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Musculoskeletal » Superficial
Left supraumbilical hernia
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Presentation A 50 year old obese woman with history of multiple abdominal surgeries reports a left abdominal wall swelling of one month duration. This was directly superior to a midline abdominal incision. The swelling increases in size with cough.
Caption: Sagittal image of the left supraumbilical region.
Description: An opening is noted in the peritoneal lining [white line], through which hypoechoic, tubular cystic structures are seen protruding.
Caption: Transverse image of the left supraumbilical region
Description: The opening in the peritoneum is noted again with the tubular cytic structure protruding through the defect. This tubular structure shows peristalsis, is a bowel loop and it reduces spontaneously.
Caption: Sagittal image of the contralateral side.
Description: Normal anatomy is demonstrated on the contralateral side.
Caption: Doppler study of the bowel.
Description: Normal areas of flow are noted within the bowel loops that are protruding through the peritoneal defect.
Differential Diagnosis Ventral hernia.
Final Diagnosis Left supraumbilical [ventral] hernia.
Discussion Acquired hernias are of many types. One way of classifying them is external or abdominal wall hernias [defect in the abdominal wall], internal hernias [protrusion of intraperitoneal contents through a defect in the peritoneum or mesentery] and diaphragmatic hernias [protrusion of intraabdominal contents into the chest]. Both internal and external hernias may contain bowel, omentum or both. Although the diagnosis is usually clinical, hernias may pose a diagnostic dilemma in obese patients, patients with multiple scars due to abdominal surgeries and in patients presenting with acute abdomen due to an incarcerated/ strangulated hernia. In such a situation, clinicians may have to rely on imaging findings which easily show the defect and confirm the diagnosis. In a few instances, asymptomatic occult [clinically not detectable] hernias may also be revealed by imaging.

High resolution ultrasound demonstrates the cross-sectional anatomy well and the layers of the abdominal wall up to the peritoneal layer can be well discerned unless body habitus precludes adequate visualization. In cases of ventral hernia, a defect is seen in the peritoneal layer through which the intraperitoneal contents protrude. The diameter of the defect can be measured, which helps the surgeon in deciding whether a mesh repair would be required.

In cases of hernias that are in the process of being or are incarcerated, patients may present with clinical signs of bowel obstruction or an acute abdomen. Rettenbacker et al described ultrasound findings associated with incarceration, including free fluid in the hernial sac, thickened walls of the bowel in the hernia, fluid in the herniated bowel loop, and dilated bowel loops in the abdomen. Color Doppler may show reduced blood flow in the bowel trapped in the hernial sac and is a good indicator of bowel viability. Post-operative follow up of these patients following mesh placement can also be carried out. CT is an excellent alternative modality in cases where ultrasound is inconclusive, enabling identification of the hernia and evaluation of the involved and uninvolved bowel.

Case References 1. Rettenbacher T, Hollerweger A, et al. Abdominal wall hernias: cross-sectional imaging signs of incarceration determined with sonography. AJR Am J Roentgenol. 2001 Nov; 177(5):1061-6.
2. Miller PA, et al. Imaging of abdominal hernias. Radiographics. 1995 Mar; 15(2):333-47.
3. Krombach GA, et al. Panorama ultrasonography of the abdominal wall for delineation of the anatomy and diagnosis of pathological findings. Rofo Fort Geb Rontgen Neuen Bildgeb Verfahr. 2001 Aug; 173(8):714-9.
4. Liang RJ, et al. Color Doppler sonography for ventral hernias in patients with acute abdomen: preliminary findings. J Clin Ultrasound. 2001 Oct; 29(8):435-40.
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