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

[Diseases of the peritoneum and mesenterium]

Peritoneal diseases can be seen in the different imaging modalities either as fluid collections or solid tumors along the ligaments, mesenteries, and spaces of the peritoneal cavity. The broad spectrum of different abnormalities includes inflammatory, infectious, traumatic, and neoplastic diseases. In this article, a large variety of peritoneal abnormalities such as ascites, peritonitis, intraperitoneal hemorrhage, and both primary and secondary peritoneal tumors are discussed. The different imaging modalities, characteristic radiological features, and typical pathways of anatomic spread are explained.

Perineal hernia

Abdominal wall hernias are a common abdominal pathology with higher prevalence in our population. It is usually asymptomatic but complications such as strangulation, incarceration or bowel obstruction need early detection and emergency surgery. The purpose of this article is to describe the infrequent type of hernia, illustrate the imaging findings and review the differential diagnosis. A 76-year-old woman was admitted in the emergency room with abdominal pain, vomits and diarrhoea. At her admission, a colonoscopy was attempted to perform but it was not possible to go beyond the stenosis. A barium enema and a multi-detector computed tomography (MDCT) were performed revealing a large mass in the left ischiorectal fossa, containing herniated loops of sigmoid colon adjacent to rectum. Abdominal wall hernias occur at areas of congenital or acquired weakness in the abdominal wall and are considered external hernias. MDCT is essential to identify wall hernias, make an accurate diagnosis and help for its clinical assessment. Knowing the radiological features of various types of abdominal hernias on MDCT and barium-enhanced radiographs allows confident diagnosis of these pathologies.

[Diagnostic and therapeutic difficulties of left lower quadrant abdominal pain]

A patient presented with left lower quadrant abdominal pain and a lumbar hernia after pyeloplasty. In her history, diverticular disease, lumbar vertebral arthropathy, total abdominal hysterectomy and total left hip prosthesis were found. Due to the lack of special CT maneuvers and techniques (Valsalva, MDCT), laparoscopy provided a clear diagnosis finally. Closure of the hernia with absorbable sutures provided a temporary solution only. A Composix mesh was used therefore, but this resulted in postoperative neuropathic pain. This complication was treated with removal of the tacks and adhesiolysis.

Postherniorrhaphy groin pain and how to avoid it

Groin pain following inguinal hernia repair remains a challenge to most general surgeons. Prevention of groin pain may be the most effective solution to this management problem and necessitates careful anatomic dissection and precise knowledge of surgical anatomy of the groin as well as potential pitfalls of surgical intervention. When complications arise, a period of watchful waiting is warranted, but surgical intervention with triple neurectomy offers the most definitive resolution of symptoms. This article aims to provide a thorough review of pertinent anatomic landmarks for the proper identification of the nerves that, if injured, result in chronic groin pain and to provide a treatment algorithm for patients suffering with this morbidity.

The accuracy of ultrasonography in classification of groin hernias according to the criteria of the unified classification system

BACKGROUND

The modern concept of type-related individualized groin hernia surgery imposes a demand for precise and accurate preoperative determination of the type of groin hernia. The aim of this prospective study was to evaluate the accuracy of ultrasonography in classification of groin hernias, according to the criteria of the unified classification system. Unified classification divides groin hernias into nine types (grades): type I (indirect, small), II (indirect, medium), III (indirect, large), IV (direct, small), V (direct, medium), VI (direct, large), VII (combined-pantaloon), VIII (femoral), and O (other).

PATIENTS AND METHODS

One hundred and twenty-five adult patients with clinically diagnosed or suspected groin hernias were examined. Ultrasonography of both groins was performed with a 5 to 10-MHz linear-array transducer. Preoperative ultrasonographic findings of type of groin hernia were compared with the intraoperative findings, which were considered the gold standard.

RESULTS

Total accuracy of ultrasonography in determination of type of groin hernia was 96% (119 of 124 correct predictions of type of groin hernia compared with surgical explorations). All hernias of types I, IV, V, VII, and VIII were correctly identified with ultrasonography (sensitivity and specificity 100%). In the remaining five cases of the 124 (4%), hernia was incorrectly classified with ultrasonography: type VI (direct, large) was misdiagnosed as type III (indirect, large) in three cases, type III as type VI in one case, and type III as type II (indirect, medium) in one case. The sensitivity and the specificity of ultrasonography in classifying type II were 100 and 99%, respectively, for type III, 85 and 97%, and for type VI, 90 and 99%.

CONCLUSION

Ultrasonography of the groin regions could be used with great accuracy for precise classification of groin hernias in adults. Each type of groin hernia, according to the unified classification system that we used for classification, has a characteristic ultrasonographic presentation, which is demonstrated in this study.

Dolor originado en la pared abdominal: una alternativa diagnóstica olvidada

Chronic abdominal pain is a common clinical problem in primary care, and is usually referred to gastroenterologists or general surgeons. Although up to 20% of cases of idiopathic abdominal pain arise in structures of the abdominal wall, this is frequently overlooked as a possible cause. It includes pain arising from structures of the abdominal wall including skin, parietal peritoneum, cellular subcutaneous tissue, aponeuroses, abdominal muscles and somatosensorial innervation from lower dorsal roots. The diagnosis is based on anamnesis and physical examination. Carnett's sign is a simple maneuver that discriminates between parietal and visceral pain. Management with topical anesthesia is effective in a majority of patients and can help to confirm the diagnosis.

Abdominal Hernias: Imaging Review and Historical Perspectives

Many eminent anatomists originally described abdominal hernias, some of which are still named after the original authors. In this article, the radiologic features of abdominal hernias are reviewed as imaged on x-ray, ultrasound, multidetector computed tomography, and magnetic resonance imaging. Recognition of the typical appearance of various types of abdominal hernias and associated adverse features such as bowel obstruction, perforation, strangulation, or volvulus formation can help in formulating an accurate diagnosis. A short biography of the scientists associated with eponymous hernias and their other important scientific contributions are also described.

A rare hernia of intra-abdominal fat in the thorax under an intact diaphragm: multidetector computed tomography

Neither abdominal wall hernia nor diaphragmatic hernia is an unusual disease. But some may have difficulty diagnosing the presence of intra-abdominal fat in the thorax under an intact diaphragm. We report a case with an external compression of the right lower lung from intra-abdominal fat owing to a hernia through the right lateral abdominal wall and secondary through the ninth intercostal space of the chest wall to the right lower thorax without traumatic history. Multiple images, including multidetector row computed tomography, are reviewed.