Presentation
Lower anterior abdominal wall swelling following abdominoplasty
Patient Data
A large well defined nearly midline parietal cystic lesion is noted within the anterior wall of the right rectus sheath. It has a lentiform shape, measuring 12.2 x 6 x 10.5 cm in maximum dimensions. It expresses T1 hyper, T2 and T2 fat-sat mixed hyper and hypointense signals with fluid-fluid leveling and few thin internal septa.
There is mild thick uniform marginal enhancement, with linear thickening and enhancement of the surrounding fascial planes. It indents the underlying rectus muscles, more on the right side, with no intra-muscular or intra-abdominal extension. Mild associated subcutaneous oedema is noted.
Case Discussion
Radiological features are suggestive of organised rectus sheath haematoma. The well defined lentiform shape of the haematoma is suggestive of intrafascial haemorrhage. The anterior wall of rectus sheath at the infraumbilical level is composed of the aponeurosis of the external oblique and the anterior lamina of the aponeurosis of the internal oblique muscles, the latter is intimately related to the rectus muscle and encloses it along with the posterior lamina of the internal oblique muscle. Since the fluid collection is anterior to the right rectus muscle with biconvex shape and separable from the rectus muscles as well as the internal oblique aponeurosis, the anatomic site of haemorrhage is likely inside the right external oblique aponeurosis.
Superiorly, the haematoma is arrested at the level of the umbilicus. Inferiorly, it is arrested at the anatomical region of the arcuate line, below which all three abdominal wall muscle aponeuroses of the rectus sheath join anterior to the rectus abdominis muscles. This region is supplied through perforator branches from the deep inferior epigastric artery, which are likely to be the source of bleeding.
The aetiology here is iatrogenic after abdominal wall surgery (abdominoplasty). Other causes of rectus sheath/muscle haematoma include anticoagulation therapy, coagulopathies, trauma, and vascular disorders.
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