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Lumps and Bumps of the Abdominal Wall and Lumbar Region—Part 1: Hernias, What the Radiologist Should Know

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Lumps and Bumps of the Abdominal Wall and Lumbar Region—Part 1: Hernias, What the Radiologist Should Know Published online: 2019-06-18 THIEME 12 Review Article Lumps and Bumps of the Abdominal Wall and Lumbar Region—Part 1: Hernias, What the Radiologist Should Know Sangoh Lee1 Sarah R. Hudson1 Catalin V. Ivan1 Tahir Hussain1 Ratan Verma1 Arumugam Rajesh1 James A. Stephenson1 1Gastrointestinal Imaging Group, Department of Radiology, Address for correspondence James A. Stephenson, MD, FRCR, University Hospitals of Leicester NHS Trust, Leicester General Gastrointestinal Imaging Group, Department of Radiology, Hospital, Leicester, United Kingdom University Hospitals of Leicester NHS Trust, Leicester General Hospital, Leicester LE5 4PW, United Kingdom (e-mail: [email protected]). J Gastrointestinal Abdominal Radiol ISGAR 2018;1:12–18 Abstract Abdominal hernias represent common conditions and occur when a structure of the abdominal cavity protrudes through a defect in the abdominal wall. Recently, there has Keywords been an increase in demand from the clinical teams to confirm the clinical suspicion ► abdominal wall of an abdominal wall hernia, and to assess preoperatively large or complex hernias ► hernias through imaging. This pictorial review aims to present the different appearances of ► lumbar region abdominal wall and lumbar region hernias on imaging. however, many surgeons now prefer to have confirmatory Introduction imaging prior to invasive corrective surgery. Moreover, Abdominal hernias occur when part of or an organ of a body imaging can be particularly useful in assessing large abdom- 1 cavity protrudes through a defect in the wall of that cavity. inal wall defects with involvement of different abdominal It is a common condition with lifetime risk of developing a anatomical boundaries/walls (such as large incisional hernias 2 groin hernia estimated at 27% for men and 3% for women. in patients with multiple abdominal surgeries) and involving External hernias that protrude through the abdominal loss of domain. Imaging (particularly cross-sectional imag- wall are classified by their location: groin (inguinal and fem- ing) can add significant value to the process of preoperative oral), ventral (umbilical and paraumbilical), lumbar, and planning in terms of helping the surgeon decide what type incisional hernias. These also include rare hernias such as of surgery can be performed (laparotomy vs. laparoscopy—a interparietal (Richter, Littre Maydl, and Amyand) and pelvic key factor in the future outcome of the repair and patient 3 hernias (sciatic, obturator, and perineal) (►Fig. 1). Symptoms morbidity), in choosing the best surgical approach but also of hernias are wide ranging and are largely dependent on the in ensuring the correct size and type of mesh and surgical location and the content of the hernia. In up to one-third of equipment are available. Imaging (especially the radiology 4 patients, a hernia remains asymptomatic. Others may expe- report) can offer the surgeons a descriptive tridimensional rience several symptoms such as pain, vomiting, distension, representation of the abdominal wall defect and of the hernia or a dragging sensation that can be e xacerbated by cough- sac contents helping with decision making. 1 ing, micturition, defecation, exercise, or sexual intercourse. We present our experience of hernia imaging of the Clinical signs include a tender abdominal mass, dehydration, abdominal wall and lumbar region presenting their variable 5 and eventual peritonism. imaging characteristics and related complications. Entrapment of bowel into the hernia sac can cause bo wel obstruction; if these hernias remain irreducible or strangu- Imaging of Abdominal Wall Hernias lated, complications can occur as the blood supply to the affected bowel becomes compromised. The primary diagnosis of a hernia can usually be made by Imaging studies were previously only used when the physical examination, with imaging studies only necessitated typical expected signs and symptoms of hernias were absent; when typical physical signs and symptoms are absent. received DOI https://doi.org/ ©2018 Indian Society of August 10, 2018 10.1055/s-0038-1676156. Gastrointestinal and Abdominal accepted after revision Radiology October 5, 2018 Lumps and Bumps of the Abdominal Wall and Lumbar Region Lee et al. 13 Fig. 1 Hernia types. An ultrasound scan (USS) is the first-line investigation6 is particularly helpful in assessing the enhancement of the with which a good superficial anatomical resolution and herniated bowel wall, especially in incarcerated hernias or dynamic assessment can be made. The US assessment of the closed-loop obstructions. hernia orifices should be done using linear high-frequency In younger patients, a low-dose CT protocol with probes to begin with (range: 6–15 MHz). This helps define IV contrast may be used. This uses low milliampere- the anatomical detail of the abdominal wall and of the her nia second (mAs). Consequently, the patient radiation dose is sac and its contents. If the