Sonography of the Hernias - SD

Sonography of Abdominal Wall Hernias

Hello, I'm Cindy Rapp from Denver, Colorado
and today we're gonna be talking about sonography
of abdominal wall hernias.

What is a Hernia?

A hernia is a protrusion of an organ
or tissue through an abnormal opening in the body.
Not all hernias contain bowel loops.
Fat is the most common sonographic hernia
content that we will see.

Where Do Hernias Occur?

Areas of natural weakness in the abdominal wall,
basically anywhere that plumbing goes through.
The internal inguinal ring, the inguinal canal,
the femoral canal, the fetal canal such
as the umbilical ring.
Anywhere there's aerosa,
these typically will be directing hernias, spion,
or defects of the linear elbow.
And also anywhere that there has been a surgical scar,
a hernia can occur.

Causes of Hernias

Some of the causes of hernias are increase in intraabdominal
pressure due to obesity, chronic coughing, lifting,
heavy objects, patient straining, constipation,
pregnancy and ascites.

Advantages of Sonography

What's neat about sonography,
we can determine not only the location
or the type of the hernia,
we can determine the actual contents if those contents are
reducible or if they are strangulated.

Types of Abdominal Wall Hernias

Looking at abdominal wall hernias is netter illustration.
You can see that inguinal hernias, there are direct
and indirect inguinal hernias that we'll talk about.
Umbilical hernias, femoral hernias occur
below the abdominal curl crease.
We'll take a look at those. Spion hernias are another type
of hernia of the aosa that we'll talk about
and epigastric hernias, any type of a hernia that is midline
above the belly button is an epigastric hernia
and hypogastric hernias occur below the belly button.
Incisional hernias are another type of hernia
that we'll also take a look at.

Hernia Contents

Hernia contents can be intraperitoneal
and those could be fat fluid bowel vessels and membranes.
Or you may have a hernia that is only prop peritoneal.
These tend to be fat containing only hernias.
And I'll describe what
or how we evaluate prop peritoneal hernias.
Then we can not only tell the contents of the hernia,
are the contents incarcerated?
Does a patient have a bowel obstruction
or is there incarceration of the hernia contents?
Looking at these different images,
we can see the image on the left is a fat containing hernia.
The image in the middle contains fluid
and also a loop of bowel
that is projecting into the contents.
And then the image on the far right we can see
that there are blood vessels and membranes.
And with color doppler we can see that they're still flow.
So we know this is not a strangulated hernia.
Hernia contents, we can also see shadowing gas within loops
of small bowel and we may see peristalsis within some
of these hernia contents.
This is an indirect inguinal hernia
that we can see peristalsis of a loop of small bowel
through the defect in this inguinal canal.

Preperitoneal Fat Hernias

When we talk about pre
or prop peritoneal fat, if we're scanning hernias
of the midline or the linear alba,
everybody has a little layer of fat that sits
between the peritoneal membrane and the linear alba,
and this is referred to as pro peritoneal fat.
What can happen is you get a defect through the linear alba
but the peritoneal membrane is still intact.
These are very common.
The patient will present as a palpable abnormality
and rarely are these hernias reducible.
Here you can see the peritoneal membrane.
We have the linear elbow and you can see the defect.
It almost looks like a mushroom cloud extending up.
This patient presented with a palpable lump
that was a preperitoneal hernia, all only,
which means there are no intraperitoneal contents.
So the patient really is not at risk of getting
strangulation of intrabdominal contents
with this type of a hernia.
A lot of these midline line alba defects are non reducible
and they are strangulated.
So here's a transverse view between the two rectus muscles.
The peritoneal membrane can be seen here.
This is the linea alba
and you can see the defect right through this area
rotating the transducer 90 degrees.
You can see the long axis view of the line elbow
and right through here it's a defect with just a little bit
of preperitoneal fat on that particular patient.

Dynamic Maneuvers in Sonography

With sonography we can do dynamic maneuvers,
we can do Valsalva, we can check for compression
or we can stand the patient upright.
These are unique in the things
that cannot typically be done
with the patient in a CT scanner.

