Diagnostic ultrasound ( PDFDrive )

500 PART II Abdominal and Pelvic Sonography
FIG. 13.61 Strangulated Femoral Hernia. Short-axis view shows
strangulated left femoral hernia that shows two additional gray-scale
indings of strangulation: transudative or exudative luid and isoechoic
thickening of the hernia sac wall. See also Video 13.23.
Nuck (see Fig. 13.63A; Video 13.24). Hydroceles are usually
unilocular and ixed in position within the canal, but can become
lobulated and septated as they enlarge.
Hematomas and inlammation may occur in the inguinal
regional in proximity to the round ligament and can give rise
to cysts and leiomyomas. Unlike inguinal canal hydroceles, which
are ixed in position, round ligament cysts can be mobile and
can move back and forth between the abdominal cavity and the
inguinal canal. he round ligament contains smooth muscle ibers
from which leiomyomas can arise. Round ligament varices
develop as collateral pathways for uterine venous drainage during
pregnancy. hey are usually asymptomatic and incidental, but
in some patients can cause a tender, palpable, inguinal or labial
abnormality that can mimic a hernia 55 (see Fig. 13.63B). hey
usually resolve spontaneously and completely ater delivery, but
in a few patients can persist and cause inguinal pain and swelling
months or years ater the last pregnancy. hey are relatively
inapparent with the patient in the supine position, but become
larger and have faster low in the upright position. Occasionally,
round ligament variceal thrombosis occurs spontaneously, most
oten in the postpartum period when collateral uterine low
through them regresses. Endometriomas can occur along the
course of the round ligament within the inguinal canal (see Fig.
13.63C). hey oten have a history of cyclic variation in size and
tenderness.
he most common benign tumor of the inguinal region is a
lipoma. 6 Most so-called inguinal canal lipomas are not true
lipomas, but rather nonsliding-type indirect inguinal hernias
that contain only properitoneal fat. However, true lipomas can
occur anywhere along the length of the inguinal canal and into
the scrotum or labium majus (see Fig. 13.63D-E).
Other benign tumors of the groin include leiomyomas, dermoid
cysts, epidermoid cysts, and lymphangiomas.
Other entities that can occur in the inguinal region include
desmoids, sarcomas, hematomas, seromas, undescended testes,
and metastatic peritoneal implants. 6
Inguinal lymphadenopathy, common femoral or external iliac
artery aneurysms and pseudoaneurysms, iliopsoas bursae, and
sebaceous cysts can all occur within the groin, but outside the
inguinal canal. In addition, pain from intraabdominal inlammatory
processes can simulate groin pain; acute appendicitis
and acute diverticulitis can cause pain near the groin.
FIG. 13.62 Strangulated Periumbilical Epigastric Linea Alba
Hernia. The fat is hyperechoic, the sac wall is isoechoic and thickened,
and a small bowel loop (b) has a thickened wall and is aperistaltic. The
hernia sac is outlined by arrows.
does not fuse while segments proximal and distal to it do fuse.
his leads to accumulation of luid within the unfused segment
of processus vaginalis and forms a localized process hydrocele.
In males these occur within the inguinal canal next to the
spermatic cord and can compress the cord. In females the unfused
processus vaginalis is called the canal of Nuck, so this localized
cyst or hydrocele is termed a cyst or hydrocele of the canal of
Entities That Simulate Anterior Abdominal
Wall Hernias
Subcutaneous or intramuscular lipomas have a sonographic
appearance identical to those of the inguinal canal or labium.
In patients being evaluated for incisional hernias, exuberant
scars and fat necrosis resulting from previous surgeries can
clinically simulate an anterior abdominal wall incisional hernia.
Hematomas of the rectus abdominis (Fig. 13.64A) or oblique
muscles can cause pain and swelling that simulate anterior
abdominal wall hernia. he patient usually (but not always) has
a history of signiicant acute trauma.
Anterior abdominal wall desmoids are usually sporadic.
hey arise from the ibrous elements of the anterior abdominal