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Abdominal Wall Hernias: MDCT Findings

¹ All authors: Department of Radiology, University of California, San Diego, 200 W Arbor Dr., San Diego, CA 92103.

View larger version (103K): [in a new window]   Fig. 1A. —72-year-old woman with cirrhosis and indirect inguinal hernia, abdominal pain, distention, and palpable mass in left groin. Axial contrast-enhanced reformatted MDCT image obtained through level of symphysis pubis shows left indirect inguinal hernia containing thickened and dilated small-bowel loops (arrows) with radiating mesenteric fat stranding (arrowhead) indicative of incarceration. In this case, prominent subcutaneous collaterals related to patient cirrhosis made identification of epigastric vessels difficult.

View larger version (178K): [in a new window]   Fig. 1B. —72-year-old woman with cirrhosis and indirect inguinal hernia, abdominal pain, distention, and palpable mass in left groin. Oblique coronal 3D volume-rendered MDCT image obtained through hernia shows incarcerated small-bowel loops and ascitic fluid in hernia sac (arrows).

View larger version (153K): [in a new window]   Fig. 1C. —72-year-old woman with cirrhosis and indirect inguinal hernia, abdominal pain, distention, and palpable mass in left groin. Sagittal reformatted MDCT image obtained through left groin delineates size of defect and hernia sac. Again note prominent vascularity (arrows) in abdominal wall secondary to portal hypertension.

View larger version (102K): [in a new window]   Fig. 2A. —79-year-old woman with direct inguinal hernia and small-bowel obstruction secondary to incarcerated left direct inguinal hernia. Axial contrast-enhanced reformatted MDCT image obtained at level of symphysis pubis shows bilateral inguinal hernias containing small-bowel loops (black arrows). Note epigastric vessels (white arrows) displaced anteriorly by hernia sacs. In multiple images on monitor, hernia sacs were medial to vessels consistent with direct inguinal herniation.

View larger version (150K): [in a new window]   Fig. 2B. —79-year-old woman with direct inguinal hernia and small-bowel obstruction secondary to incarcerated left direct inguinal hernia. Coronal reformatted MDCT image shows dilation of intraabdominal loops (black arrows) with protrusion of small-bowel loops and ascitic fluid through wall defect (white arrow). Notice that left hernia sac is located medial to epigastric vessels (arrowhead), diagnostic of direct herniation.

View larger version (122K): [in a new window]   Fig. 2C. —79-year-old woman with direct inguinal hernia and small-bowel obstruction secondary to incarcerated left direct inguinal hernia. Sagittal oblique MDCT image obtained through left inguinal hernia shows abdominal wall defect with herniation of dilated small bowel (large arrow). Note multiple small-bowel air–fluid levels (small arrows) secondary to obstruction caused by incarcerated hernia.

View larger version (107K): [in a new window]   Fig. 3A. —43-year-old man with femoral hernia and history of rectal cancer who presented with mass in left femoral region. Axial contrast-enhanced reformatted MDCT image obtained through symphysis pubis shows left femoral hernia, containing properitoneal fat (arrow) medial to femoral vessels (arrowhead) protruding into upper thigh. Compare with other side, where no hernia sac is seen. Note bulky rectal mass.

View larger version (143K): [in a new window]   Fig. 3B. —43-year-old man with femoral hernia and history of rectal cancer who presented with mass in left femoral region. Sagittal oblique reformatted MDCT image shows that defect originates in attachment of fascia transversalis to pubis (arrow).

View larger version (145K): [in a new window]   Fig. 4A. —55-year-old woman with cirrhosis who presented with umbilical hernia. Axial volume-rendered MDCT image obtained through umbilicus shows voluminous hernia sac containing properitoneal fat and ascitic fluid (arrowhead) related to underlying cirrhosis; ascites (not shown) was also present in upper abdomen. Mass was not palpable clinically, perhaps because of thickness of subcutaneous adipose tissue.

View larger version (141K): [in a new window]   Fig. 4B. —55-year-old woman with cirrhosis who presented with umbilical hernia. Sagittal volume-rendered MDCT reformation obtained through umbilicus shows defect in abdominal wall with protrusion of herniated sac into subcutaneous tissue (arrow).

View larger version (119K): [in a new window]   Fig. 5A. —47-year-old man with history of previously repaired paraumbilical hernia who presented with enlarging mass in umbilical area. Axial contrast-enhanced reformatted MDCT image obtained through umbilicus shows diastasis and atrophy of rectus abdominis muscles with protrusion of omental fat into abdominal wall (arrowheads) on both sides of umbilicus, consistent with bilateral paraumbilical hernias.