Valsalva Maneuvers

Why do we wanna use Valsalva maneuvers?
Sometime hernias are only symptomatic when the patient is
staying standing or actually was straining the cons.
Acuity of fat containing hernias is typically poor.
The motion or key to diagnosing these fat containing hernias
and hernia contents may change.
Something that looks like it may be only a
fat containing hernia.
Once the patient val Salvas, we may see loops of small bowel
that extend into the hernia also.
On this particular image on the left hand side,
we can see an indirect inguinal hernia with fat.
Once we have the patient val salva,
the hernia contents expand
and actually move down the canal a little bit more
so we can see that with Val Salva maneuver.
We definitely have an increase in the fat contained with
inside this hernia.
Looking at this loop here,
we can see once again it's an indirect inguinal hernia
that is fat containing.
We can see with compression
of the transducer this hernia is completely reducible.

Compression Maneuvers

Why will we use compression maneuvers?
The concept acuity of fat containing hernias is also low.
It kind of creates abnormal motion for hernia contents.
The motion created by the compression is smoother than
having the patient Valsalva.
It's something else that we always wanna check.
The reduce ability of her hernias, some
of the hernias may be present
with a patient just in the supine position.
Then we want to reduce those hernia
and that's a good way to check for tenderness.
Hernias are a lot more common than clinically suspected a
lot of times and may not really be the true cause
for the patient's pain.
Asymptomatic incidental hernias are very common
and significant hernias are usually tender.
This is a patient that in supine position we could see this
small hernia extending up.
We wanna check to see if the hernia is reducible.
With transducer pressure we were able to reduce that.
Looking at this indirect neural hernia with reducing
or compression of the transducer,
this hernia is partially reducible.
We can see the loop of small bowel that goes down,
but notice still down the inguinal canal are additional
loops of small bowel and this was a partially reducible
indirect inguinal hernia containing small bowel.

Upright Position

The reason we'll stand the patient upright is sometimes
we'll see puddling of the peritoneal fluid,
especially in female patients.
When they ovulate, there'll be some fluid in there.
Standing the patient up, a lot
of times hernia contents will change.
Gravity is more reliable than the Valsalva maneuver.
In some patients, many hernias are symptomatic when the
patient is in the upright position
and usually hernias are going
to become larger when the patient stands up.
Another thing is some hernias are present only in the
patient in the upright position.
This tends to be true for ilion hernias.
Even if patients have a very good Valsalva maneuver, a lot
of times we'll only see the spion hernias
in an upright position.
Few hernias are reducible.
Also, when the patient is standing upright,
sometimes the neck may be pinched off
with a patient sup supplying,
standing them in the upright may change the position
of the neck and then a hernia may be become reducible.
This is a patient that when they were supine we can see this
fat containing indirect angle hernia.
Once we stood the patient upright, we can see
that there's not only fat within the hernia,
but now there is also fluid.
The difference in staying the patient upright, we're able
to see additional contents within the hernia.

Terminology for Hernias

As far as terminology, we prefer
to use the term non reducible rather than using the
term incarcerated.
The reason for this is clinicians get confused between
incarceration and strangulation.
All strangulated hernias are incarcerated
but most of your incarcerated hernias are not strangulated.
Once again, rather than using the term incarcerated,
we prefer to say that a hernia is non reducible
or incompletely reducible rather than stating
that it is incarcerated.

Finding Inguinal Hernias: Key Landmarks

How do we find inguinal hernias?
What is the key to diagnosing the landmarks
for inguinal hernias?
The key is to find the inferior epigastric vessels
and what we do is follow those
to their origin From the external iliac artery,
the inferior epigastric origin marks the origin
of the internal inguinal ring.
Looking at this netter illustration,
we can see these are the inferior epigastric vessels.
He shows that there's a single artery and single vein
and actually patients have one artery with paired veins.
Normally you're going to see three vessels just under the
surface of the rectus muscle.
What I'll do is typically start scanning in this area
and what you'll notice that
as you slide your transducer more inferiorly,
these vessels will move out laterally.
Here's our first image.
It would be taken about in this area.
You can see the patient's rectus muscle.
Here is the artery
with paired veins just under the edge of the rectus muscle.
As I move my transducer down, you can see the vessels start
to move more lateral.
As I keep moving down, you can see they're right at the edge
of the rectus muscle just
before they go into the external iliac artery.
Right at this point you can rotate your transducer in a long
axis and a short axis view.
If you notice it's more to the crease of the leg
and not straight longitudinal
and transverse imaging on the patient,
but more long axis to the inguinal canal and short axis.
And the internal inguinal ring is right at the location
of where the inferior epigastric artery dives into the
external iliac artery.
In male patients, the spermatic cord can be seen within
the inguinal canal.
Females have the round ligament,
but typically we don't visualize the round ligament very
well on our female patients.

