Abdominal Wall Hernias: Imaging Features, Complications, and Diagnostic Pitfalls at Multi–Detector Row CT

Spontaneous posterior rectus sheath hernia: a case report

Background

Hernias of the posterior rectus sheath are very rare abdominal wall hernias with only a handful of cases reported in the literature to date. As an uncommon disease, it is important to recognize and report this case in order to enhance scientific knowledge of this disease.

Case presentation

This case report presents a spontaneous posterior rectus sheath herniation in a 79-year-old white man with previous abdominal surgery for appendicitis. His herniation was discovered incidentally during an examination for his chief complaints of lower abdominal pain and diarrhea which were later diagnosed as Salmonella-related gastroenteritis. A computed tomography scan of his abdomen and pelvis showed abdominal wall hernia with loops of small bowel extending into his rectus abdominis muscle. In this case, it was decided to leave the situation alone for now due to no evidence of bowel obstruction and the low risk of this hernia getting strangulated, which otherwise would have warranted urgent surgery.

Conclusions

This report adds to the limited stock of available literature on this unusual issue and strengthens the evidence base on the best approach to support informed clinical decision making. The significant clinical implication of such case reports is increased identification rate of rare clinical conditions which otherwise often go unnoticed.

Don't Forget the Abdominal Wall: Imaging Spectrum of Abdominal Wall Injuries after Nonpenetrating Trauma

Abdominal wall injuries occur in nearly one of 10 patients coming to the emergency department after nonpenetrating trauma. Injuries range from minor, such as abdominal wall contusion, to severe, such as abdominal wall rupture with evisceration of abdominal contents. Examples of specific injuries that can be detected at cross-sectional imaging include abdominal muscle strain, tear, or hematoma, including rectus sheath hematoma (RSH); traumatic abdominal wall hernia (TAWH); and Morel-Lavallée lesion (MLL) (closed degloving injury). These injuries are often overlooked clinically because of (a) a lack of findings at physical examination or (b) distraction by more-severe associated injuries. However, these injuries are important to detect because they are highly associated with potentially grave visceral and vascular injuries, such as aortic injury, and because their detection can lead to the diagnosis of these more clinically important grave traumatic injuries. Failure to make a timely diagnosis can result in delayed complications, such as bowel hernia with potential for obstruction or strangulation, or misdiagnosis of an abdominal wall neoplasm. Groin injuries, such as athletic pubalgia, and inferior costochondral injuries should also be considered in patients with abdominal pain after nonpenetrating trauma, because these conditions may manifest with referred abdominal pain and are often included within the field of view at cross-sectional abdominal imaging. Radiologists must recognize and report acute abdominal wall injuries and their associated intra-abdominal pathologic conditions to allow appropriate and timely treatment. ^© RSNA, 2017.

Incisional Hernia Repair: What the Radiologist Needs to Know

OBJECTIVE

Incisional hernias are becoming more prevalent with increases in the obesity of the population and the complexity of abdominal surgeries. Radiologists' understanding of these hernias is limited. This article examines abdominal wall anatomy, surgical techniques, the role of imaging (current and emerging), and complications from the surgical perspective, to enhance to the role of the radiologist.

CONCLUSION

Knowledge of the relevant anatomy, surgical techniques, and postoperative complications in patients with incisional hernial repair can help the radiologist improve care.

Sonographic Assessment of a Spigelian Hernia

Spigelian hernias are a rare type of lateral ventral hernia that arises through a defect in the spigelian fascia within the anterior abdominal wall. This type of hernia can be either congenital or acquired. Herniation occurs due to weakness or a defect in the transversus aponeurotic layer between the rectus abdominis muscle medially and the semi-lunar line laterally. Due to difficulty in accurately diagnosing spigelian hernias and the risk of strangulation of herniated contents, surgical repair is often recommended. A spigelian hernia case is presented in which sonography was used in the assessment and diagnosis of the abnormality. The case report highlights important diagnostic features for differentiating a spigelian hernia from other forms of abdominal wall hernia so that proper diagnosis and surgical repair can be accomplished.

