1 1 The “Ins and Outs” of Abdominal

Christopher D. Scheirey, M.D. Abdominal Imaging Lahey Hospital and Medical Center

Frederick B. Murphy, M.D., F.A.C.R. Associate Professor Department of Radiology Emory University School of Medicine

Murphy Scholz Scheirey 1 1 2 2 Objectives

• Be able to recognize the most common internal and external hernias in the abdomen • Know the potential complications from these hernias • Understand the anatomical defect leading to various abdominal hernias • To differentiate internal from external hernias

Murphy Scholz Scheirey 2 2 3 3

Disclosures

• Christopher Scheirey MD – None

• Frederick B. Murphy MD, FACR – none

Murphy Sholz Scheirey 3 3 4 4 Clinical Features

• Colicky pain, distention • Post-prandial • Pain with bending or exercise • Acute or chronic • , •GE reflux

Murphy Scholz 4 4 5 5 Abdominal Hernias

• External hernias – The prolapse of bowel loops or intra-abdominal contents through a defect in the abdominal or pelvic wall

• Internal hernias – The protrusion of a viscus through a normal or abnormal peritoneal or mesenteric opening within the peritoneal cavity

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Location: External • Outside Abdominal Cavity. • Carry Parietal Peritoneal Lining. – If not: “evisceration” • Through normal holes - stretched open –Wall – Diaphragm: Bochdalek, Morgagni, Hiatal, ParaHiatal – Pelvic holes: • Direct, Indirect IH, Femoral, Sciatic. • Vagina, SB, – Into Retroperitoneum • Through an incisional hole: – Incisional / trochar Scholz Lahey Clinic 6 6 7 7

Location: Internal

• Within normal abdomen cavity. • Does not extend thru Wall, Diaphragm, Pelvis. •In – Lesser or Greater Sac. – Embryologic third Sac (paraduodenal H) – “neo sac” from surg compartmentalization. • Caught under an . • Through mesenteric rent.

Scholz Lahey Clinic 7 7 8 8 Hiatal

• Type I - sliding (reducible) • Type II – paraesophageal • Type III- combined I and II • Type IV- intrathoracic stomach

Murphy Scholz Canon et al 8 8 RADIOGRAPHICS 2005:25;1485-99 9 9 Bochdalek hernia

• Bilateral defects in the posterior diaphragm • Top of kidneys or fat may protrude through • Usually asymptomatic • Failure of closure of the pleuroperitoneal membrane

Murphy Scholz 9 9 10 10 Morgagni hernia

• Midline anterior • Due to maldevelopment of the central tendon • Transverse colon, fat, liver may herniate • May be associated with other congenital abnormalities

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Ventral Hernias

• Usually midline • Protrude through defects in the linea alba • If above the umbilicus, epigastric hernia • Incisional hernias, para-median • Trochar site hernias

Scholz Lahey Clinic 11 11 12 12 Internal hernias

• Increasing due to large number of newer surgical procedures such as liver transplants and gastric bypass surgery • Many of these involve transmesenteric or transmesocolon procedures • Increased fragility of the blood supply to the small bowel • High mortality rate, up to 50 % • Often difficult to diagnosis

Martin C, Merkle EM, Thompson WM Murphy AJR 2006;186:703-717 Scholz 12 12 13 13 Paraduodenal

• Most common- 53 % • Male : female 3:1 • Left – Bowel prolapses throught Landzert’s fossa (present in 2 % of the population) • Right – Bowel herniates through Waldeyer’s fossa (1 %) – Associated with non-rotated small bowel • Middle

Murphy Scholz 13 13 14 14 Foramen of Winslow

• 8 % of internal hernias • A normal communication between the greater and lesser peritoneal cavities • Usually small bowel but may also contain colon, gallbladder and omentum