Indirect Inguinal Hernias

Two types of inguinal hernias that can be seen.
There is an indirect inguinal hernia
and direct inguinal hernia.
The majority of inguinal hernias are indirect
and the way to tell these, they go up and over
or in other words they are superficial
to the inferior epigastric artery.
If you're scanning transverse over the spermatic cord
down a little bit lower in the inguinal canal,
they will be entered to the spermatic cord
and they may communicate with the scrotum.
Typically if you see a hernia contents
that are in the scrotum,
usually it will be an indirect inguinal hernia.
Direct inguinal hernias are inferior
to the inguinal ring.
It is a defect through the conjoined tendon
and these tend to be more posterior
and medial to the spermatic cord.
We will see them behind the spermatic cord rather
than anterior to it.
This image we can see is a view
of the left inguinal canal on a male patient
that we can see the spermatic cord located right here.
We can see the spermatic artery,
some of the veins within it.
And then the echogenic area is just the fat inside
of the spermatic cord.
Your inferior epigastric, I'm sorry,
your iliac vessels would be off to the side
of the image right over in this area.
Indirect a**l hernias will be anterior
to the spermatic cord.
Direct a**l hernias are going to come up posterior
and medial to the spermatic cord.
You can see spermatic cord here.
Once again, indirect inal hernias will be anterior direct
will be posterior and medial.
Looking at this loop here,
this patient has got two hernias.
There is a direct inguinal hernia located right here
and an indirect inguinal hernia was located right at the
edge of the spermatic cord.
Next we're gonna talk about indirect inguinal hernias.
That is the most common type they arise in the internal
inguinal ring, superior
and lateral as they pass anterior
to the inferior epigastric artery.
We follow those vessels from the rectus muscle down into
the external iliac artery and when a hernia course is up
and over, those are indirect inal hernias.
We can see our inferior epigastric artery.
Here we can see the hernia contents extending down.
This is a fat containing indirect inal hernia
rotating the transducer 90 degrees.
We can see the spermatic cord is compressed here
and we have the hernia contents located here
that are anterior to anterior to the spermatic cord.
Not all indirect anular hernias will always be seen
anterior to the spermatic cord.
What can happen is they start out anterior
to the spermatic cord,
but as they travel down the ula canal, sometimes they rotate
around and can be seen actually posterior
to the spermatic cord.
Here we see our inferior epigastric vessel.
We can see the hernia contents coming up
and over in a short axis view.
Here we have the spermatic cord but the hernia contents
or posterior to the spermatic cord and that's just
because it has rotated posterior to it
as it traveled down the canal.
But this is still an indirect inal hernia,
which is the most common type of inal hernia we'll see
in hernias may have a wide neck or may have a narrow neck.
Patients tend to be more symptomatic when the hernia
contents have a narrow neck rather than a wide neck.
But here we can see a very wide neck,
indirect inguinal hernia that is fat containing.
Looking at this loop, we can see hernia contents
with very wide neck indirect inguinal hernia.
Fairly easy to diagnose on the cine loop.
Narrow neck hernias even can be fairly small
and the patients typically are much more symptomatic
with these than they are with the large hernias.
But here's our inferior epigastric vessel.
We can see the small indirect inal hernia cosing up
and over the inferior epigastric artery.
On this cine loop when the patient valsalva,
we can see the small hernia coming up and over.
We notice the inferior epigastric arteries right here
and a small narrow neck indirect inal hernia is seen
coursing up and over the inferior epigastric artery.
Looking at this in a short axis view,
we can see the hernia contents
and this is actually compressing the transducer.
We're able to push the contents back in.
This is on a female patient,
we don't see the round ligament,
but you can see a very small indirect angle hernia.
On a short axis view, hernias can be very large
and if you have a hernia that's extremely large, going
to a curved array transducer may actually be helpful
to make sure that we get all of the hernia contents in.
But this is a very large small bowel peristalsing hernia
that is an indirect ular hernia that we can see there.
And as I mentioned earlier, if you have hernia contents
that extend into the scrotum,
typically those are indirect inguinal hernias.
On this wonderful barium minimum,
we can see the contents extending down
through the inguinal canal.
This is a patient that came in
because they had a palpable scrotal mass.
We can see the top of the testis here
and when the patient val Salva,
we can see this fat containing indirect ular hernia
extending down into the scrotum.
And this turned out to be the palpable mass in the patient's
scrotum that was diagnosed
as an indirect inguinal hernia.

