456 lines
48 KiB
Markdown
456 lines
48 KiB
Markdown
---
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title: "Inguinal Hernia"
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docid: "cf4d4a15-6a85-4aeb-9563-7be7e8131bc7"
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authors:
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- key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
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value: "Siva P. Raman, MD"
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breadcrumbs:
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-
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name: "Gastrointestinal"
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slug: "gastrointestinal"
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treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
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-
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name: "Diagnosis"
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slug: "diagnosis"
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treeNodeId: "5a7c51af-b1c6-4629-8f0e-d99e6fe57a98"
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-
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name: "Peritoneum, Mesentery, and Abdominal Wall"
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slug: "peritoneum-mesentery-and-abdominal-"
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treeNodeId: "a3fb9f00-f894-4b38-9e01-2f78406cf547"
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-
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name: "External Hernias"
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slug: "external-hernias"
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treeNodeId: "71ab3f79-4332-463c-9f60-d3dd2902d974"
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-
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name: "Inguinal Hernia"
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slug: "inguinal-hernia"
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treeNodeId: null
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category: "Gastrointestinal"
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documentVersionId: "fd9a73be-5244-455c-a430-d7c83db9aca5"
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imageCount: 31
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lastUpdated: "04/22/25"
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pageDescription: "Inguinal Hernia"
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pageKeywords: "Gastrointestinal, Diagnosis, Peritoneum, Mesentery, and Abdominal Wall, External Hernias, Inguinal Hernia"
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pageTitle: "Inguinal Hernia | STATdx"
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enhancedTitle: "Inguinal Hernia"
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type: "DX"
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references: true
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ddx: true
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anatomy:
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- "{'authors': 'Atif Zaheer, MD, FSAR; Siva P. Raman, MD; Michael P. Federle, MD, FACR', 'bookmarked': False, 'bookmarkUrl': '/document/bookmark/6691f48d-ac34-477b-8ec1-b9dd731a14a8', 'category': 'Gastrointestinal', 'compareUrl': '/compare/document/6691f48d-ac34-477b-8ec1-b9dd731a14a8/related-anatomy/treeNode?subContext=Peritoneal Cavity', 'documentId': '6691f48d-ac34-477b-8ec1-b9dd731a14a8', 'documentType': 'ANATOMY', 'documentUrl': '/document/peritoneal-cavity/6691f48d-ac34-477b-8ec1-b9dd731a14a8', 'enhancedTitle': 'Peritoneal Cavity', 'entryDate': '07/06/23', 'imageCount': 53, 'imageUrl': '/image/thumbnail/e305c4ce-1242-49fa-bc19-e0f5461cdafa?size=174&quality=85', 'inCompareCart': False, 'rank': 1, 'referenceCount': 0, 'showCompareButton': False, 'title': 'Peritoneal Cavity'}"
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- "{'authors': 'Eric Turner, MD; Mark E. Lockhart, MD, MPH; Daniel Childers, MD', 'bookmarked': False, 'bookmarkUrl': '/document/bookmark/79a4117f-773a-40b3-bdb5-b0195f84e087', 'category': 'Ultrasound', 'compareUrl': '/compare/document/79a4117f-773a-40b3-bdb5-b0195f84e087/related-anatomy/treeNode?subContext=Mesenteric Vessels', 'documentId': '79a4117f-773a-40b3-bdb5-b0195f84e087', 'documentType': 'ANATOMY', 'documentUrl': '/document/mesenteric-vessels/79a4117f-773a-40b3-bdb5-b0195f84e087', 'enhancedTitle': 'Mesenteric Vessels', 'entryDate': '05/13/24', 'imageCount': 22, 'imageUrl': '/image/thumbnail/102e0a5e-f97c-46b9-9dc0-6193e796506d?size=174&quality=85', 'inCompareCart': False, 'rank': 2, 'referenceCount': 0, 'showCompareButton': False, 'title': 'Mesenteric Vessels'}"
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cases: 2
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breadcrumbs:
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- "Gastrointestinal"
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- "Diagnosis"
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- "Peritoneum, Mesentery, and Abdominal Wall"
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- "External Hernias"
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- "Inguinal Hernia"
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---
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# KEY FACTS
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- ## Imaging
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- **Direct inguinal hernia**: Hernia passes through Hesselbach triangle (bounded by inguinal ligament, lateral margin of rectus abdominis, and inferior epigastric artery)
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- CT: Arises **anteromedial**to origin of inferior epigastric artery and extends through anterior abdominal wall lateral to rectus muscle
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- Contents of inguinal canal (testicular vessels, vas deferens) can be seen as crescent of density along lateral aspect of hernia (**lateral crescent sign**)
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- No compression of femoral artery/vein
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- **Indirect inguinal hernia**: Hernia passes through internal inguinal ring, down inguinal canal, and emerges at external ring
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- CT: Arises **superolateral** to inferior epigastric vessels and extends lateral to medial within inguinal canal
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- Lateral crescent sign not present with indirect hernias
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- **US**: Can scan patient either with Valsalva maneuver or in upright position to precipitate hernia
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- US can determine reducibility of hernia (unlike CT) and identify reducible hernias that may not be seen on CT
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- ## Pathology
