Abdominal Wall Hernias, Noninguinal

• • Typically manifests clinically with an asymptomatic bulge or small bowel obstruction

  • The abdominal wall defects are sometimes discovered during radiographic evaluation for vague abdominal discomfort or an unrelated condition

  • Incarceration and strangulation are frequently presenting symptoms due to the elusive nature of these fascial defects

Epidemiology

• • Noninguinal abdominal wall hernias are much less common than inguinal or incisional hernias

  • Littre and Richter hernias occur in the setting of other hernia and are not an anatomically distinct herniatype (ie, a hernia subtype)

  • Lumbar hernias occur most frequently in young athletic women

Symptoms and Signs

• • Spigelian hernia: Pain and abdominal wall bulge at the lateral edge of the rectus muscle at the level of the umbilicus

  • Lumbodorsal hernia: Persistent flank bulge (hernia sac usually filled with retroperitoneal fat)

  • -Grynfeltt: Superior lumbar triangle

    -Petit: Inferior lumbar triangle

  • Obturator hernia: Pelvic sidewall mass appreciated on rectal or pelvic exam; pain extending down medial aspect of the thigh on abduction, extension, or internal rotation of the knee indicates a positive Howship-Romberg sign

  • Perineal hernia: Typically manifests as easily reducible perineal bulges but may also include pain, dysuria, bowel obstruction, or perineal skin breakdown

  • Interparietal hernia: Abdominal wall mass that occurs primarily or in the setting of a muscle-splitting appendectomy incision; this hernia defect is often confused with an abdominal wall tumor

  • Sciatic hernia: Rarely appreciated externally; bowel obstruction is usually presenting symptom, and the hernia defect is discovered during abdominal exploration

  • Traumatic hernia: Ecchymosis and abdominal wall bulge detected in the setting of significant blunt abdominal trauma

  • Supravesicular hernia: Laterally displaced suprapubic mass associated with urinary or bowel obstruction symptoms

Imaging Findings

• • Imaging findings specific to type of hernia

  • US can detect an abdominal wall mass and differentiate between tumor, abscess, and hernia

  • CT scan most useful method for identifying noninguinal abdominal wall hernias and differentiating between tumor, abscess, hematoma, and hernia

• • Richter hernia: Any strangulated hernia in which only part of the bowel wall becomes ischemic and gangrenous, thus complete bowel obstruction does not occur; typically occurs in the setting of a ventral hernia

  • Littre hernia: A hernia that contains Meckel diverticulum in the hernia sac

  • Spigelian hernia: Acquired ventral hernia through the linea semilunaris, located at the junction between the rectus abdominals muscle and the abdominal oblique musculature

  • Lumbodorsal hernia: Hernia defects through the posterior abdominal wall at different levels in the lumbar region

  • -Grynfeltt: Superior lumbar triangle

    -Petit: Inferior lumbar triangle

  • Obturator hernia: Herniation through the obturator canal

  • Perineal hernia: Myofascial defects of the perineum, usually following perineal surgery

  • Interparietal hernia: Hernia between the layers of the abdominal wall

  • Sciatic hernia: Outpouching of the intra-abdominal contents through the greater sciatic foramen

  • Traumatic hernia: Direct blunt traumatic abdominal injury with resulting myofascial defect

  • Supravesicular ...