Direct Inguinal Hernias

Next we'll talk about direct inguinal hernias.
Direct inal hernias are right inferior and medial
and they never will pass anterior
to the inferior epigastric artery.
Here's our inferior epigastric artery
that comes down into the external iliac artery.
Instead of coming up
and over that such as the indirect, these tend
to be more posterior and medial in location.
A precursor to the direct angle hernia is
where we will actually see thinning
and bulging of the conjoin tendon.
It's not an actual hole through that,
but these a lot of times, will be also referred to
as a sports hernia
and these patients are quite tender,
when they diagnose these.
This is looking at a transverse view
of the spermatic cord.
These are the hernia contents that are posterior and medial.
When we rotate long axis view, you can just see the bulging.
Normally this line would come straight across here.
We can see bulging
of the conjoining tendon when the patient relaxes,
you can see that that goes back in.
But this is thinning of the conjoin tendon sort
of a precursor to the actual direct inguinal hernia.
Looking at the long axis view here we can see the
inferior epigastric artery.
Normally your indirect angle hernias are going to come up
and over the inferior epigastric artery.
This defect is posterior and medial.
This is a true hernia containing fat that is posterior
to the spermatic cord.
Another example you can see the spermatic cord posterior
and medial and short axis view is this
direct inguinal hernia.
Another patient with a fairly large hernia arises inferior
and medial to it does not drape over the inferior
epigastric artery.
This is also a very large direct inguinal hernia.
Looking at this loop, you can see this short axis view.
The patient's spermatic cord is located right
through here and when the patient val Salva, you can see
that on this right side we have this area that bulges up.
This is just weakening of the conjoined tendon,
not an actual defect.
When we look at this in a sh long axis view, you can see
that when the patient val salva this area bulges down
but not an actual hole.
This is thinning of the conjoin tendon, sort
of a precursor to the direct inal hernia.

Femoral Hernias

Next we're gonna talk about femoral hernias.
Femoral hernias occur below the abdominal choal crease
and literature reports femoral hernias to be fairly rare,
but we find them much more often than literature reports.
One reason is it's a tough diagnosis to make clinically,
with inguinal hernias on male patients
who can do the cough test
where the doctor will actually feel in the inguinal canal
and see if they can feel hernias.
Whereas femoral hernias are deeper in location
and much more difficult to evaluate clinically,
the most common location for a femoral hernia
to occur is medial to the femoral vessels.
Right in this area is the most common location,
but you can see all the different areas
that a femoral hernia can occur.
They can be anterior to or posterior,
but once again the most common
or typical location is just medial to the femoral vein.
Looking at this view, this is a short axis view
of the left femoral canal.
You can see when the patient val SVAs,
we can easily see the femoral vein and the artery
and just medial to
that we can see the fat containing femoral hernia.
This is also with quiet respiration.
You can see here's the artery.
Here is the compressed femoral vein.
This is the area that we're going to see the hernia.
Once the patient Valsalva, we can see the vein expand
and the hernia contents that move just medial to
that femoral vein.
This is a patient that was nice enough
to have bilateral femoral hernias.
On the first loop we can see here's the femoral artery in
the femoral WA vein.
When the patient Valsalva,
you can see a fairly large fat containing femoral hernia
just medial to the femoral vein.
We look at the left side,
these hernia contents are already out.
What we have to do is compress.
Here you can see the artery and the vein
and you can see hernia contents coming and extending out.
This is using the transducer
to compress the femoral hernia.

