CASE 83

Clinical Presentation

A 57-year-old man presents with abdominal pain and discomfort. Physical examination reveals a palpable mass in the anterior abdominal wall, in the midabdomen.

Fig. 83.1 (A,B) Axial CT image show small bowel loops herniating through the abdominal wall and surrounded by a rim of soft tissue density with stranding, consistent with mild inflammation. There is mild distention of the small bowel proximally to the herniated loops.

Radiologic Findings

Axial computed tomography (CT) images (Figs. 83.1) show small bowel loops herniating through the abdominal wall and surrounded by a rim of soft tissue density with stranding, consistent with mild inflammation. There is mild distention of the small bowel proximally to the herniated loops.

Diagnosis

Differential Diagnosis

• Abdominal wall tumors (desmoid, lymphoma, hemangiomas, lipoma, metastases, etc.)
  
• Rectus sheath hematomas (posttraumatic, associated with coagulopathy)
  
• Enlarged lymph nodes (infections, lymphomas, etc.)
  
• Enlarged, prominent vessels (as seen in cirrhotic patients with portal venous shunts)
  
• Undescended testis
  
• Abdominal wall endometriosis

Fig. 83.2 An axial contrast-enhanced CT image through the pelvis demonstrates a direct left inguinal hernia. Small bowel loops are present along the left spermatic cord. Neither inflammatory changes nor signs of strangulation are present.

Fig. 83.3 Axial contrast-enhanced CT image shows a left ventral hernia containing small bowel loops and mesentery.

Discussion

Background

A hernia is commonly defined as the protrusion of any viscus from its proper cavity into a saclike structure formed by the same membrane with which the cavity is usually lined. Different types of hernias have been described according to their anatomical distribution, the most frequent in both men and women being inguinal hernias (direct Fig. 83.2 and indirect). Others include

• Femoral hernia: occurs medial to the femoral vein and posterior to the inguinal ligament; commonly right-sided
  
• Ventral hernia:
  
  
  
  • Midline defects: umbilical, paraumbilical, epigastric, and hypogastric hernias. Umbilical is the most common type, usually occurring in women (risk factors: obesity, multiple pregnancies, ascites, intra-abdominal masses)
    
  • Lateral defects—spigelian hernia (Fig. 83.3): occurs along the lateral aspect of the rectus muscle through the hiatus semilunaris
  
  
• Posterior defects—lumbar hernia: occurs either through defects in the superior (Grynfeltt) (Fig. 83.4
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