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- 75-80% of all hernias occur in inguinal region with indirect hernias 5x more common than direct
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- Indirect inguinal hernia usually congenital defect due to patency of processus vaginalis, whereas direct hernias are acquired due to abdominal wall weakness
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- ## Clinical Issues
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- Much more common in men than women
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- Symptoms often worse when standing, lifting, or straining
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- Complications: Incarceration and strangulation (much more common with indirect than direct inguinal hernia)
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- Emergent surgical repair (laparoscopic or open) in patients with strangulated inguinal hernia
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- Symptomatic hernias usually surgically repaired on elective basis, although conservative management possible in some asymptomatic or minimally symptomatic patients
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- Conservative management possible in patients who are asymptomatic or have minimal symptoms
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# TERMINOLOGY
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- ## Abbreviations
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- Inguinal hernia (IH)
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- ## Synonyms
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- Pelvic hernia, groin hernia
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- ## Definitions
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- IH: External hernia with orifice in inguinal location
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- External hernia: Abnormal protrusion of intraabdominal tissue through defect in abdominal/pelvic wall with extension outside abdominal cavity
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# IMAGING
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- ## General Features
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- ### Location
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- Inguinal canal is opening in anterior abdominal wall connecting deep and superficial inguinal rings
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- Contains spermatic cord, ductus deferens, testicular artery and veins, genital branch of genitofemoral nerve, and ilioinguinal nerve in males
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- Contains round ligament, ilioinguinal nerve, and genital branch of genitofemoral nerve in females
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- Bounded by external and internal oblique aponeurosis anteriorly, conjoint tendon and fascia transversalis posteriorly, internal oblique and transversus abdominis muscles superiorly, and inguinal/lacunar ligaments inferiorly
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- **Indirect IH**: Hernia passes through internal inguinal ring, down inguinal canal, and emerges at external ring
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- Lateral IH: Arises superior and lateral to epigastric vessels (lateral umbilical fold)
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- Can extend along spermatic cord into scrotum (i.e., complete hernia) in male patients
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- Can follow course of round ligament of uterus into labium majus in female patients
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- Juxtafunicular hernia: Indirect hernia that passes outside spermatic cord into surrounding soft tissues
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- Occurs most often on right in both men and women
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- **Direct IH**: Hernia passes through Hesselbach triangle (in floor of inguinal canal bounded by inguinal ligament, lateral margin of rectus abdominis, and inferior epigastric artery)
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- Arises medial to course of inferior epigastric vessels
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- Not contained in spermatic cord and generally does not pass into scrotum
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- Medial umbilical fold divides Hesselbach triangle into medial and lateral parts and directs IH into medial and lateral types
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- ### Morphology
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- Indirect IH within spermatic cord has smooth contour with elongated, oblique course
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- Juxtafunicular hernia has more irregular contour without protrusion into preformed sac
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- Dissect through subcutaneous fat and fibrous tissue
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- Direct IH appears broad and dome-shaped
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- ## CT Findings
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- Some IHs, particularly when small, have tendency to reduce when patient is supine and may be missed on CT
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- Primary landmark is inferior epigastric artery, which arises opposite to origin of deep circumflex iliac artery from external iliac artery
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- **Direct IH**: Arises **anteromedial**to origin of inferior epigastric artery, extends through anterior abdominal wall lateral to rectus muscle, and courses below inferior epigastric artery
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- Contents of inguinal canal (testicular vessels, vas deferens) can be seen as crescent of density along lateral aspect of hernia as it protrudes (**lateral crescent sign**)
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- No compression of nearby femoral artery and vein (unlike femoral hernias)
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- Relationship of hernia sac relative to pubic tubercle may help differentiate inguinal and femoral hernias
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- IH seen anterior to horizontal plane connecting pubic tubercles (femoral hernias seen posterior)
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- **Indirect IH**: Arises **superolateral** to epigastric vessels and extends lateral to medial within inguinal canal
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- Lateral crescent sign seen with direct hernias not present with indirect hernias, as normal contents of inguinal canal are not compressed
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- Direct and indirect hernias can very rarely be visualized in same groin: **Saddlebag**or**pantaloon** hernia (combined-type hernia)
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- CT very helpful for identifying contents of hernia sac (omental fat, bowel, bladder) and identifying complications (bowel obstruction, ischemia, perforation, etc.)