Murphy Scholz 14 14 15 15 Pericecal

• 13 % of internal hernias • Acquired or congential defect in the cecal mesentery • Higher incidence of strangulation and higher mortaility rate of 75 % • Mimics appendiceal symptoms

Murphy Scholz 15 15 16 16 Transmesenteric

• Increasing in number due to newer surgical procedures involving transmesenteric routes • Associated with retrocolic Roux-en-Y type operations

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Pelvic Hernias

• Location & Name – Inguinal, Femoral, Spigelian, Obturator, Sciatic • Type – Complete vs Partial (Richter = one wall only) • Content – Bowel, bladder, or fat. • Severity – Obstructed – Incarcerated (Non-Reducible) – Strangulated (Ischemic) Murphy – Infarcted (Dead) Scholz/S cheirey 17 17 18 18 Contents • Colon, SB, fat, Bladder. • Pre-existing Diverticulum: “Littre” – Meckel, SB, Colon Diverticulum. • : – “de Garangeot” Femoral – “Amyand” Indirect Inguinal

Amyand 18 18 19 19

Severity / Stage

• Obstructing. • Reducible versus Incarcerated: – “Belly in” “Belly In” • Strangulated: – Ascites MORE in hernia than peritoneal cavity. – Loss of perfusion. – Wall changes: thickening, pneumatosis, etc.

19 19 20 20 Incarcerated • Incarceration – Compressed Abd Wall. • SBO upstream. – Efferent Limb collapsed. – Neck squeezed.

• LOOK FOR: – Closed Loop • SB Distended in Hernia. – Strangulation

Scholz Lahey Clinic 20 20 21 21 Inguinal Hernias • “” not precise. • Surgeons need our precision. – Different approaches • Inguinal “Big 3” – Indirect –Direct – Femoral: DANGER • Spigelian: upward or downward. • Obturator: Rare “Pelvic” • Sciatic: Rarest “Pelvic”

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Hesselbach’s Triangle

• Medial: – lateral edge of rectus • Supero-lateral: – inferior epigastric artery • Inferior: – inguinal ligament

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Indirect Inguinal Hernia

• First hernia orifice. • Opening lateral to IEA. • Descend to testicle or labia. • “Prominent fat filled inguinal canal” often seen.

23 23 24 24 Direct Inguinal

• Directly Med/Inf to IEA. •M > F • Common, Fat, Bladder. • LOW danger • “Lateral Crescent Sign” • Compression of Inguinal Canal by DIH DIH

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Maydl Hernia

• Combination: – loops in and out • M shaped loop configuration. • Needs surgery. • Maydl, 1898.

25 25 26 26 “Fem”ale

• Dangerous! – Incarceration, infarction prone. • 3rd hernia orifice • IEA artery not visible. • Compression of Femoral Vein. • Lateral to Inguinal Canal • Never medial to pubic tubercle.

26 26 27 27 “De Garangeot” Hernia

• Femoral, right. • Appendix. • Incarcerated/Strangulating. • No bowel obstruction. • “Croissant de Garangeot” Hernia. 1731 – in F H

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Spigelian Hernia “Intramural Hernia” • Lateral to Rectus & Caudal to Umbilicus. • Through 2/3 of abd wall – Internal Oblique – Transversalis – NOT through EXTERNAL – (TROCHAR thru 3) • May dissect Cephalad – More room cephalad. – Pelvis muscles tighter • DANGER PRONE Hernia

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Obturator Hernia

• Elderly • F >> M • R >> L • Obstruction: Up to 80% • High Incidence Strangulation. • Howship-Romberg Sign – Pain medial thigh 50% • Hannington Kiff – Thigh adductor reflex lost

29 29 30 30 Pelvic Hernias

• All hernias must be reported even if empty. • Axial appearance mainstay of all CT Dx. • Landmarks, signs & eponyms. – Incarceration & strangulation. – Inferior epigastric vessels. – Femoral Vein. – Lateral Crescent Sign. – Amyand, de Garangeot hernia.

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