Laparoscopic repair of ventral/incisional hernias with the "Slim-Mesh" technique without transabdominal fixation sutures: preliminary report on short/midterm results

This study details our experience with a new laparoscopic technique called "Slim-Mesh" without using transabdominal full-thickness stitches, to treat ventral and incisional hernias (V/IH). Since 2009-May 2015, 28 consecutive patients with V/IH were treated in our center, with this new SM technique. Fifty percent males were included in this retrospective study, averaging 59 years (range 31-81 years). Mean body mass index was 26 and VH size was <10 cm in 24 cases and in 4 cases was larger, up to 22 cm. Mean operative time in the 28 V/IH patients was 97 min (range 57-160 min) and in those with V/IH larger than 10 cm it was 135 min. In 14.2% of patients laparoscopy diagnosed others V/IH previously undetected by physical examination and CT-scan. In all patients a composite mesh was used, up to 30 cm in size. In this series we had one intraoperative complication (3.6%) with transient bradycardia, but no conversion occurred; no early postoperative complication was detected. Mean length of hospital stay was 3.0 days. Mean follow-up time was 40 months (range 13-78 months). Late surgical complications included one case (3.6%) of incisional hernia recurrence and one case of 10 mm trocar site incisional hernia. This new surgical technique for V/IH repair, makes easy the handling and fixation of the composite mesh without using transabdominal fixation sutures, and appears in our experience fast, and simple.

Outcomes following repair of incarcerated and strangulated ventral hernias with or without synthetic mesh

Background

The use of synthetic mesh for ventral hernia repair under contaminated conditions is a controversial issue due to the considerable risk of surgical site infection (SSI). This study aimed to review the outcomes of repair of incarcerated and strangulated ventral hernias with or without synthetic mesh in compliance with established clinical guidelines regarding the incidence of SSI and hernia recurrence.

Methods

The records of patients with complicated ventral hernias who were treated with or without synthetic mesh repair were reviewed. Variables collected included the characteristics of patients and of ventral hernias, type of repair, and incidence of SSI and recurrence.

Results

One hundred twenty-two patients (56 males) of a mean age of 56 years were included. Fifty-two (42.6%) and 70 (57.4%) patients presented with incarcerated and strangulated ventral hernias, respectively. Sixty-six (54%) patients were treated with on-lay mesh repair, and 56 (46%) were managed with suture repair. Twenty-one patients required bowel resection. SSI was detected in eight (6.5%) patients. There was no significant difference between both groups regarding the incidence of SSI (7.5% for mesh group vs 5.3% for suture group). Recurrence occurred in seven patients. Median follow-up period was 24 months. The suture repair group had a significantly higher incidence of recurrence than the mesh group. Diabetes mellitus, previous recurrence, and intestinal resection were significant predictors for SSI.

Conclusion

Following established guidelines, synthetic mesh repair of incarcerated and strangulated ventral hernias attained lower recurrence rate, comparable incidence of SSI, and higher rate of seroma formation than suture repair.

Trial registration

Research Registry, researchregistry1891

Parastomal gallbladder hernia in a septic patient

Parastomal gallbladder herniation is a rare complication of enterostomies with only 6 previously reported cases. Most cases have occurred in elderly women. Patients typically presented with acute abdominal pain and the majority was managed operatively. Here, we report the clinical course of an 88-year-old female who presented with signs of sepsis and minimal abdominal symptoms. She was subsequently found to have a parastomal gallbladder herniation and Klebsiella pneumoniae bacteremia. Given the patient's multiple comorbidities, she was managed nonoperatively with manual reduction of the parastomal hernia and antibiotics.

CT findings of complications after abdominal wall repair with prosthetic mesh

Postoperative complications following prosthetic mesh repair are relatively rare and depend on the type and location of prosthetic mesh. They include abscess, hematoma, seroma, fistula, bowel obstruction, mesh retraction, granuloma and recurrent hernia. Computed tomography (CT) is the imaging examination of choice for the diagnosis of such complications. This pictorial review illustrates the CT presentation of the most and less common postoperative complications following prosthetic mesh repair of the abdominal wall.

What we know about management of traumatic abdominal wall hernia: review of the literature and case report

Traumatic abdominal wall hernia (TAWH) is an uncommon form of hernia caused by blunt traumatic disruption of the abdominal wall musculature/fascia and abdominal organ herniation. Diagnosis of TAWH is challenging and requires a high level of suspicion. This form of hernia seems to be underrepresented in the English-language medical literature. There is currently no consensus on the optimal management for TAWH. In this article, we discuss the management of a 36-year-old motorcycle driver who was involved in a road traffic accident. On evaluation at our trauma center, he was found to have TAWH. Diagnostic criteria, imaging modalities and different management options for TAWH will be discussed.