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- IH described as **sliding**hernias when partially retroperitoneal structures (bladder, distal ureters, ascending/descending colon) are within hernia sac
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- Key to identify, as blood vessels supplying herniated segments may be injured during surgery or trauma
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- Appendix within hernia sac: Amyand hernia
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- Meckel diverticulum within hernia sac: Littre hernia
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- Other uncommon contents in IH can be ureter, ovaries, uterus, and undescended testis
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- CT should be 1st-line modality in patients presenting with acute symptoms from hernia
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- **Normal postoperative imaging findings**
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- Polypropylene mesh patch appears as thin, linear structures of soft tissue density (often difficult to distinguish from fascia and muscle)
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- Polytetrafluoroethylene mesh patch appears hyperdense and more easily visualized
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- Polypropylene mesh plugs appear as soft tissue density nodules at internal inguinal ring (usually 2-3 cm in size) and should not be confused with enlarged lymph node or mass
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- Can rarely demonstrate central fat density with higher density rim (perhaps in up to 40% of cases)
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- Spermatic cord may appear thickened after surgery (and may remain thickened for years) due to surgical manipulation and should not be confused for pathology
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- Surgical staples for fascial fixation not common with modern surgical techniques
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- ## Ultrasonographic Findings
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- Some debate in literature regarding efficacy of US in diagnosing hernias: Various studies have shown sensitivities ranging from 29-100%
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- Most useful if patient presents nonurgently with history suggesting reducible IH
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- Typically high-frequency transducer (> 10 MHz) best, since IHs are superficial, but lower frequencies may be utilized in more obese patients
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- US probe placed longitudinal to inguinal canal and anterior to inferior epigastric artery (at site of origin from external iliac artery)
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- Advantage of US is ability to scan patient either with Valsalva maneuver or in upright position to precipitate hernia (if hernia not seen initially at rest in supine position)
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- Bowel loops may peristalsis within hernia sac and may aid in identification of hernia
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- US can determine reducibility of hernia (unlike CT) and identify reducible hernias that may not be seen on CT due to supine scan position
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- Primary sonographic landmarks are pubic tubercle and inferior epigastric artery (along lateral border of rectus abdominis and can be traced back to external iliac artery)
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- **Indirect IH:** Hernia seen to originate **lateral** to inferior epigastric artery and extend medially toward pubic tubercle
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- Valsalva maneuver: Impaired swelling of pampiniform plexus
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- **Direct IH:**Hernia seen to originate **medial**to inferior epigastric artery and extend anteriorly toward probe
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- Valsalva maneuver: Distended pampiniform plexus is displaced by hernia sac
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- ## Radiographic Findings
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- ### Radiography
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- Soft tissue density or gas-containing mass overlying obturator foramen on affected side suggests hernia
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- Presence of dilated bowel loops with convergence of distended intestinal loops toward inguinal region suggests bowel obstruction due to IH
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- Fluoroscopy: Tapered narrowing or obstruction of intestinal segments entering hernia orifice
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- Visualize afferent and efferent loops of protruding intestine
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- ## Imaging Recommendations
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- ### Best imaging tool
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- US is appropriate 1st-line modality in patients with nonurgent presentation
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- CECT in patients with acute symptoms or suspicion of complications related to hernia
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# DIFFERENTIAL DIAGNOSIS
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- [Femoral Hernia](/document/femoral-hernia/45d54e6d-97bd-4dd4-beed-b31f572d7b95)
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- Protrusion of abdominal contents through femoral ring and into femoral canal
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- Omental fat or bowel herniating into femoral canal medial to femoral vein and inferior to inferior epigastric vessels
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- Femoral vein often indented/compressed by hernia sac
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- Hernia sac located posterior to horizontal plane of pubic tubercle, whereas IH located anterior
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- More common in women
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- ## Lymphadenopathy
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- Soft tissue nodule near inguinal ligament might mimic IH clinically, but distinction easily made with imaging
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- CT and US can help differentiate hernia contents from other groin and scrotal masses, such as hydrocele, varix, lipoma of spermatic cord, undescended testicle, abscess, tumor, etc.
