Diagnostic ultrasound ( PDFDrive )

CHAPTER 13 Dynamic Ultrasound of Hernias of the Groin and Anterior Abdominal Wall 491
FIG. 13.43 Linea Alba Tear. Tiny tear of the linea alba (arrows)
caused pain but was not palpable. Such tears are relatively common in
patients with preexisting diastasis recti abdominis.
FIG. 13.44 Two Epigastric Hernias. Longitudinal view shows a
small, fat-containing, nonreducible, epigastric linea alba hernia inferiorly
and a tiny tear superiorly. This patient had three other small hernias
more superiorly. Multiple epigastric linea alba hernias are common enough
that the entire length of the linea alba should be investigated in any
patient with an identiied epigastric hernia. See also Video 13.16.
Simply identifying diastasis in a patient with epigastric midline
pain is insuicient. he linea alba in the area of pain and along
its entire epigastric segment must be examined for hernias, because
patients with diastasis are at increased risk for multiple epigastric
hernias. It is important to assess the entire length of the linea
alba in any patient in whom one epigastric linea alba hernia is
found. Most hernias contain only properitoneal fat, so they cannot
be seen laparoscopically and must be repaired externally. If
surgeons do not know that multiple hernias are present, they
may use too small a piece of mesh to repair all the hernias. It is
our experience that “recurrent” epigastric hernias are more likely
to be secondary hernias that were not recognized and repaired,
rather than true recurrences (Fig. 13.44, Video 13.16 and
Video 13.17).
he much less common hypogastric linea alba hernia usually
lies within a few centimeters of the umbilicus. Inferior to this
area, the rectus muscles are more closely apposed or even fused.
As with epigastric hernias, hypogastric linea alba hernias have
narrow necks, usually are small to moderate-sized, contain only
preperitoneal fat, are usually not reducible, and are prone to
strangulation (Fig. 13.45).
Umbilical Hernias
Umbilical hernias occur through a widened umbilical ring. In
newborns, they result from delayed return to the abdomen of
bowel loops that lie in the base of the umbilical cord in the irst
trimester. In many cases, umbilical hernias in newborns will
regress spontaneously by 3 or 4 years of age. hose that do not
regress by age 4 are usually repaired.
Umbilical hernias can, however, develop at any time during
life. Any cause of chronically increased intraabdominal pressure
or connective tissue weakness can lead to dilation of the umbilical
ring and formation of an umbilical hernia. Umbilical hernias
FIG. 13.45 Hypogastric Linea Alba Hernia. Longitudinal view shows
a moderate-sized, fat-containing, periumbilical hypogastric linea alba
hernia (*) immediately inferior to the umbilicus (U). Note that neck of
the hernia (arrows) is very narrow and that the edematous strangulated
fat is hyperechoic in comparison to the surrounding subcutaneous fat.
contain intraperitoneal contents, but smaller umbilical hernias
usually contain only intraperitoneal fat (Fig. 13.46). We are asked
to evaluate umbilical hernias sonographically much less frequently
than we are asked to evaluate patients for groin pain, because
the diagnosis of umbilical hernia is usually obvious clinically.
he role of ultrasound is usually limited to evaluating for umbilical
pain in patients who are so morbidly obese that an umbilical
hernia cannot be detected clinically, or to assess for strangulation.
In obese patients the umbilicus courses obliquely from deep
superiorly to supericial inferiorly (Fig. 13.47). hus the umbilical
ring may be much more superiorly located than is suspected
from the location of the umbilicus in obese patients. Untreated
umbilical hernias tend to increase in size over time. hey are
usually reducible but may become nonreducible and can also