AJR 2003; 180:864-865
© American Roentgen Ray Society
Bilateral Arcuate-Line Hernia
Olivier Cappeliez,
Vincent Duez,
Jean-Louis Alle and
Francis Leclercq
Centre Hospitalier Universitaire de Tivoli B-7100 La Louvière,
Belgium
A 73-year-old man presented with recurrent right flank pain that resolved
spontaneously. Findings on conventional abdominal radiography, upper abdominal
sonography, and laboratory tests were normal. Initially, we thought functional
colic pain might be responsible for the patient's symptoms. However, CT showed
a bilateral hernia of the small-bowel loops between the rectus abdominis
muscles and the posterior rectus sheath. The hernia orifice was at the level
of the free inferior edge of the posterior rectus sheath, referred to as the
arcuate line. On the right side, the herniated bowel loop appeared somewhat
stretched, probably due to peritoneal adhesions (Figs.
3A,3B,3C).
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Fig. 3A. —73-year-old man with bilateral small-bowel hernia between
rectus abdominis muscle and free inferior edge of posterior rectus sheath.
Axial CT scan obtained 2 cm below level of umbilicus shows small-bowel loop
(solid arrow) between left rectus abdominis muscle and inferior part
of posterior rectus sheath (open arrows).
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Fig. 3B. —73-year-old man with bilateral small-bowel hernia between
rectus abdominis muscle and free inferior edge of posterior rectus sheath.
Axial CT scan obtained 8 mm inferior to level of A at inferior edge of
posterior rectus sheath (open arrows) reveals stretching of herniated
loop on right side (solid arrow).
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Fig. 3C. —73-year-old man with bilateral small-bowel hernia between
rectus abdominis muscle and free inferior edge of posterior rectus sheath.
Sagittal reformatted CT scan shows another perspective of left herniated bowel
loop (solid arrow) and free inferior edge of left posterior rectus
sheath (open arrow).
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Fig. 3D. —73-year-old man with bilateral small-bowel hernia between
rectus abdominis muscle and free inferior edge of posterior rectus sheath.
Photograph obtained at laparoscopic surgery shows right hernia orifice at
level of free inferior edge of right posterior rectus sheath (open
arrows) and released peritoneal adhesions (solid arrow).
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Laparoscopic surgery revealed peritoneal folds between the rectus abdominis
muscles and the lower limit of the posterior rectus sheath. Adhesions were
confirmed as being present in the right hernial sac and were surgically
released. Treatment for the hernia consisted of laparoscopic mesh fixation.
The patient's postoperative course was uneventful.
Although this condition could be classified as an abdominal wall hernia, we
found no prolapse of intestinal loops through an abdominal wall defect. For
this reason, we classified it as an internal hernia. Clinical diagnosis of an
internal hernia is notoriously difficult, and CT provides the best
preoperative evidence of such a hernia
[1]. The hernia orifice is
often a preexisting anatomic structure. In our patient, the orifice was
located a few centimeters below the umbilicus, at the lower limit of the
posterior ensheathment of the rectus abdominis by the internal oblique and
transversus abdominis aponeuroses. The anatomic feature is a sudden shift of
the aponeuroses from the posterior to the anterior rectus sheath, forming a
sharp concave transition; this feature is called the arcuate line or the
semicircular line of Douglas
[2]. Other anatomic features of
the lower half on the posterior rectus sheath have also been described
[3]. Because the nomenclature
used for specific hernias refers to the anatomic location of their orifice, we
choose to call this hernia an arcuate-line hernia. To our knowledge, ours is
the first report of this kind of hernia.
References
- Blachar A, Federle MP, Dodson SF. Internal hernia: clinical and
imaging findings in 17 patients with emphasis on CT criteria.
Radiology
2001;218:68
-74[Abstract/Free Full Text]
- Monkhouse WS, Khalique A. Variations in the composition of the
human rectus sheath: a study of the anterior abdominal wall. J
Anat 1986;145:61
-66[Medline]
- Rizk NN. The arcuate line of the rectus sheath: does it exist?
J Anat
1991;175:1
-6[Medline]
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