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- ## Iatrogenic Hematoma
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- Arterial puncture following arteriography, needle biopsy, aspiration
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- Hematoma may extend into rectus muscle, lateral abdominal wall muscles
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- Blood can track directly from groin along transversalis fascia and transversus abdominis muscle
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- CT, US, MR: Appearance of blood; extent of lesion changes over time
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- Pseudoaneurysm: Perivascular, rounded mass; neck and track connecting with injured artery
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- ## Spermatic Cord Lipoma or Liposarcoma
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- Rare, fat-containing masses that typically grow into scrotum but can involve inguinal canal and mimic IH containing omental fat
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- Well-differentiated liposarcomas or lipomas may be difficult to differentiate from omental fat in hernia, but lesions usually appear more mass-like, and liposarcomas often demonstrate some internal complexity
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# PATHOLOGY
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- ## General Features
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- ### Etiology
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- 75-80% of all hernias occur in inguinal region with**indirect hernias 5x more common than direct**
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- Indirect IH considered most often congenital defect due to patency of processus vaginalis and weakness of crus lateralis at lateral aspect of inguinal canal
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- Although congenital, may not become clinically apparent until later in life
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- Direct IH considered acquired lesion arising due to weakness in transversalis fascia of posterior wall of inguinal canal in Hesselbach triangle
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- Related to a number of factors, including old age, chronic cough, pregnancy, connective tissue abnormalities, constipation, etc.
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# CLINICAL ISSUES
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- ## Presentation
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- ### Most common signs/symptoms
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- Highly variable depending on hernia size
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- May be asymptomatic (especially when small), palpable lump in groin, heavy sensation in groin, or cause groin pain
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- Symptoms often increase when standing, lifting, or straining
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- Incarcerated or strangulated hernias may have severe fulminant presentations
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- Most hernias diagnosed on clinical examination (without imaging) with hernia best palpated with patient standing, coughing, or performing Valsalva maneuver
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- Diagnosis can be made with history and physical examination, although physical exam fails to properly make distinction between direct and indirect IHs in as many as 30% of cases
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- ## Demographics
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- ### Age
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- Indirect IH may occur from infancy to old age but generally present by 5th decade
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- Occurs in 1-3% of all children with 1.5-2x greater incidence in premature infants
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- Pediatric IH almost always indirect with increased incarceration risk
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- Usually right (60-75%) but often bilateral (10-15%)
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- Direct IH increases in incidence with age
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- ### Sex
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- Indirect IH 5-10x more common in men
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- Direct IH occurs mostly in men
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- Overall lifetime risk is 27% in men and 3% in women
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- ## Natural History & Prognosis
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- Complications: Incarceration, strangulation, and bowel obstruction
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- Direct IH rarely incarcerated and has lower association with strangulation
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- Indirect IH accounts for 15% of intestinal obstructions
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- Diverticulitis, appendicitis, or primary/metastatic tumor may occur within hernia sac
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- IH may recur after herniorrhaphy in ~ 20%
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- Direct IH may develop after indirect IH repair
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- ## Treatment
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- Emergent surgical repair (laparoscopic or open) in patients with strangulated IH
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- Symptomatic hernias repaired electively using open or laparoscopic surgical technique
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- Conservative management possible in patients who are asymptomatic or have minimal symptoms
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# DIAGNOSTIC CHECKLIST
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- ## Consider
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- Indirect IH protrude from lateral inguinal fossa