View larger version (144K): [in a new window]   Fig. 5B. —47-year-old man with history of previously repaired paraumbilical hernia who presented with enlarging mass in umbilical area. Sagittal volume-rendered MDCT image shows wall defect in umbilical area (arrow) immediately inferior to mesh in supraumbilical region (arrowheads) from previous hernia repair.

View larger version (160K): [in a new window]   Fig. 6A. —66-year-old obese woman with multiple previous abdominal surgeries who presented with periumbilical mass. Axial contrast-enhanced reformatted MDCT image obtained immediately superior to umbilicus shows diastasis of rectus muscles and protrusion of properitoneal and mesenteric fat into subcutaneous tissue (arrow).

View larger version (179K): [in a new window]   Fig. 6B. —66-year-old obese woman with multiple previous abdominal surgeries who presented with periumbilical mass. Axial reformatted MDCT image obtained inferior to umbilicus shows separate diastasis of rectus abdominis muscles with protrusion of contrast material–filled small-bowel loops into subcutaneous tissue (arrowheads).

View larger version (175K): [in a new window]   Fig. 6C. —66-year-old obese woman with multiple previous abdominal surgeries who presented with periumbilical mass. Sagittal 3D volume-rendered MDCT image shows complex anatomy of paraumbilical hernia, with component above umbilicus (arrow) and second component below umbilicus (arrowhead).

View larger version (144K): [in a new window]   Fig. 7A. —91-year-old man with no previous surgeries who presented with epigastric mass. Axial reformatted MDCT image obtained through level of kidneys shows midline defect in anterior abdominal wall with diastasis of rectus muscles and protrusion of omental fat (arrowheads). Note close relationship of hernia to transverse colon.

View larger version (132K): [in a new window]   Fig. 7B. —91-year-old man with no previous surgeries who presented with epigastric mass. Sagittal reformatted midline MDCT image shows wall defect (arrow) between xiphoid process and umbilicus (arrowhead).

View larger version (131K): [in a new window]   Fig. 8. —60-year-old woman with left flank mass. Axial MDCT image obtained at level below umbilicus shows protrusion of mesenteric fat through defect in left linea semilunaris, characteristic of spigelian hernia (arrowheads). Subcutaneous hernia sac can be confused with abdominal wall lipoma if muscular defect is not recognized. Clinical diagnosis is extremely difficult in these patients.

View larger version (159K): [in a new window]   Fig. 9A. —70-year-old woman with history of cholecystectomy who now has mass at incision site as spigelian incisional hernia. Oblique coronal 3D reformatted MDCT image shows abnormal protrusion of colon (arrow) and right hepatic lobe (arrowhead) through abdominal wall defect.

View larger version (143K): [in a new window]   Fig. 9B. —70-year-old woman with history of cholecystectomy who now has mass at incision site as spigelian incisional hernia. Axial MDCT image obtained at level of kidneys shows hernia sac protruding between right rectus abdominis muscle (arrow) and aponeuroses of right transversus abdominis and internal oblique muscles (arrowheads), consistent with spigelian hernia.

View larger version (147K): [in a new window]   Fig. 10. —Diagram shows distribution of lumbar triangles. Coronal reformatted MDCT image obtained through dorsal aspect of abdominal wall shows superior lumbar triangle (double asterisk) bordered superiorly by 12th rib, laterally and anteriorly by internal oblique muscle (arrowhead), and posteriorly by erector spinal muscle (ES). Inferior lumbar triangle (single asterisk) is shown on right side, bordered inferiorly by iliac crest, laterally and anteriorly by external oblique muscle (arrow), and posteriorly by latissimus dorsi muscle (LD).

View larger version (131K): [in a new window]   Fig. 11A. —34-year-old man after motor vehicle crash. Axial contrast-enhanced reformatted MDCT image obtained through lower pole of kidneys shows right perirenal hematoma (arrowheads). On left side, posterior herniation of descending colon (arrow) is noted with adjacent soft-tissue stranding, consistent with traumatic lumbar herniation.

View larger version (97K): [in a new window]   Fig. 11B. —34-year-old man after motor vehicle crash. Sagittal 3D volume-rendered MDCT image reveals protrusion of descending colon into posterior abdominal wall (arrowheads) in superior lumbar triangle, characteristic of Grynfeltt–Lesshaft hernia (most frequent lumbar hernia).