Incarcerated Grynfeltt-Lesshaft Hernia

Superior lumbar triangle hernia, also known as Grynfeltt-Lesshaft hernia, denotes a subtype of abdominal wall hernia, and more specifically of lumbar hernia, occurring between the 12th rib, the internal oblique muscle, and the quadratus lumborum muscle. We report the case of a 92-year-old female patient in which this form of hernia occurred, complicated by incarceration and acute bowel obstruction. The discussion contains a short résumé of the different kinds of abdominal wall hernias.

Small Bowel Obstruction Secondary to Interstitial Hernia: Laparoscopic Approach

Interstitial hernias are a rare entity. Most of them are detected incidentally on imaging studies. We present a case of abdominal bowel obstruction secondary to interstitial hernia on the fifth postoperative day of an open incisional hernia repair. Laparoscopy confirmed the diagnosis and led to an accurate treatment avoiding a new laparotomy. In this case, prompt surgical decision based on clinical and CT scan findings allowed a mini-invasive approach with satisfactory outcome.

Case report and operative management of gallbladder herniation

Background

Incarcerated abdominal wall hernias may contain a variety of contents, but very rarely contains the gallbladder. This rare diagnosis is often not considered and, when diagnosed, has a different management approach. The experience of the small number of case reports have yet to be collected and summarised.

Case presentation

We report a presentation and management of an 85 year old Caucasian female with a gallbladder hernia into a parastomal defect, and outline the operative management.

Conclusion

Incarcerated gallbladder hernia is an extremely unusual condition, best diagnosed by CT scan. Management should involve operative reduction, cholecystectomy and consideration of repair of the defect.

Identification of implanted mesh after incisional hernia repair using an automated breast volume scanner

OBJECTIVES

This study aimed to evaluate the utility of an automated breast volume scanner (ABVS) versus handheld ultrasound (US) for identifying implanted mesh after incisional hernia repair.

METHODS

In vitro, the appearances of 3 samples of different flat mesh and a mesh plug on both ABVS and handheld US examinations were evaluated. In vivo, 97 patients received both ABVS and handheld US examinations in the incisional region. The frequency used for handheld US was 11 MHz. The presence of the previously implanted mesh in the incisional region was evaluated and compared between the US modalities. The identified results were confirmed by surgical findings.

RESULTS

In the in vitro study, the ABVS had more visualized and efficient imaging results for implanted mesh than handheld US. In the in vivo study, among 97 cases, 39 and 32 were identified as regions with mesh by the ABVS and handheld US, respectively. The ABVS had better identification performance than handheld US in terms of accuracy (94.8% versus 83.5%), sensitivity (90.5% versus 69.0%), and specificity (98.2% versus 94.5%). The κ values showed that handheld US had substantial agreement with surgical findings (κ = 0.78; 95% confidence interval, 0.66-0.90), whereas the ABVS had almost perfect agreement with surgical findings (κ = 0.93; 95% confidence interval, 0.86-1.00). More importantly, the ABVS could display the texture of lightweight mesh in the coronal plane. The specificity and sensitivity for mesh texture were 100.0% (55 of 55) and 94.4% (17 of 18), respectively.

CONCLUSIONS

The use of an ABVS may help identify the presence of implanted mesh after incisional hernia repair in some cases in which the implant is difficult to appreciate on handheld US imaging with an 11-MHz transducer.

Blood vessel matrix seeded with cells: a better alternative for abdominal wall reconstruction-a long-term study

PURPOSE

The aim of this study was to present abdominal wall reconstruction using a porcine vascular graft seeded with MSC (mesenchymal stem cells) on rat model.

MATERIAL AND METHODS

Abdominal wall defect was prepared in 21 Wistar rats. Acellular porcine-vascular grafts taken from aorta and prepared with Triton X were used. 14 aortic grafts were implanted in place, of which 7 grafts were seeded with rat MSC cells (Group I), and 7 were acellular grafts (Group II). As a control, 7 standard polypropylene meshes were used for defect augmentation (Group III). The assessment method was performed by HE and CD31 staining after 6 months. The mechanical properties have been investigated by Zwick&Roell Z0.5.