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- Direct IH are from medial and supravesical fossae
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1600ad5b-4439-49c2-8ba2-966c88beb385
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## References
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# Selected References
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1. [Hammoud M et al: Inguinal hernia. StatPearls, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=30020704%5Bpmid%5D)
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1. [Morrison Z et al: Adult inguinal hernia. 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=30725926%5Bpmid%5D)
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1. [Ganesan G et al: A radiological review of the unusual contents of inguinal region. Indian J Radiol Imaging. 33(3):373-81, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=37362368%5Bpmid%5D)
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1. [Kopscik M et al: Sports hernias: a comprehensive review for clinicians. Cureus. 15(8):e43283, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=37692688%5Bpmid%5D)
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1. [Plumb AA et al: Contemporary imaging of inguinal hernia and pain. Br J Radiol. 95(1134):20220163, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35348361%5Bpmid%5D)
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1. [Wu WT et al: Ultrasound imaging for inguinal hernia: a pictorial review. Ultrasonography. 41(3):610-23, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35569836%5Bpmid%5D)
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1. [Liu N et al: Unnecessary use of radiology studies in the diagnosis of inguinal hernias: a retrospective cohort study. Surg Endosc. 35(8):4444-51, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=32909205%5Bpmid%5D)
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1. [Chaudhary SR et al: Thinking beyond hernia: a review of non-hernia groin lumps. Abdom Radiol (NY). 45(6):1929-49, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31786622%5Bpmid%5D)
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1. [Kohga A et al: Does preoperative enhanced CT predict requirement of intestinal resection in the patients with incarcerated myopectineal hernias containing small bowel? Hernia. 25(5):1279-17, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=33128678%5Bpmid%5D)
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1. [Piga E et al: Imaging modalities for inguinal hernia diagnosis: a systematic review. Hernia. 24(5):917-26, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32328842%5Bpmid%5D)
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1. [Sim WY et al: Sonographic appearance of a large lipoma of the spermatic cord presenting clinically as an inguinoscrotal hernia. J Clin Ultrasound. 49(4):395-7, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32914871%5Bpmid%5D)
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1. [Itani KMF et al: Approach to groin hernias. JAMA Surg. 154(6):551-2, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30865244%5Bpmid%5D)
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1. [Cabarrus MC et al: From inguinal hernias to spermatic cord lipomas: pearls, pitfalls, and mimics of abdominal and pelvic hernias. Radiographics. 37(7):2063-82, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=29131768%5Bpmid%5D)
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1. [Revzin MV et al: US of the inguinal canal: comprehensive review of pathologic processes with CT and MR imaging correlation. Radiographics. 36(7):2028-48, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27715712%5Bpmid%5D)
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1. [Tonolini M: Multidetector CT of expected findings and complications after contemporary inguinal hernia repair surgery. Diagn Interv Radiol. 22(5):422-9, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27460285%5Bpmid%5D)
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1. [Burkhardt JH et al: Diagnosis of inguinal region hernias with axial CT: the lateral crescent sign and other key findings. Radiographics. 31(2):E1-12, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21415178%5Bpmid%5D)
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1. [Lassandro F et al: Abdominal hernias: radiological features. World J Gastrointest Endosc. 3(6):110-7, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21860678%5Bpmid%5D)
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1. [Light D et al: The role of ultrasound scan in the diagnosis of occult inguinal hernias. Int J Surg. 9(2):169-72, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21059415%5Bpmid%5D)
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1. [Narci A et al: O. Preoperative sonography of nonreducible inguinal masses in girls. J Clin Ultrasound. 36(7):409-12, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18506746%5Bpmid%5D)
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1. [Cherian PT et al: Radiologic anatomy of the inguinofemoral region: insights from MDCT. AJR Am J Roentgenol. 189(4):W177-83, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17885029%5Bpmid%5D)
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1. [Suzuki S et al: Differentiation of femoral versus inguinal hernia: CT findings. AJR Am J Roentgenol. 189(2):W78-83, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17646443%5Bpmid%5D)
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1. [Robinson P et al: Inguinofemoral hernia: accuracy of sonography in patients with indeterminate clinical features. AJR Am J Roentgenol. 187(5):1168-78, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=17056901%5Bpmid%5D)
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1. [Alam A et al: The accuracy of ultrasound in the diagnosis of clinically occult groin hernias in adults. Eur Radiol. 15(12):2457-61, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15986204%5Bpmid%5D)
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1. [van den Berg JC: Inguinal hernias: MRI and ultrasound. Semin Ultrasound CT MR. 23(2): 156-73, 2002](http://www.ncbi.nlm.nih.gov/pubmed/?term=11996229%5Bpmid%5D)