Spigelian Hernias

Spion hernias are the next type
of hernia that we'll talk about.
If we look at spion hernias, they occur between the edge
of the rectus muscle and the oly muscles.
And what we'll notice with spion hernias, you're going
to have a tear of the transverse abdominus.
Sometimes the internal oly aerosa will also have a defect
through it, but the external oly will be intact.
Here you can see on this patient with a ilion hernia,
we have the transverse Alis fascia that there's a defect.
We have the internal oly that there's a defect
and the external oly is still intact.
The hernia contents are extending up here.
This is the edge of the rectus muscle.
These are the three oly muscles
and here we can see this small spion hernia that was
palpable on this particular patient.
Looking at this left spion hernia,
here we can see the edge of the rectus muscle.
Spion hernia is most common.
Location is right
where the inferior epigastric vessels leave the edge
of the rectus muscle
to go down into the external iliac artery.
Just lateral to that location, you can see
that the spion hernia comes up sort of a narrow neck
and is very superficial.
Inguinal hernias tend
to occur a little bit lower down in the canal
or I should say a little more posterior,
but spion, her hernias tend to be more anterior in location.
Here's another example.
You can see the edge of the rectus muscle,
the inferior epigastric vessels.
And here we have a fairly large fat
and bowel containing spion hernia.
Also notice how superficial this is just under the edge
of the skin just lateral to the inferior epigastric vessels.
These occur only a centimeter
or two away from the origin of the internal inguinal ring.
And many times these are mistaken
as inguinal hernias instead of spion hernias.
The way we can tell the difference,
typically we'll image a spion hernia in the transverse view.
You can see here's the defect
and notice how superficial this occurs
where your inguinal hernias tend to be more
of a hernia content.
If you're in a transverse view
that comes straight out at you in transverse,
you typically do not see the neck like you do
on a spion hernia.
This is looking at an inguinal hernia versus a spion
hernia and they're very close proximity, of where both
of these will occur.

Ventral Hernias

Next type of hernia, we'll talk about our ventral hernias.
If the hernia is located above the belly button,
those are called epigastric
and any type of hernia below the umbilicus is going
to be a hypogastric hernia.
If we look at the layers,
we talked about prop peritoneal fat
or epigastric hernias, normal amount of fat
that's within there, but we can also see fat that comes in
that we'll see prop peritoneal fat.
Scanning a patient midline, this is
what we're gonna notice is one rectus muscle here,
the other rectus muscle, this is the normal linear elbow.
This is the peritoneal membrane
and this is the normal pre peritoneal fat
that we will sometimes see on patients that get a defect.
What happens is you'll get a defect through that area
and it'll look just like a mushroom cloud coming up
but the peritoneal membrane itself will be intact.
This is a patient that we can see has a small preperitoneal
hernia and
what we're doing is actually have the
patient breathe in and out.
We're trying to compress. This does not reduce at all.
You can see that the linear elbow has the defect right
through here, but the peritoneal membrane is intact.
Most of the time when you have a non reducible hernia,
it is going to be one of these pre peritoneal hernias,
with just a defect through the linear elbow only.
This is a patient that has a strangulated
or incarcerated non reducible hernia.
Here is the umbilicus, this is an epigastric hernia.
The patient was very tender.
You can see that once it becomes strangulated the fat
typically becomes more echogenic rather than being
more iso coic.
This is a patient that had had a previous hernia repair.
You can see the mesh here. She had delivered triplets.
They wanted us to reevaluate the line alba
and you can see she has multiple defects through here.
A patient in doing this scan we can see
that not only did she have this mesh that had repaired some
of her hernias, but now she had three additional defects
through the linear alba that had not been repaired.
The first time. This is a patient with a very large
reducible defect through the linear elbow.
You can see this is a quite obese patient.
We're using a curved array transducer,
a very wide defect through this area.
And this contained fat
and small bowel that we could reduce this
very large epigastric hernia.

