiciency and direct
inguinal hernia have diferent shapes. he posterior wall insuficiency
is semicircular, whereas the direct inguinal hernia
protrudes inferiorly within the inguinal canal in a ingerlike
projection (Fig. 13.36). At the level of the proximal inguinal
canal, insuiciency and hernia can be distinguished only in the
long axis, appearing identical in the short axis. More distally
within the inguinal canal, however, the distinction can be made
in the short axis. he direct inguinal hernia sac will be seen
posterior to the spermatic cord (see Fig. 13.14), whereas in
posterior inguinal wall insuiciency, the inguinal canal will appear
normal.
Posterior inguinal wall insuiciency can progress to direct
inguinal hernia in two ways: the conjoined tendon can tear
completely, or the tendon can become so thinned and stretched
that it is pushed inferomedially into the distal inguinal canal.
Both complications arise inferior and medial to the origin of
the inferior epigastric vessels. In patients with acute tendon tears,
the neck is small, and the hernia sac appears thin (transversalis
fascia and peritoneum) (Fig. 13.37). In severe stretching of the
conjoined tendon, however, the neck is wide, and the hernia sac
appears thicker (aponeuroses of internal oblique and transverse
abdominis muscles as well as transversalis fascia and peritoneum)
(see Figs. 13.20 and 13.36).
Because there is usually some degree of tendinosis or osteitis
pubis, even when a direct inguinal hernia or posterior inguinal
wall insuiciency is present, simply assessing sonographically
for hernia is oten insuicient for the workup of these patients.