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1. [Shadbolt CL et al: Imaging of groin masses: inguinal anatomy and pathologic conditions revisited. Radiographics. 21 Spec No: S261-71, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11598262%5Bpmid%5D)
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1. [Zhang GQ et al: Groin hernias in adults: value of color Doppler sonography in their classification. J Clin Ultrasound. 29(8): 429-34, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11745848%5Bpmid%5D)
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1. [Toms AP et al: Illustrated review of new imaging techniques in the diagnosis of abdominal wall hernias. Br J Surg. 86(10): 1243-9, 1999](http://www.ncbi.nlm.nih.gov/pubmed/?term=10540124%5Bpmid%5D)
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## Differential diagnosis
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### Abdominal Wall Mass
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DDX:d51e2268-67b6-4a60-9222-f5a86f61ddec
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### Acute Abdomen in Infants and Children
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DDX:88dc4860-4e13-441f-815c-45180d11fa50
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### Acute Left Abdominal Pain
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DDX:65c32297-ce9e-41dd-80b5-60fd7160f2a6
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### Defect in Abdominal Wall (Hernia)
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DDX:5af046fa-59ef-45b5-952b-acbcdee36196
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### Extratesticular Solid Mass
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DDX:43677c94-f36b-46ff-adde-e0e0134d78c6
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### Groin Mass
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DDX:160e727f-dabe-4187-aa46-c29625076cc5
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### Scrotal Pain
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DDX:24bdc87e-2601-4ba9-b559-e12ff3a20dce
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### Small Bowel Obstruction
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DDX:ad8209f0-71e5-4496-860f-d2724ca22892
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## Anatomy
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### Peritoneal Cavity
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Gastrointestinal/ANATOMY:6691f48d-ac34-477b-8ec1-b9dd731a14a8
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### Mesenteric Vessels
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Ultrasound/ANATOMY:79a4117f-773a-40b3-bdb5-b0195f84e087
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## Cases
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- {'cases': [{'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'd02ca38c-fb31-48ee-b26b-70f2b4063699', 'description': 'CT and barium studies show small bowel herniated into the hernia.\n\nAxial CECT images (#1-4) show the hernia sac, lying anterior to the right femoral vessels. Contrast-opacified small bowel is present within the hernia (arrows, #2, 3), but there is no sign of bowel obstruction.\n\nA barium small bowel follow through study (#5, 6) shows the herniated small bowel (open arrow). Note the constriction of the bowel (curved arrows, #6) as it passes through the inguinal ring.', 'history': 'Elderly woman with painful swelling in groin and abdominal pain.', 'imagePoolId': '663fc803-015b-415e-a026-ad2084ca6857', 'name': 'Classic, with bowel herniated', 'teachingPoint': None, 'demographics': '82 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '8e4a2dd7-63ec-46f0-ae98-81f1dd218de9', 'description': 'CT (#1-4) shows herniation of small bowel loops (curved arrows, #2,5) and fat through an inguinal hernia, causing low grade obstruction of more proximal SB. SBFT (#5) confirms the hernia (open arrows)and the dilation of more proximal small bowel.', 'history': 'Elderly woman with intermittent crampy abdominal pain and a palpable groin mass.', 'imagePoolId': '8bc4bbae-1a3b-4613-9687-9eeb6f972f7b', 'name': 'shown on SBFT + CT; partial SBO', 'teachingPoint': None}], 'caseType': 'typical', 'name': 'TYPICAL'}
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- {'cases': [{'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '83ad66eb-24a3-427b-9f42-e7fac6c63041', 'description': 'CT shows ascites fluid within bilateral inguinal hernias.\n\nCT shows extensive ascites. Some of the ascites distends the inguinal canals bilaterally (arrows, #2), a common finding in patients with tense ascites and patent funicular process (processus vaginalis).', 'history': 'Young man with ascites due to chronic renal failure.', 'imagePoolId': 'abe3f4f3-350a-4a81-91e2-d1d5a2e21e3e', 'name': 'With ascites', 'teachingPoint': None, 'demographics': '37 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '8c480ba2-235d-4b75-95da-0c22bad9034b', 'description': 'CT confirms a pelvic bleed and an incidental inguinal hernia.\n\nCT shows a small hemorrhage in the right obturator region (open arrow, #2). Also noted is a large left inguinal hernia (arrow, #3) that contains a segment of sigmoid colon. The hernia sac has a wide opening with little apparent constriction of the colon. There is no sign of bowel obstruction.', 'history': 'Elderly man being evaluated for a bleed on anticoagulant therapy.', 'imagePoolId': 'ee799b3b-145d-4596-9adf-778ffc99e68a', 'name': 'Containing colon', 'teachingPoint': None}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'a76f7550-35f4-4535-bc19-c24a95f9c800', 'description': 'Radiographs show huge inguinal hernia.\n\nAn abdominal radiograph (#1) shows a "gasless" abdomen. Most of her bowel lies in the pelvis, and much of the small bowel has protruded into a large left inguinal hernia (arrow).', 'history': 'Elderly woman with abdominal discomfort.', 'imagePoolId': '73f63393-f3e1-4ae4-8e34-3bfabdca9b38', 'name': 'Huge', 'teachingPoint': None, 'demographics': '85 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'b761a521-8c46-44e0-8451-e6cb55e46e3a', 'description': 'A supine film of the abdomen (#1) shows distention of the colon (but not the rectum). Both the inner and outer walls of the transverse colon are sharply defined (arrow) and there is a triangular collection of gas density between the colon and the liver shadow (curved arrow).