Umbilical Hernias

Looking at umbilical hernias,
umbilical hernias typically are just incomplete closure
of the umbilical ring.
We can see this very large umbilical hernia on this
patient that has ascites.
When the patient Valsalva, we can see that a loop
of bowel extends up and we get blood flow within that.
This is a patient that knew he had an umbilical hernia,
he was out mowing his lawn and had some severe pain
and actually sort
of strangulated the hernia became more echogenic.
When you compare strangulated fat that is echogenic
to normal fat, normal fat tends to be more iso coic.
One way we can tell the strangulated fat on ultrasound is
look for this echogenic fat.
Typically we won't see any blood flow in this area
and the patient tends to be more tender.
Usually these can be fairly large
but the patients are usually asymptomatic other than they
have a palpable lump.
Here's a patient also with a very large umbilical hernia.
You can see this patient has quite a bit of massive ascites.
We can see this loop of small bowel
and all the fluid that's extending up
in this fairly large umbilical hernia.

Incisional Hernias

Incisional hernias can occur anywhere the patient
has had prior surgery.
One thing to remember is now patients have more
and more laparoscopic procedures.
Anywhere that they have had a trocar
site they can actually develop hernia through
and it may be difficult to sometimes locate these areas.
This is a patient that had one
of the good old fashioned gallbladder scars that used
to extend halfway across the abdomen.
And in scanning over that site we were able
to see this fairly large incisional fat containing hernia
along an old gallbladder incision.
This is also a hernia that we can see intraparietal
contents and we can see
between the different muscle planes we've got fat
that extend and then fat that extends down both ways.
An incisional hernia that we can see,
different components of the hernia extending.
A lot of times we're asked to evaluate patients
that are post-op and scan over the mesh.
Now one thing when you're looking at mesh you will not get a
hernia that occurs through the mesh.
What we wanna do is scan anterior,
superior I should say an inferior medial
and lateral to the mesh but nothing will protrude
or you won't get a defect through the actual mesh.
This is what mesh will look like A lot
of times on ultrasound you just get an area of shadowing
behind it but the defect will not occur
through the mesh when we're scanning these patients.
Looking for recurrent hernias.
On this loop here we're looking at the
upper edge of the mesh.
You can see the mesh located right through here
and when the patient valsalva we have a very small fat
containing hernia right at the upper edge of the mesh.
This is a recurrent hernia, just superior to the edge
of the mesh and that is kind of where you want to look
for recurrent hernias is not directly over the mesh
but all around the edges of it.

