Ultrasound of Hernias Disclosures: • Consultant: Bioclinica Jon A. Jacobson, M.D. • Advisory Board: Philips • Book Royalties: Elsevier Professor of Radiology • Not relevant to this talk Director, Division of Musculoskeletal Radiology University of Michigan Note: all images from the textbook Fundamentals of Musculoskeletal Ultrasound are copyrighted by Elsevier Inc. Groin Pain: Objectives: • Hip joint: labral tear • Groin pain • Pubic symphysis • Inguinal region hernias • Fracture • Sports hernia • Tendon tear • Inguinal hernia • Algorithm: radiographs, US, MRI US protocol: Inguinal Region Hernia: • Hip joint: effusion, labrum • Indirect inguinal • Tendons: • Direct inguinal –Rectus abdominis, adductors • Femoral –Rectus femoris, sartorius • Spigelian • Inguinal region hernias –Include Valsalva 1 Inguinal Region Hernia: Posterior View Imaging Inguinal Hernias: Rectus • In diagnosis of occult inguinal hernias: Abdominis • Ultrasound: Inferior – 86% sensitivity and 77% specificity Epigastric Artery • CT: – 80% sensitivity and 65% specificity • Herniography: – 91% sensitivity and 83% specificity Inguinal Ligament Robinson A. Surg Endosc 2013; 27:11 Inguinal Region Hernia: Posterior View Inguinal Region Hernia: Posterior View Deep Spigelian Hesselbach’s Inguinal Indirect Triangle Ring Inguinal Direct Inguinal Femoral Femoral Ring Jamadar et al. AJR 2006; 187:185 How do you Valsalva? Indirect Inguinal Hernia: • Tighten belly • Extends through deep inguinal ring • Hold breath • Lateral to external iliac artery • Courses medial within inguinal canal • Blow on back of hand • Parallel to skin surface • Stand up • May contain fat or less commonly bowel • Clue: femoral vein should distend • Confirm in two planes 2 Indirect Hernia Indirect Inguinal Hernia Medial Lateral Midline Lateral Indirect Inguinal Hernia Indirect Inguinal Hernia: to external ring Medial Lateral Medial Lateral Indirect Inguinal Hernia: containing bowel Indirect Hernias: Pitfalls • Relying on transducer position in plane or Medial Lateral long axis to inguinal canal – Must scan short axis to inguinal canal • Lipoma of inguinal canal – True hernias enter through internal ring • Round ligament varicosities: pregnancy – Do not call hemangiomas 3 Indirect Hernia: Pitfall Indirect: Pitfall • You must also scan area in the sagittal plane short axis to inguinal canal • Inguinal canal may move out of plane relative to transducer Midline Lateral Pitfall: Pseudo Indirect Hernia Indirect: Pitfall Medial Lateral • Lipoma of spermatic cord • May simulate indirect hernia • True hernia will enter through internal inguinal ring Medial Lateral Superior Inferior Axial Sagittal Spermatic Cord Lipoma Indirect Inguinal Hernia: deepring Medial Lateral 4 Round Ligament Varicosities Indirect: Pitfall • Round ligament varicosities • Early 3rd trimester of pregnancy • Resolves after childbirth • Do not misinterpret as vascular malformation Kahriman G. J Clin Ultrasound 2010; 38:512 Indirect: Pitfall • Canal of Nuck cyst Indirect: Pitfall • Patent processus • Undescended testicle vaginalis • In males Direct Inguinal Hernia Direct Inguinal Hernia: • Extends through Hesselbach’s triangle • Medial to external iliac artery • Protrudes anterior toward skin surface • May contain fat or less commonly bowel A • Confirm in two planes Medial Lateral 5 Direct Inguinal Hernia Direct Inguinal Hernia Medial Lateral A A + Valsalva Direct Inguinal Hernia Direct Inguinal Hernia A A Axial Sagittal + Valsalva Pseudo Direct Hernia Direct Hernia: Pitfall Transducer: Axial Plane Transducer: • If only scanning long axis to inguinal Sagittal Sagittal Plane canal in Hesselbach’s triangle Plane • Intra-abdominal contents may move Spermatic inferior Cord • Simulate direct hernia Superior Belly Fat Inferior • True hernia shows focal movement in two planes Deep 6 Direct Inguinal Hernia Direct Inguinal Hernia Artery Artery Superior Inferior Medial Lateral Superior Inferior Medial Lateral Axial Sagittal Axial Sagittal “Sports Hernia”: medial direct inguinal hernia Inguinal Hernias: reporting • Indirect inguinal: Medial Lateral – Contents – Cross-section and length – Incarcerated or reducible • Direct inguinal – Contents – Cross-section and height Femoral Hernia Femoral Hernia: • Extends through femoral ring • Usually medial to femoral vein A V • Protrudes inferior to inguinal ligament A • May contain fat or less commonly bowel • Confirm in two planes Medial Lateral • Femoral vein should distend with adequate Valsalva! 7 Femoral Hernia Femoral Hernia Medial Lateral Artery Medial Lateral Superior Inferior Axial Sagittal Paralabral Cyst into Femoral Canal Lateral Spigelian Hernia: • Extends lateral to rectus abdominis • Protrudes anterior toward skin surface • May contain fat or less commonly bowel Spigelian Hernia Spigelian Hernia Medial Lateral Rectus Abdominis O Medial Lateral 8 Hernia Repair: mesh Hernia Repair: • Polypropylene mesh • Placed laparoscopically • Between transversalis fascia and anterior abdominal muscles • Ultrasound: echogenic CT and shadowing From: Jamadar, et al. Jamadar, et al. J Ultrasound Med 2008; 27:907 J Ultrasound Med 2008; 27:907 Recurrent Inguinal Hernia Recurrent Inguinal Hernia: incarcerated Mesh Hernia Mesh Lateral Medial Umbilical Hernia Rectus Sheath Hematoma • Canal of Nuck cyst • Patent processus vaginalis Transverse Sagittal 9 Other Masses Take Home Points • Anatomic landmarks: – Inferior epigastric artery, Hesselbach’s triangle • Indirect: lateral to vessels, moves medial • Direct: medial to vessels, moves anterior • Femoral: inferior to inguinal ligament Ewing Sarcoma Ovarian Carcinoma • Confirm in two planes See www.jacobsonmskus.com for syllabus and other educational material Twitter: @jjacobsn 10.