RESULTS

The strongest angiogenesis and lowest inflammatory response were observed in Group I. Average capillaries density was 2.75, 0.75, and 1.53 and inflammatory effect was 0.29, 1.39, and 2.72 for Groups I, II, and III, respectively. The means of mechanical properties were 12.74 ± 1.48, 7.27 ± 1.56, and 14.4 ± 3.7 N/cm in Groups I and II and control, respectively.

CONCLUSIONS

Cell-seeded grafts have better mechanical properties than acellular grafts but worse than polypropylene mesh. Cells improved mechanical and physiological properties of decellularized natural scaffolds.

Abdominal wall hernia and aortic injury secondary to blunt trauma: Case report and review of the literature

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Traumatic abdominal wall hernias (TAWHs) and traumatic abdominal aortic injuries (TAAIs) are complications of severe blunt trauma.

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CT is a sensitive imaging modality to detect TAWHs.

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As only severe TAAI will have positive physical exam findings, imaging techniques, surgical exploration, or on-table angiogram may aid in diagnosis.

INTRODUCTION

Traumatic abdominal wall hernia (TAWH) and traumatic abdominal aortic injury (TAAI) are two uncommon complications secondary to blunt trauma. In both TAWH and TAAI, reported cases are often associated with poly-trauma. TAWH may be initially missed if more pressing issues are identified during the patient's primary survey. TAAI may be an incidental finding on imaging or, if severe, a cause of an acute abdomen and hemodynamic abnormality.

PRESENTATION OF CASE

A 54-year-old white male suffered a TAWH and TAAI (pseudoaneurysm) due to severe blunt trauma. TAWH was apparent on physical exam and the TAAI was suspected on computed tomography (CT). The patient's TAWH was managed with a series of abdominal explorations and the TAAI was repaired with endovascular stenting.

DISCUSSION

TAWH and TAAI are commonly due to severe blunt trauma from motor vehicle collisions. Diagnosis is made through physical exam, imaging studies, or surgical exploration. A variety of surgical techniques achieve technical success.

CONCLUSION

The patient with blunt trauma to the abdomen is at risk for TAWH and TAAI, which are often associated with other injuries. Investigations should include thorough clinical exam through secondary survey and radiologic imaging in the hemodynamically normal patient.

Imaging of complications associated with port access of abdominal laparoscopic surgery

Advanced techniques and equipment in laparoscopic surgery offer advantages over open surgery, expanding the application of this minimally invasive procedure to a wide range of abdominal operations that used to be performed as an open procedure. Laparoscopic surgery is performed in the closed abdominal cavity in which the space is limited. To create a working space in the abdominal cavity, an artificial pneumoperitoneum is established and multiple ports are placed for the introduction of various laparoscopic instruments. Unlike open surgery in which the incision is made just above the target organ, laparoscopic access is made away from the area of dissection, with the instruments triangulated around the target organ within the abdomen. This fundamental difference in approach between the open and laparoscopic procedures may lead to peculiar postoperative complications after laparoscopic surgery, which may be present away from the target organ or in the abdominal wall, and be easily missed on postoperative imaging studies. These complications include port-related direct organ injuries, such as abdominal organ or vascular injury; abdominal wall complications related to laparoscopic port insertion such as vascular injury, infection, and hernia; abdominal wall complications related to specimen removal, such as port site tumor seeding and endometriosis; and complications related to gas insufflation. The radiologist plays an important role in the diagnosis of complications after laparoscopic surgery, and therefore should be familiar with the features of such complications on imaging scans in the era of laparoscopic surgeries.

Pediatric vasitis: A rare complication of epididymitis

Vasitis represents an inflammation of the vas deferens. This is a rare entity seen mostly in adult males following local surgery (e.g., vasectomy, hernia repair). Children with groin masses have a wide differential diagnosis. We describe a child with a groin mass following epididymitis diagnosed with vasitis and review the known literature regarding diagnostic tools and treatment. Vasitis in children, although rare, can be seen as a complication of epididymitis.

Acutely incarcerated abdominal wall hernia: what if it is a consequence?

PURPOSE

The aim of this study was to emphasize the importance of differential diagnosis in patients with acutely incarcerated abdominal wall hernia (AWH).

METHODS

The medical records of patients who underwent emergency surgery with preoperative diagnosis of acutely incarcerated AWH and in whom acutely incarcerated AWH was the consequence of increased intraabdominal pressure due to other abdominal emergencies were reviewed. The following data were collected: demographics, the duration between the onset of symptoms and admission, clinical findings, biochemical test results that were abnormal, radiological findings, preoperative and intraoperative diagnosis, operative findings, surgical procedure, different diagnosis made in the postoperative period, reoperation, morbidity, mortality, and the length of hospital stay.