hernia sac contains bowel, the decreased at the detriment of image quality. However, a appearance of it should be further assessed and described balanced approach may decrease the dose to up to one- (e.g., bowel wall thickening and loss of the definition of the third of that of a normal scan and provide adequate image bowel wall layers indicating possible ischemic changes or quality, allowing the correct interpretation of the findings. strangulation). The presence or absence of free fluid in the CT cannot provide functional assessment of hernias that hernia sac should also be indicated in the report. Moreover, USS and, more recently, dynamic MRI are able to provide.8 assessment of the vascularity of the herniated bowel with CT predominantly aids the assessment of the hernia content Doppler should be strongly considered; the vascularity, along and is commonly used acutely to assess for c omplications. with the morphologic changes of the herniated abdominal In our institution, we reserve MRI (fast-spin echo and fast content can help diagnose a strangulated hernia (acute find- gradient echo sequences) for cases with a high clinical sus- ing). A general review of the abdomen (e.g., for free fluid) can picion of a hernia, but it has not been ident ified on USS. be done with the curvilinear probe (1–5 MHz). These probes Sequences are acquired in axial and sagittal planes with can also be used for larger hernias. Key to this is 3D spatial and without straining maneuvers. In the case of the later understanding of the anatomy in the region of interest, espe- (dynamic MRI), the scan is performed in the plain that best cially for groin hernias. The area of interest is assessed with anatomically demonstrates the hernia by using a steady- the patient supine to identify a defect and/or a protrusion. state sequence such as FIESTA (fast imaging employing Maneuvers to increase intra-abdominal pressure can be used steady-state acquisition) that is capable of acquiring an to help accentuate protrusions as well as scanning patients in image per second, which can then be reviewed in a cine- a standing position. loop. The standard static MRI protocol includes T1 and T2 Multidetector computed tomography (CT) and magnetic fat-saturated axial and sagittal sequences, covering the resonance imaging (MRI) provide excellent anatomical detail region of interest. To focus on a region of interest, a skin and have the highest specificity and sensitivity.7 marker is often used to help identify the area of clinical In our institution, the assessment of hernias on a CT scan suspicion. involves a portal phase post intravenous (IV) contrast scan MRI and CT are also used to assess complex incision- with thin, 1-mm slices covering the abdomen and pelvis and al hernias prior to abdominal wall reconstruction where the area of interest (if not already covered by the protocol, domain loss can be assessed. e.g., in the case of a femoral hernia). Axial, coronal, and sag- ittal reformats are transferred to the picture archiving and Groin Hernias communication system (PACS). Depending on the clinical scenario, if the patient has acute kidney injury with an esti- Careful distinction is required of hernias in the groin specif- mated glomerular filtration rate (eGFR) < 30, after discussion ically direct inguinal, indirect inguinal, and femoral hernias with the clinical team contrast may be withheld. IV contrast due to differences in their predisposition and management. Journal of Gastrointestinal and Abdominal Radiology ISGAR Vol. 1 No. 1/2018 14 Lumps and Bumps of the Abdominal Wall and Lumbar Region Lee et al. A direct inguinal hernia occurs as a result of weakness when compared with other types of groin hernias, so prompt in the transversalis fascia in Hesselbach’s triangle. This is identification and distinction from other hernias are import- common in the elderly and those with increased abdominal ant. The European Hernia Society (EHS) has created a simple pressure, for example, patients with chronic obstructive pul- classification based on Aachen’s classification (►Fig. 6). This monary disease, chronic constipation, and bladder outflow can be used as an effective radiologic tool for describing and obstruction. These directly protrude through the inguinal classifying findings in terms of anatomical locations and size wall, medial to the epigastric vessels (►Fig. 2). An indirect that allows meaningful comparison with the intraoperative inguinal hernia is five times more common than a direct findings. This provides good preoperative pretest probability inguinal hernia and seven times more common in males. This for inguinal and femoral hernias and ensures a common type of hernia follows the inguinal canal from the deep to language between radiologists and surgeons.9 superficial ring and into the scrotum in males (►Fig. 3). It is therefore lateral to Hesselbach’s triangle and the inferior epi- gastric vessels (►Fig. 4). A femoral hernia is the protrusion of abdominal content through the femoral ring into the f emoral canal. It is more commonly seen on the right side and in women. It protrudes inferior to the inguinal ligament/ inferior epigastric vessels and is found medial to the femoral vein.
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