\nAxial NECT sections confirm massive free intraperitoneal gas (arrows, # 2-6). The colon is massively dilated (curved arrows, #3-7). A few bubbles of extraluminal gas (arrows, #7) are seen immediately adjacent to a markedly dilated cecum and ascending colon. The dilated colon can be followed into a large left inguinal hernia (open arrow, #8-9) that contains a portion of sigmoid colon. The rectum is collapsed. Axial NECT images viewed at "lung windows" (#10-13) demonstrate the free intraperitoneal gas outlining the falciform ligament (arrow, #10) and the outer wall of the transverse colon (arrow, #11). Some of the smaller gas bubbles are seen (black arrow, #12) adjacent to the wall of the ascending colon. Sagittal reconstruction (#13) optimally demonstrates the free air sharply outlining the ventral surface of the transverse colon and liver (arrows). Coronal reformatted images (#14-15) optimally demonstrate the sigmoid colon that is incarcerated and obstructed within the left inguinal hernia (open arrow, #14-15).\n\nComment: It is uncommon though not rare for the colon to become incarcerated and obstructed within a hernia. Any cause of marked colonic distention (obstruction or ileus) may lead to ischemia and perforation of the colon, usually of the cecum or ascending colon. At surgery, a small perforation of the posterior wall of the ascending colon was confirmed and treated with partial colectomy, along with repair of the inguinal hernia.', 'history': 'Patient with abdominal distention and severe pain.', 'imagePoolId': '553e48b4-c170-4caf-a551-202efca183ac', 'name': 'Hernia causing colonic perforation', 'teachingPoint': None, 'demographics': '64 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '61054b2d-9307-4e72-9b3b-d0595d69754d', 'description': 'CTs (#1-10) show an inguinal hernia (arrows, #6-10). The herniated fat within the inguinal hernia is infiltrated, and there is a tubular structure (curved arrows, #2-9) within the hernia that represents an inflamed appendix. \n\nComment: The position of the appendix can be quite variable, although the base of the appendix almost always arises from the tip of the cecum. Depending on the location of the tip of the appendix, focal symptoms of pain and tenderness may be encountered in almost any part of the abdomen. When the appendix is located within a hernia (inguinal, Spigelian, etc.), symptoms are especially likely to be misinterpreted as a complication of the hernia, such as strangulation of herniated bowel or omental fat.', 'history': 'Right lower abdominal and groin pain.', 'imagePoolId': '2efeca50-1f68-4b5d-9cc1-ee0d196efabc', 'name': 'Appendix within hernia', 'teachingPoint': None, 'demographics': '44 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'd79f8e7b-2a58-4cab-94e4-5a3e90460766', 'description': 'CT shows a right inguinal hernia (arrow, #1, 2) that contains herniated fat. The fat is somewhat "dirty", or infiltrated, in appearance, suggesting incarceration or ischemia of the herniated fat.', 'history': 'Young man with painful swelling in groin.', 'imagePoolId': '2a2b52ef-4c45-4633-adf3-8656028d4c76', 'name': 'Containing only fat', 'teachingPoint': None, 'demographics': '21 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '6f8f0a5c-c3b5-46ba-9edf-5e1805cbbd09', 'description': 'The radiograph (#1) shows gross dilation of the small bowel. Following placement of an NG tube, the bowel became less dilated, as shown on the CT scan (#2-4). However, CT showed persistent dilated, fluid-filled segments of bowel (arrows, #2,3), extraluminal gas bubbles (curved arrow, #3), and small bowel incarcerated within an inguinal hernia (open arrow, #4). At surgery, a segment of obstructed small bowel (arrow, #5) was necrotic from ischemia and was resected.', 'history': 'Patient with abdominal pain and hypotension.', 'imagePoolId': 'bd9f3993-d089-4463-b105-cb7bb91656f9', 'name': 'SBO with infarct; inguinal hernia', 'teachingPoint': None, 'demographics': '77 Years old female'}], 'caseType': 'variant', 'name': 'VARIANT'}
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## Images
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### Selected Images
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*Graphic demonstrates a direct inguinal hernia <img src='img/arrows/WO.png'/> with the hernia neck <img src='img/arrows/WS.png'/> located medial to the inferior epigastric artery and vein <img src='img/arrows/WC.png'/>.*
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*Graphic demonstrates an indirect inguinal hernia <img src='img/arrows/WO.png'/> with the hernia neck <img src='img/arrows/WS.png'/> located lateral to the inferior epigastric artery and vein <img src='img/arrows/WC.png'/>. The inferior epigastric vessels serve as the key landmark in distinguishing direct and indirect inguinal hernias.*
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*Axial CECT in a patient with a palpable groin mass demonstrates a right inguinal hernia <img src='img/arrows/WS.png'/> containing loops of small bowel <img src='img/arrows/WC.png'/>.*
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*Coronal NECT demonstrates the typical appearance of an inguinal hernia in the coronal plane with involvement of small bowel loops <img src='img/arrows/WS.png'/>.*
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*Coronal CECT demonstrates small bowel extending into an inguinal hernia <img src='img/arrows/WO.png'/> with a transition point <img src='img/arrows/WC.png'/> and dilatation of the proximal small bowel <img src='img/arrows/WS.png'/>, compatible with bowel obstruction.*
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*Coronal NECT demonstrates a sliding inguinal hernia containing a portion of the bladder <img src='img/arrows/WS.png'/>. Sliding inguinal hernias contain portions of partially retroperitoneal structures, such as the bladder, and care must be taken at surgery to avoid damage to these structures or their supplying vessels.*