RESULTS

Ten patients were included to the study. The primary pathology was found to be perforated peptic ulcer disease in three, bowel obstruction due to neoplastic mass in three, complicated appendicitis in two, acute mesenteric ischemia in one, and acute diverticulitis in one. The correct diagnosis was made during emergency surgery for hernia repair, whereas the primary pathology was identified postoperatively in two patients.

CONCLUSIONS

Patients who are diagnosed to have acutely incarcerated AWH preoperatively should undergo further diagnostic workup, if any level of clinical suspicion for differential diagnosis is present. Moreover, the surgeon should consider general abdominal exploration if contradictory findings are encountered during the exploration of the hernia sac, even if preoperative diagnostic studies reveal no gross pathology or non-specific findings.

True-FISP MRI in diagnosis of postoperative hernia recurrence: a brief report

BACKGROUND

A 24-year-old man underwent laparoscopic mesh repair of a right direct inguinal hernia which had recurred after previous surgery 3 months previously. A large swelling was noted in the right groin 4 h postoperatively, which was reduced initially but recurred within 24 h. A differential diagnosis of postoperative recurrence versus hematoma was considered, and patient was referred for imaging.

METHODS

The patient was imaged using different modalities including B-mode ultrasonography, computed tomography (CT) of the pelvis, and True-FISP magnetic resonance imaging (true imaging with steady-state precession MRI).

RESULTS

Initial focused ultrasound (US) [corrected] was suggestive of but equivocal for recurrence. Subsequent non-contrast CT of the region followed by rapid sequence (true-FISP) MRI confirmed the presence of bowel in the inguinal canal.

CONCLUSION

Imaging has a role in the diagnosis of postoperative hernia recurrence in cases where there is a clinical diagnostic dilemma, especially MRI using true-FISP sequence, which is acquired in seconds, is a non-ionising radiation modality and does not have inter operator variability.

Dynamic power Doppler ultrasonography of anterior abdominal wall hernias: confirmation of incarceration

PURPOSE

Power Doppler ultrasonography (PD-US) is a motion-sensitive modality that can display flow characteristics regardless of the direction. This increased motion sensitivity can be used as a parameter to show the tissue motion on artificially generated fremitus images. This study aimed to confirm any signs of incarceration in abdominal wall hernias proven by herniorrhaphy by examination with dynamic PD-US (during manual compression-decompression maneuvers).

METHODS

Twenty-seven patients with anterior abdominal wall hernia with a narrow neck (<1 cm in diameter) were examined firstly with gray-scale ultrasonography (GS-US), and then with dynamic PD-US. Two independent radiologists, who were blinded to the real-time images showing the orientation and motion of the hernia neck, completed the examinations. These images were evaluated for any signs of incarceration, as well as the orientation of the hernia neck.

RESULTS

Orientations of the hernia neck were not described on GS-US images in 13 lesions and on dynamic PD-US images in 3 lesions. While the GS-US examination revealed incarcerated hernia in four of the patients, the dynamic PD-US examination revealed an additional seven patients with symptoms associated with incarceration.

CONCLUSION

Dynamic PD-US may show the orientation of the hernia neck and any sign of incarceration more accurately and clearly than conventional GS-US. Being informed about these features preoperatively is of utmost importance. Thus, anterior abdominal wall hernias should be examined by dynamic PD-US.

Multi detector CT Imaging of Abdominal and Diaphragmatic Hernias: Pictorial Essay

Diagnosis of abdominal wall hernia is often a clinical problem, especially in occult or in obese patients. Multidetector CT is an accurate method of detecting various types of abdominal and diaphragmatic hernias. It clearly demonstrates the anatomical sites of hernial sac, its contents and possible complications.

Abdominal wall lump after cesarean delivery

BACKGROUND

An abdominal wall desmoid tumor is a rare event, has a strong tendency for local invasion and recurrence, and usually presents as an abdominal lump.

CASE

A 35-year-old multiparous woman presented with a painful abdominal lump that had been slowly increasing in size. The pain was not associated with menstruation. Clinical examination, ultrasonography, and abdominal magnetic resonance imaging were performed and suggested a large, sharply defined mass measuring approximately 11 × 7.1 cm in the right anterolateral abdominal wall. There was no family history of familial adenomatous polyposis. The mass was excised and sent for histopathologic examination, which indicated abdominal wall desmoid tumor.

