DIAGNOSIS OF ABDOMINAL WALL HERNIAS

Manuel Cadena G, MD, Juan Jos Santivaez, Diego Aguirre, MD,, Juliana Ocampo, MD,
Arturo Vergara, MD.

INTRODUCTION
INTRODUCTION

Abdominal
Abdominal wall
wall hernias:
hernias: Fascial
Fascial defects
defects on
on
the
the aponeurotic
aponeurotic and
and muscular
muscular wall
wall through
through
which
which the
the pre
pre peritoneal
peritoneal or
or intra-abdominal
intra-abdominal
content
may
protrude.
(1,
content may protrude. (1, 2)
2)
Surgical
Surgical conditions,
conditions, varying
varying in
in presentation
presentation
from
from asymptomatic
asymptomatic to
to life-threatening
life-threatening
emergencies.
emergencies. (3).
(3). The
The medical
medical history
history and
and
physical examination
examination are
are the
the primary
primary
physical
methods
methods for
for the
the diagnosis
diagnosis (4)
(4)
From
From 5
5 to
to 10%
10% of
of these
these hernias
hernias are
are not
not
detectable
detectable on
on physical
physical examination
examination and
and
require diagnostic
diagnostic images.
require
images. Among
Among the
the
imaging
studies
that
are
used,
imaging
studies
that
are
used,
ultrasonography and
and computed
computed tomography
tomography
ultrasonography
are
are most
most widely
widely available
available and
and used,
used,
providing
providing exquisite
exquisite anatomic
anatomic detail
detail of
of the
the
wall defect
defect and
and hernia
hernia content,(4,5)
content,(4,5)
wall

ULTRASOUND
ULTRASOUND

Widely
Widely available
available
Dynamic
Dynamic
No radiation
radiation exposure
exposure
No
Relative
Relative low
low cost
cost (6)
(6)
Diagnostic
Diagnostic Performance
Performance sensitivity
sensitivity and
and
specificity
close
to
100%
(6)
specificity close to 100% (6)
Limitation
operator
dependence
and
Limitation
operator
dependence
and
subjectivity.
subjectivity.
Useful
Useful for
for pediatric
pediatric population
population female
female
women
women on
on fertile
fertile ages
ages thin
thin patients.
patients.
Limited
Limited in
in acute
acute setting,
setting, obese
obese patients,
patients, and
and
patients
patients with
with excessive
excessive scarring
scarring

INDICATIONS
INDICATIONS FOR
FOR
IMAGING
STUDIES
IMAGING STUDIES
Painful
Painful inguinal
inguinal canal
canal without
without palpable
palpable mass.
mass.
Limitations
Limitations on
on physical
physical examination.
examination.
Obese patients,
patients, or
or with
with excessive
Obese
excessive scarring
scarring
Hernia
Hernia characterization
characterization (defect
(defect size,
size, hernia
hernia sac
sac
content,
content, integrity
integrity of
of the
the fascial
fascial planes)
planes) and
and
complications.
complications.
Evaluation
Evaluation of
of postoperative
postoperative complications
complications and
and
recurrences.
recurrences.
Identification
Identification of
of differential
differential diagnosis.
diagnosis.

CT
CT

Widely
available
-Provides
multiplanar
Widely
available
Provides
multiplanar
capabilities,
capabilities,
Excellent anatomic
anatomic detail
Excellent
detail required
required for
for adequate
adequate
surgical
surgical planning.
planning.
Identification
Identification of
of hernia
hernia complication.
complication.
Disadvantage:
radiation
Disadvantage: radiation exposure
exposure

Figure
Figure 2.
2. Coronal
Coronal CT
CT images
images through
through the
the pelvis
pelvis demonstrating
demonstrating
left
left sided
sided obturator
obturator hernia
hernia containing
containing small
small bowel
bowel loops
loops
(arrows).
(arrows).

MRI
MRI

Figure
Figure 1.
1. Ultrasound
Ultrasound image
image
demonstrates
demonstrates umbilical
umbilical hernia
hernia
(arrow)
containing
small
(arrow) containing small bowel
bowel
loops.
loops.

HERNIOGRAPHY
HERNIOGRAPHY
Contrast
Contrast media
media injected
injected into
into the
the peritoneal
peritoneal
cavity
cavity
Useful
Useful for
for diagnosis
diagnosis of
of occult
occult inguinal
inguinal hernias
hernias
Invasive
Invasive radiation
radiation exposure
exposure

CONCLUSIONS
CONCLUSIONS

Multiplanar
Multiplanar capability
capability
Excellent
anatomic
Excellent
anatomic
detail
detail
Not
Not useful
useful in
in acute
acute
setting.
setting.
High
High costs
costs
Limited availability.
availability.
Limited
Figure
Figure 4.
4. Axial
Axial MRI
MRI of
of the
the
abdomen
abdomen demonstrates
demonstrates
ventral
hernia
containing
ventral hernia containing
transverse
transverse colon.
colon.
Figure
Figure 3.
3. Plain
Plain film
film of
of the
the pelvis
pelvis
following
following intraperitoneal
intraperitoneal
injection
of
contrast
media
injection of contrast media
(herniography)
(herniography) demonstrate
demonstrate
pelvic
pelvic peritoneal
peritoneal recesses.
recesses. Note
Note
left sided
sided inguinal
inguinal hernia
hernia (arrow)
(arrow)
left

1.
1. Imaging
Imaging assessment
assessment of
of abdominal
abdominal wall
wall is
is important
important for
for adequate
adequate anatomic
anatomic characterization
characterization in
in
patients
patients with
with suspected
suspected abdominal
abdominal wall
wall hernias,
hernias, complementing
complementing physical
physical exam.
exam.
2. CT
CT and
and Ultrasound
Ultrasound are
2.
are the
the principal
principal imaging
imaging modalities
modalities used
used for
for hernia
hernia defect
defect depiction
depiction and
and hernia
hernia
content
content characteristics.
characteristics.
3.
3. Finally,
Finally, the
the CT
CT is
is recommended
recommended when
when there
there is
is diagnostic
diagnostic uncertainty
uncertainty after
after the
the initial
initial physical
physical or
or
ultrasound
examination,
or
as
first
choice
when
resulting
complications
are
suspected.
ultrasound examination, or as first choice when resulting complications are suspected.
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