View larger version (139K): [in a new window]   Fig. 12A. —39-year-old woman with previous left nephrectomy for renal cell carcinoma who presented with bulging mass in incision area as lumbar hernia. Axial contrast-enhanced reformatted MDCT image obtained through lower pole of right kidney shows defect in abdominal wall at inferior lumbar triangle, with protrusion of small bowel into subcutaneous tissue (arrow).

View larger version (181K): [in a new window]   Fig. 12B. —39-year-old woman with previous left nephrectomy for renal cell carcinoma who presented with bulging mass in incision area as lumbar hernia. Coronal volume-rendered MDCT image shows protrusion of small-bowel loops into inferior lumbar triangle (arrow) below 12th rib (arrowhead) through site of previous nephrectomy incision, consistent with inferior lumbar (Petit's) incisional hernia.

View larger version (129K): [in a new window]   Fig. 13A. —69-year-old woman with previous right nephrectomy who presented with right abdominal bulge as incisional hernia. Axial contrast-enhanced reformatted MDCT image obtained through inferior pole of left kidney shows defect in right internal oblique muscle, with protrusion of contrast material–filled small-bowel loops into abdominal wall (arrow).

View larger version (151K): [in a new window]   Fig. 13B. —69-year-old woman with previous right nephrectomy who presented with right abdominal bulge as incisional hernia. Oblique coronal volume-rendered MDCT image shows protrusion of intraabdominal content through incisional scar into abdominal wall (arrow).

View larger version (124K): [in a new window]   Fig. 14. —71-year-old man with history of partial colectomy for colon carcinoma who presented with enlarging mass next to colostomy in left flank as parastomal hernia. Axial contrast-enhanced reformatted MDCT image obtained through lower abdomen shows parastomal herniation of small bowel (arrowhead) adjacent to colonic stoma (arrow).

View larger version (130K): [in a new window]   Fig. 15A. —60-year-old woman who presented with bulging masses in both lower quadrants. Axial reformatted MDCT image obtained through subumbilical area shows bilateral defects in abdominal wall with protrusion of small-bowel loops and mesenteric fat into intermuscular plane between internal (solid arrowheads) and external oblique (open arrowheads) muscles characteristic of interparietal hernias.

View larger version (139K): [in a new window]   Fig. 15B. —60-year-old woman who presented with bulging masses in both lower quadrants. Axial reformatted MDCT image obtained through neck of right-sided hernia shows protrusion of mesenteric fat, vessels, and bowel loops (arrow) into interparietal hernia sac.

View larger version (144K): [in a new window]   Fig. 16. —42-year-old man who presented with abdominal distention as Richter's-type umbilical hernia. Axial contrast-enhanced reformatted MDCT image obtained through mid abdomen shows dilatation of small-bowel loops with numerous air–fluid levels. At level of umbilicus, protrusion of antimesenteric wall of dilated small-bowel loop is seen (arrowheads) without involvement of opposite wall (arrows), characteristic of Richter's hernia. This patient had small-bowel obstruction caused by adhesions in distal ileum, and Richter's hernia was incidental.

View larger version (105K): [in a new window]   Fig. 17. —50-year-old woman with vague pelvic pain from pelvic floor hernia. Axial CT image of lower pelvis shows bowel loops in right ischiorectal fossa (arrowheads) consistent with sciatic hernia. These rare hernias are usually caused by abnormal development or atrophy of piriform muscle. Sac may contain small bowel, urinary bladder, ovary, ureters, or colon. Sciatic hernia also is known as sacrosciatic, ischiatic, or gluteal hernia (hernia incisurae, ischiadicae, and ischiocele).

View larger version (138K): [in a new window]   Fig. 18. —80-year-old woman with abdominal distention. Axial CT image obtained through pelvic floor shows artifact from bilateral hip prosthesis. Note fluid-filled bowel loops lateral to right obturator foramen (arrowhead), characteristic of obturator hernia. These rare hernias are mainly seen in older patients.

View larger version (127K): [in a new window]   Fig. 19A. —Three-dimensional maximum-intensity-projection reformations of osseous pelvis show distribution of pelvic hernias. Anterior (A) and lateral (B) projections show distribution of perineal (vertical arrow), obturator (oblique arrow), and sciatic hernias (curved arrow).

View larger version (126K): [in a new window]   Fig. 19B. —Three-dimensional maximum-intensity-projection reformations of osseous pelvis show distribution of pelvic hernias. Anterior (A) and lateral (B) projections show distribution of perineal (vertical arrow), obturator (oblique arrow), and sciatic hernias (curved arrow).

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