CONCLUSION

Abdominal wall desmoid tumors can be diagnostic dilemmas and should be considered in the differential diagnosis for lumps in the abdomen in women.

MDCT of abdominal wall lumbar hernias: anatomical review, pathologic findings and differential diagnosis

PURPOSE

To review the anatomical landmarks of the abdominal wall lumbar region and its normal appearance on multidetector computed tomography (MDCT) and to briefly describe the MDCT features of lumbar hernias.

METHODS

We performed a retrospective search of the imaging report database from November 2007 to October 2011. We retrieved the clinical data and MDCT studies of patients suffering from abdominal wall lumbar hernias. We reviewed the imaging features of abdominal lumbar hernias and compared those with the normal appearance of the lumbar region in asymptomatic individuals.

RESULTS

We classified lumbar wall hernias as diffuse, superior (or Grynfelt-Lesshaft) and inferior (or Petit) lumbar hernias. We briefly describe the imaging features of each subtype and review the anatomy and MDCT appearance of normal lumbar region.

CONCLUSIONS

Currently available MDCT provides an excellent opportunity for reviewing the normal anatomy of the wall lumbar region and may be considered a useful modality for evaluating lumbar hernias.

Computed tomography scan diagnosis of occult groin hernia

BACKGROUND

The value of computed tomography (CT) for the diagnosis of clinically occult (hidden) groin hernia was assessed in a series of patients presenting with undiagnosed groin pain.

METHODS

A total of 158 consecutive patients presenting over a period of 5 years with undiagnosed groin pain or lower abdominal pain and negative or equivocal clinical findings were radiologically assessed with non-contrast CT. The decision to manage operatively or conservatively was then based on a combination of the clinical and CT findings. Outcomes were assessed at 10 years follow-up.

RESULTS

The study cohort comprised 158 patients presenting with groin or lower abdominal pain and/or swelling, and was studied prospectively. Seven of these patients were re-investigated at a later date after developing new pain on either the ipsilateral or contralateral side, giving a total of 165 CT examinations. One-third of cases (54) had clinically occult groin hernias and most of the remaining cases had diagnoses that could be managed non-operatively. Of those who came to surgery, the pre-operative CT diagnosis of hernia had a positive predictive value (PPV) of 92% and a negative predictive value (NPV) of 96% (overall accuracy 94%). Lipoma of the spermatic cord was responsible for three of five false-positive CT results. The concept of sports hernia/groin disruption injury (GDI) was encountered, and this entity is discussed in this paper. In the group of patients without hernia findings on CT, the most common diagnoses were rectus abdominis and/or pyramidalis muscle injury which could be treated by physiotherapy (22%), GDI (16%), post-surgical problems (14%), miscellaneous (20%) and 'no abnormality' was identified in 15%. Overall, there were 111 patients with a 'non-hernia' CT diagnosis, of which urological, gynaecological, gastrointestinal and neuralgia contributed to the non-musculoskeletal diagnosis.

CONCLUSION

This prospective non-contrast CT study of patients with undiagnosed chronic groin pain detected the majority of occult hernias requiring surgical intervention. These results suggest that CT can be a useful adjunct to the evaluation of patients presenting with chronic undiagnosed groin pain, but that experienced clinical judgment remains a critical element in the diagnostic pathway.

Partial nephrectomy in a patient with a left ventricular assist device

Left ventricular assist device (LVAD) use has increased as a bridge to heart transplant as well as destination therapy in patients with severe heart failure. Presence of LVAD is not a contraindication to noncardiac surgery but does present special challenges to the surgical, anesthesia, and cardiac teams. We present the case of a 40-year-old woman with idiopathic cardiomyopathy necessitating LVAD who underwent left partial nephrectomy for a renal mass. She had undergone three nondiagnostic percutaneous image-guided biopsies. Left partial nephrectomy was performed. Perioperative care was without incident due to careful oversight by a multidisciplinary team. Pathology revealed high-grade clear cell renal cell carcinoma (RCC) with negative margins. Polytetrafluoroethylene (PTFE) bolsters were misidentified six months postoperatively on computed tomography (CT) at an outside institution as a retained laparotomy sponge. This is, to our knowledge, the first report of a partial nephrectomy performed in a patient with LVAD.

