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Sonography of Inguinal Region Hernias

David A. Jamadar1, Jon A. Jacobson1, Yoav Morag1, Gandikota Girish1, Farhad Ebrahim1, Thomas Gest2 and Michael Franz3

1 Department of Radiology, University of Michigan Hospitals, 1500 E Medical Center Dr., TC2910, Ann Arbor, MI 48109.
2 Division of Anatomical Sciences, University of Michigan Medical School, Ann Arbor, MI.
3 Department of Surgery, University of Michigan Hospitals, Ann Arbor, MI.


Figure 1
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  		Fig. 1 —Illustration of man's dissected right inguinal region from anterior view shows reflected external oblique aponeurosis (E), reflected internal oblique aponeurosis (I), and transversus abdominis muscle (T). Conjoint tendon (C) is medial to deep ring through which passes vas deferens and accompanying artery and vein to form spermatic cord (S). Note superficial ring (straight arrow), inguinal ligament (curved arrow), and transversalis fascia and extraperitoneal fat (F).

 

Figure 2
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  		Fig. 2 —Illustration of man's right inguinal region as viewed from within abdomen. Inferior epigastric artery (solid straight arrow), rectus abdominis muscle (R), and inguinal ligament (curved arrow) define boundaries of Hesselbach's triangle (H), location of direct hernia. Indirect inguinal hernia passes through deep ring (open arrow), which is lateral to inferior epigastric artery and above inguinal ligament. Location of femoral hernia (asterisk) is usually lateral to lacunar ligament (L) and inferior in relation to medial inguinal ligament. Note conjoint tendon (C) and vas deferens (arrowhead).

 

Figure 3
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  		Fig. 3 —57-year-old man with intraoperative laparoscopic view of right direct inguinal hernia. Open arrows show inferior epigastric artery and solid arrows show inguinal ligament, which define lateral and inferior boundaries of Hesselbach's triangle through which direct hernia defect (D) is distended by gas used during laparoscopy. Deep inguinal ring (curved arrow) is closed by gas pressure, but medial boundary (arrowheads) can be seen. Note that extraperitoneal fat obscures vas deferens, external iliac artery, and other anatomic details.

 

Figure 4
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  		Fig. 4 —Illustration of man's right inguinal region from anterior view shows transducer position to evaluate for spigelian hernia (1), indirect inguinal hernia (2), direct inguinal hernia (3), and femoral hernia (4). Note locations of inguinal ligament (curved arrow), rectus abdominis muscle (R), lateral boundary of Hesselbach's triangle (H) defined by inferior epigastric artery (open arrow), and spermatic cord (arrowhead).

 

Figure 5
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  		Fig. 5A —25-year-old man with right spigelian hernia. Pre-Valsalva maneuver sonogram over linea semilunaris in axial plane corresponding to transducer position 1 in Figure 4 (hernia not visible) showing right rectus abdominis muscle (R), inferior epigastric artery (curved arrow), peritoneal fat stripe (straight arrows), and lateral abdominal muscles (M).

 

Figure 6
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  		Fig. 5B —25-year-old man with right spigelian hernia. Post-Valsalva maneuver sonogram in same location showing peritoneal fat stripe distorted by fat-containing spigelian hernia (arrows) at linea semilunaris. Note rectus abdominis muscle (R) and lateral abdominal muscles (M).

 

Figure 7
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  		Fig. 6A —40-year-old man with healthy right inguinal anatomy. Sonogram of inguinal region parallel and cranial to inguinal ligament corresponding to transducer position 2 in Figure 4 shows spermatic cord (C), external iliac artery (A), inferior epigastric artery (E), femoral vein (V), and superior pubic ramus (curved arrow).

 

Figure 8
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  		Fig. 6B —40-year-old man with healthy right inguinal anatomy. Sonogram of inguinal region (transducer position not illustrated in Fig. 4) directly over and parallel to inferior epigastric artery (E), spermatic cord short axis (arrows), external iliac artery (A), and rectus abdominis (R).

 

Figure 9
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  		Fig. 7 —40-year-old man showing healthy right inguinal anatomy. Sonogram of inguinal region parallel to and directly over inguinal ligament, distal to origin of inferior epigastric artery (transducer position not illustrated in Fig. 4). Note femoral artery (A), femoral vein (V), inguinal ligament (straight arrows), and superior pubic ramus (curved arrow).

 

Figure 10
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  		Fig. 8A —30-year-old man with sonogram of right indirect inguinal hernia with transducer positioned parallel to and cranial to inguinal ligament corresponding to transducer position 2 in Figure 4. Pre-Valsalva maneuver sonogram (hernia not visible) shows external iliac artery (A), inferior epigastric artery (E), and superior pubic ramus (curved arrow).

 

Figure 11
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  		Fig. 8B —30-year-old man with sonogram of right indirect inguinal hernia with transducer positioned parallel to and cranial to inguinal ligament corresponding to transducer position 2 in Figure 4. Post-Valsalva maneuver sonogram shows external iliac artery (A), inferior epigastric artery (E), dilated external iliac vein (V), superior pubic ramus (curved arrow), and indirect inguinal hernia (H) originating from lateral to external iliac artery (arrowhead) and traversing inguinal canal from lateral to medial. (Left = lateral)

 

Figure 12
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  		Fig. 9A —39-year-old man with direct inguinal hernia. Sonogram of right inguinal region parallel to and cranial to inguinal ligament corresponding to transducer position 3 in Figure 4. Pre-Valsalva maneuver sonogram shows (hernia not visible) peritoneal fat stripe (straight arrows) medial to inferior epigastric artery (curved arrow).

 

Figure 13
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  		Fig. 9B —39-year-old man with direct inguinal hernia. Sonogram of right inguinal region parallel to and cranial to inguinal ligament corresponding to transducer position 3 in Figure 4. Post-Valsalva maneuver sonogram shows direct inguinal hernia deforming peritoneal reflection (straight arrows) medial to inferior epigastric artery (curved arrow). (Left is lateral, right is medial.)

 

Figure 14
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  		Fig. 10A —31-year-old woman with femoral hernia. Sonogram of right inguinal region parallel to and caudad to inguinal ligament corresponding to transducer position 4 in Figure 4. Pre-Valsalva maneuver sonogram shows (hernia not visible) femoral artery (A), femoral vein (V), and superior pubic ramus (curved arrow).

 

Figure 15
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  		Fig. 10B —31-year-old woman with femoral hernia. Sonogram of right inguinal region parallel to and caudad to inguinal ligament corresponding to transducer position 4 in Figure 4. Post-Valsalva maneuver sonogram shows dilated femoral vein (V) lateral to femoral hernia (arrows). Superior pubic ramus (curved arrow) is also seen.

 

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