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*Axial NECT demonstrates a right lower quadrant transplant kidney <img src='img/arrows/WS.png'/> with marked hydronephrosis <img src='img/arrows/WC.png'/>.*
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*Axial NECT in the same patient demonstrates the cause of the hydronephrosis with the right ureter <img src='img/arrows/WC.png'/> trapped and dilated within a right inguinal hernia.*
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*Grayscale ultrasound of the inguinal canal shows bowel loops <img src='img/arrows/WS.png'/> herniating into the right inguinal canal <img src='img/arrows/WO.png'/> with echogenic foci of gas in the lumen <img src='img/arrows/WC.png'/>. Note the relation of the hernia sac to the testis <img src='img/arrows/BO.png'/>.*
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*Axial CECT demonstrates the characteristic appearance of a mesh plug <img src='img/arrows/WS.png'/> utilized for inguinal hernia repair. This is a characteristic appearance and location, which should not be confused for an abnormal lymph node or mass.*
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### Additional Images
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*Axial CECT shows a hernia sac <img src='img/arrows/WS.png'/> lying anterior to the right femoral vessels. A contrast-opacified small bowel is present within the hernia, but no sign of bowel obstruction is seen.*
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*Axial CECT shows an inguinal hernia causing small bowel obstruction. Note the entrapped and thickened small bowel in the right inguinal hernia sac <img src='img/arrows/WS.png'/>.*
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*Axial CECT at a higher level in the same patient demonstrates a dilated small bowel <img src='img/arrows/WS.png'/> from obstruction.*
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*Axial CECT of a right inguinal hernia <img src='img/arrows/WS.png'/> contains herniated fat. The fat is somewhat "dirty" or infiltrated in appearance, suggesting incarceration or ischemia of herniated fat.*
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*Axial CECT at a higher level in the same patient demonstrates abdominal wall defect <img src='img/arrows/WS.png'/>.*
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*CECT shows an incarcerated small bowel with perforation within the inguinal hernia sac. Note the thickened small bowel within the large hernia sac <img src='img/arrows/WS.png'/>.*
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*Axial CECT shows a dilated small bowel entering the inguinal canal and the leaving collapsed bowel <img src='img/arrows/WS.png'/>.*
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*Axial CECT shows a "knuckle" of fluid-filled small intestine strangulated within the right inguinal hernia <img src='img/arrows/WS.png'/>.*
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*Axial CECT shows a left inguinal hernia containing only fat and spermatic cord.*
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*Small bowel follow-through shows a large portion of the small intestine within the scrotum due to a right inguinal hernia.*
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*Axial CECT shows a left inguinal hernia at the upper end of the inguinal canal. There is a mass effect due to the herniated fat and bowel.*
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*Axial CECT shows a left inguinal hernia containing a sigmoid colon. Also note the right thigh hematoma.*
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*Axial CECT shows a right inguinal hernia with the colon in the upper scrotum.*
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*Axial CECT in an older woman shows a left inguinal hernia, right obturator hernia <img src='img/arrows/WS.png'/>, and pessary <img src='img/arrows/WC.png'/>.*
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*Coronal CECT demonstrates a large right inguinal hernia <img src='img/arrows/WC.png'/> in a patient who reported a long history of a growing bulge in the groin. The hernia contains multiple small bowel loops, portions of the colon, and small ascites <img src='img/arrows/WS.png'/>.*
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*Axial CECT in an older man who presented with sepsis and a large right scrotal mass demonstrates a large scrotal abscess <img src='img/arrows/WS.png'/> from perforated incarcerated bowel within an inguinal hernia.*
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*Axial CECT in the same patient illustrates a collection of bowel <img src='img/arrows/WS.png'/> and omental fat <img src='img/arrows/WC.png'/> within the hernia sac.*
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*Coronal CECT demonstrates multiple dilated loops of small bowel <img src='img/arrows/WS.png'/> in the pelvis, compatible with small bowel obstruction.*
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*Coronal CECT in the same patient demonstrates that the small bowel extends into a right inguinal hernia <img src='img/arrows/WC.png'/> with a transition point in the hernia sac. This incarcerated hernia could not be manually reduced, and urgent surgery was performed for repair.*
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*Axial CECT in an older man who presented with a large groin mass and a small bowel obstruction demonstrates a large right inguinal hernia containing sections of the small bowel <img src='img/arrows/WS.png'/>, colon <img src='img/arrows/WC.png'/>, and omentum <img src='img/arrows/WO.png'/>.*
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*Barium small bowel follow-through study in a patient with a right inguinal hernia shows the herniated small bowel <img src='img/arrows/WO.png'/> lying over the right femoral head. Note the constriction of the bowel <img src='img/arrows/WC.png'/> as it passes through the inguinal ring.*
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