Diagnosis of inguinal region hernias with axial CT: the lateral crescent sign and other key findings

Differentiation of direct inguinal hernias, indirect inguinal hernias, and femoral hernias is often difficult at clinical examination and presents challenges even at diagnostic imaging. With the advent of higher-resolution multidetector computed tomography (CT), the minute anatomic detail of the inguinal region can be better delineated. The authors examine the appearance of these hernias at axial CT, as the axial plane remains the diagnostic mainstay of evaluation of acute abdomen. They review and label key anatomic structures, present cases of direct and indirect inguinal hernias and femoral hernias, and demonstrate their anatomic differences on axial images. Direct inguinal hernias protrude anteromedial and inferior to the course of the inferior epigastric vessels, whereas indirect inguinal hernias protrude posterolateral and superior to the course of those vessels. The proposed lateral crescent sign may be useful in diagnosis of early direct inguinal hernias, as it represents lateral compression and stretching of the inguinal canal fat and contents by the hernia sac. Femoral hernias protrude inferior to the course of the inferior epigastric vessels and medial to the common femoral vein, often have a narrow funnel-shaped neck, and may compress the femoral vein, causing engorgement of distal collateral veins. Familiarity with these anatomic differences at axial CT, along with the lateral crescent sign of direct inguinal hernias, may help the radiologist better assist the clinician in accurate diagnosis of the major types of hernias of the inguinal region. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.312105129/-/DC1.

Inferior lumbar triangle hernia as a rarely reported cause of low back pain: a report of 4 cases

OBJECTIVE

Lumbar triangle hernias are rarely reported causes of low back pain. We describe the symptoms, signs, and anatomical location of 2 possible defects in the posterior abdominal wall where lumbar hernias may appear. The clinical diagnosis was challenging, and advanced imaging failed to initially uncover the conditions.

CLINICAL FEATURES

We report 4 patients with spontaneous inferior lumbar triangle hernias (Petit triangle hernias) initially presenting to a primary care clinic with the primary complaint of low back pain.

INTERVENTION AND OUTCOMES

Thorough histories and examinations led to successful outcomes. All 4 patients were operated on to correct the defect. No recurrence has occurred.

CONCLUSIONS

Anatomical knowledge and clinical acumen led to correct diagnosis of these rare lumbar hernias. This information should help both medical and chiropractic clinicians detect these conditions, and aid in appropriate management.

Abdominal hernias: Radiological features

Abdominal wall hernias are common diseases of the abdomen with a global incidence approximately 4%-5%. They are distinguished in external, diaphragmatic and internal hernias on the basis of their localisation. Groin hernias are the most common with a prevalence of 75%, followed by femoral (15%) and umbilical (8%). There is a higher prevalence in males (M:F, 8:1). Diagnosis is usually made on physical examination. However, clinical diagnosis may be difficult, especially in patients with obesity, pain or abdominal wall scarring. In these cases, abdominal imaging may be the first clue to the correct diagnosis and to confirm suspected complications. Different imaging modalities are used: conventional radiographs or barium studies, ultrasonography and Computed Tomography. Imaging modalities can aid in the differential diagnosis of palpable abdominal wall masses and can help to define hernial contents such as fatty tissue, bowel, other organs or fluid. This work focuses on the main radiological findings of abdominal herniations.

The role of multi-detector computed tomography in imaging hernias

Clinical presentation of a hernia is often non-specific or atypical and in these circumstances diagnosis and management decisions can be aided by imaging. This review contains diagrammatic illustrations, explanations and computed tomography examples of the different types of external, internal and diaphragmatic hernias.

[Mechanical obstruction as a cause of acute abdomen. Radiological differential diagnosis]

Mechanical obstruction is a common cause of acute abdomen. Besides the diagnosis of the obstruction itself it is crucial to recognize the cause of the obstruction for planning of conservative or operative treatment.This article gives a general overview of the methods available for imaging obstructions in the setting of an acute abdomen. In the second part the differential diagnoses of the most common causes of obstruction will be discussed.

Pre-, intra-, and postoperative sonography of the abdominal wall in patients with incisional hernias repaired via a three-layered operative suture method

We illustrate the various sonographic (US) appearances of the abdominal wall following this type of repair, including partial and complete recurrences. Correlation is made with CT imaging. The three-layered anatomical reconstruction of an incisional hernia is described.