Abdominal hernia

This elderly lady presented with delirium, but no other medical history could be obtained. The chest x-ray showed what was assumed (by the medical registrar) to be a right sided pleural effusion. He was keen to drain it. Luckily, the physician decided that he wanted a CT of the chest first, which revealed a large right-sided diaphragmatic hernia.

The scout image from the CT is shown, which demonstrates colonic bowel gas and soft-tissue density corresponding to the liver herniating into the right hemithorax. There is also Paget’s disease of the right humerus.

Incidentally-discovered posterior diaphragmatic hernias (Bochdalek hernias) are rare (0.17% of patients having an abdominal CT). Of these, right-sided hernias are more common (68%). The great majority are small, with only 27% containing abdominal organs such as bowel, spleen or liver.

Reference

Mullins ME, et al. Prevalence of Incidental Bochdalek’s Hernia in a Large Adult Population. AJR 2001; 177:363-366

Credit

Dr Michael Tam

Image courtesy of: Dr Marina-Portia Anthony, Dr Dharmesh Modi

From the case: Indirect inguinal hernia

From the case: Inguinal hernia

This 54 year-old female presented with vomiting and obstipation. This axial CT image shows (click image for arrows):

• An isolated retrocaecal loop of small bowel, with pinched afferent and efferent limbs (blue arrows)
• Caecum displaced anteriorly (red arrow)
• Dilated loops of proximal small bowel (green arrows)
• Collapsed loops of distal small bowel (yellow arrows)

The findings are in keeping with a paracaecal hernia containing a loop of small bowel and causing obstruction.

Internal herniation is an uncommon cause of bowel obstruction. The potential sites for internal herniation are:

• The foramen of Winslow
• A hole in the mesentery
• A hole in the transverse mesocolon
• A defect in the broad ligament
• Congenital or acquired diaphragmatic hernia
• The left paraduodenal fossa
• The right duodenojejunal fossa
• The superior ileocaecal fossa
• The inferior ileocaecal fossa
• The retrocaecal fossa

Reference:

1. Mann CV, Russell RCG. Bailey & Love’s Short Practice of Surgery 21st edition. Chapman & Hall Medical 1992

incisional hernia through the scar of a previous appendicectomy.

38 year old female being evaluated for chronic left iliac fossa pain.

Findings:  The omentum is seen to herniate through a defect in the transversus abdominis and the internal oblique muscles on the left side. The omental vessels can be traced beyond the confines of the peritoneum.

Spigelian hernias is a type of abdominal hernia.