False Positives and Mimics of Hernias

What are some things that can give us false positive
diagnosis for hernias?
Clinically patients can present with a palpable groin lump
or they may present with pain.
Things that we can see would be a spermatic cord lipoma.
We can have tunic and vaginal cyst, round ligament varice.
Patients may present with a palpable lump
that are normal lymph nodes.
They may present with pain that is actually diverticulitis
And actually examples
of erectus hematoma patients have been referred
to ultrasound rule outta hernia when they
tore their rectus muscle.
This is a patient that has a spermatic cord lipoma, it's
fat containing and non reducible.
We can compress this.
We don't see a neck to it And this was a patient
with a spermatic cord lipoma tunica vais can also occur
with a patent process vaginalis.
A lot of times you'll be able to see
the cyst patients will present with a palpable abnormality
and one thing to be concerned
or to be aware of is
that they may have a tunica VA analysis.
This is a patient that has a tunica VA analysis
and we can actually reduce it
so there is a defect or a hernia.
They came in because they felt the cyst
but you can see with probe pressure were
able to reduce that.
But a mobile tunica vaginal analysis on this patient
with an indirect inguinal hernia.
Something else that we can find on ultrasound are round
ligament varice.
A lot of people are not aware of these
but a lot of times patients will come in in their third
trimester or pregnancy with a palpable lump in their groin
and what they have are varicosities of the round ligament.
The round ligament is a suspensory ligament for the uterus
and it will mimic a hernia.
When the patient stands upright these will get quite
enlarged and clinically the physician will think
that the patient does have a hernia.
If you only scan the patient in a supine view, a lot
of times you'll not make the diagnosis
of round ligament varice.
But here you can see in a short axis view,
of the right in England canal.
And then with a little bit
of color doppler we can get blood flow
within those round ligaments.
This is a patient that came in with a palpable lump.
I also want you to notice that this patient has zero,
hardly subcutaneous fat.
She was a marathon runner
and when she came in with her palpable lump,
this is just a normal groin lymph node.
We had told her that if she probably had as much fat as
as normal patients do, she never would've felt this.
But we can use colored doppler
and see the vessel feeding the hilum.
But this was a perfectly normal lymph node on somebody
who was just a marathon runner and had hardly any body fat
and that was one reason she was able to palpate this mass
and her doctor just wanted to make sure
that it was not a hernia that she had in the groin.
This particular patient presented
with left lower quadrant pain.
His physician wanted to rule out a hernia, we scanned him
for a hernia, did not find one.
He goes, yeah, but my pain is not that low.
He goes, my pain's up a little higher.
He pointed to the area of tenderness
and right here is an inflamed diverticulum.
We can see a little bit of inflammation surrounding this
but this was a case of diverticulitis.
This next patient was a lady who decided she needed
to lose some weight, went
and saw her physician, he put her on an exercise program
and kind of gave her a little bit of a challenge,
said I want you to try
and do a hundred situps a day if you can.
Well she said, that kind
of a challenge she was gonna be sure and do it.
And she got through about 15 of them
and got severe abdominal pain but wasn't going to quit
because her doctor had given her the challenge
and she came in for an ultrasound the next day, bent over
what she had done was torn her rectus muscle.
This is looking at the right rectus muscle.
This is looking at the normal left rectus muscle
and she has this very large rectus hematoma,
just from doing sit-ups.
Sort of a challenge from her physician.
And she was negative for a hernia.
This is a newborn patient that we were asked
to scan in the intensive care nursery.
One of the sonographers went up and scanned
and said the patient has a little lipoma.
Going back up to check this patient in scanning through
that area, what we found was they actually had a very small
defect of the linear alba.
Here you can see that the peritoneal membrane is intact
but there's a very small defect through the linear alba
and who knows how a newborn got a very small linearal hernia
but there was a defect there.
Something else that we'll see quite often
patients will present with a palpable lump midline
that is called diastasis recti.
When they raise their head up, they get this bulge
for the midline area
and a lot of clinicians think that these are hernias,
but all it is is just separation of the rectus muscles.
If we look at this image scanned across instead
of the rectus muscles being fairly close together like they
normally are, we can see the edge of one here,
the edge of the other one.
This is the linear alba that's all the way across
and when the patient sits up they just get bulging
of these intraabdominal contents but there's no defect.
If you're ever asked to scan somebody
that has a bulge in mid abdomen, it is not an actual hernia
but just called diastasis recti.

Case Example: Ruling Out Hernia

Last thing I wanna show you as a patient.
This is a 43-year-old patient that came in
with left groin pain indication was to rule out a hernia.
Here we scan a long axis view.
We can see our inferior epigastric vessel right here
and we can see this content that goes up
and over the inferior epigastric artery.
It appears to be an in directing well hernia.
What are the types of things we wanna do
in looking at this patient?
First thing we're gonna do is have the patient val Salva.
In having the patient Val Salva,
do the contents look like they changed?
Not really. Next we try compression.
Here's our inferior epigastric vessel. We compress down.
Does it look like it changed?
Still didn't look like it changed much.
What's the next thing we wanna have the patient do?
We'll have 'em stand upright.
Here we can see this area supine with colored doppler.
We have the patient stand upright
and now what we can see are these round
ligament varicosities.
Another thing is to always be sure
and ask your patient how are they positioned or
or what are they doing when they notice their symptoms.
If they say they notice the bulge in the groin when they're
in the upright position, it's very important to make sure
that you scan the patient in the upright position.
Round ligament varicosities are usually bilateral even
though the patient may only present
with symptoms on one side.
I will typically always scan the patient on both sides
and look at these when I try
and evaluate patient for round ligament varice.
The other thing is if a patient comes in to rule out hernia,
their symptoms are on the right side.
I will scan the right side for hernia.
I'll scan with and without Valsalva maneuvers,
stand the patient upright.
If I do not see any hernia with that,
if I still do not diagnose a hernia, I'm done.
I don't take a look at the other side.
But when they come in with right lower quadrant pain
and we're asked to evaluate that side,
if I find a hernia on the right side, I always go over
and check the left side.
Also, a lot of hernias do occur bilateral,
but if their symptomatic side is negative,
I don't wanna open up a can of worms
and take a look at the other side,
but we will check bilateral if their symptomatic
side was positive.

Conclusion

I want to thank you for your attention
and hopefully this was very helpful.