Transcript Chapter 12. The Retroperitoneum Part B

SON 2112
ULTRASOUND OF THE ABDOMEN PART II
CHAPTER 12: RETROPERITONEUM PART B
HHHOLDORF
OUTLINE
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The Abdomen - Overview
Abscess
Biloma
Ascites
Lymphocele
Urinoma
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Pseudomyxoma Peritonei
Hematoma
Lymphoma
Thorax (non-Cardiac Chest)
Baker’s cyst
Rectus Sheath Hematoma
Abdominal Wall neoplasm
Hernias/Inguinal Hernia
BOUNDARIES OF THE ABDOMINAL
CAVITY
 Superiorly….Diaphragm
 Inferiorly….Pelvis
 Anteriorly…Abdominal
Wall muscle
 Posteriorly…Vertebral column, ribs, Iliac fossa.
SURFACE LANDMARKS OF THE ANTERIOR
ABDOMINAL WALL
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Xiphoid process
 Palpated where the costal margins meet at the infra-sternal angle
Costal margins
 Curved lower margin of the thoracic wall
Iliac crest
 Palpated and ends in front at the anterior iliac spine and behind at
the posterior iliac spine
Pubic symphysis
 Cartilaginous joint that lies in the midline between bodies of the
pubic bones
Linea albea
 Midline fibrous band that extends from the pubic symphysis to the
Xiphoid process
Umbilicus
 Remnant of the fetal umbilical cord
ANATOMY OF ANTERIOR ABDOMINAL
WALL
From outermost layer working in:
 Skin- epidermis is highly echogenic
 Superficial fascia
 Subcutaneous fat- relatively anechoic.
 Muscle layers
 Transversalis fascia
 Extraperitoneal fat
IMAGES OF THE ANTERIOR ABDOMINAL WALL
ANTERIOR ABDOMINAL MUSCLES CONT.
Rectus sheath- Fibrotic band which extends from the
Xiphoid process to the symphysis pubis.
 Linea Alba- The rectus sheath joins in the midline to
form linea alba, separating the rectus muscles in the
midline.
 Linea semilunaris- A curved tendinous line placed one
on either side of the rectus Abdominis.
 Arcuate line- Located midway between the umbilicus
and symphysis pubis. At this level the post caudal
portion of the rectus sheath ends and the joining of all
three muscles pass in front of the rectus muscle.

LINEA ALBA
ARCUATE LINE
POSTERIOR ABDOMINAL WALL MUSCLES
 Psoas
Muscle
 Medial
and posterior to kidneys
 Lateral to spine
 Quadratus
 Adjacent
Lumborum
to the iliac crest
 Depending on the level; posterior to kidneys,
colon, psoas m.
 Tapers cephalically (Sag.)
 Iliacus Muscle- within the iliac space
 iliopsoas Muscle- A convergence of the iliacus
and psoas muscle.
POSTERIOR ABDOMINAL WALL MUSCLES
DIAPHRAGM
A large muscle
 Forms partition between thoracic and
abdominal cavities
 Dome shaped
 Moves with respiration- Due to large effusion
or bronchial Cancer the diaphragm might not
move with respiration and become flatten or
Convex
 Normal US- concave, echogenic
 Appearance can change due to hernia,
pleural effusion, COPD (Chronic obstructive
pulmonary disease)
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DIAPHRAGM CONT.
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
The Aorta, IVC, esophagus pass through individual
openings called Hiatuses in the diaphragm.
Crura: Are elongated muscular bands that arise from
the lumbar vertebrae and insert into the diaphragm and
connect the diaphragm and the spinal column. On the
Us Crus appears as low level echoes.
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The right crus- Post. to IVC
The left crus- Ant. to Aorta, proximal to the celiac trunk
Attachments:
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Attached to Xiphoid process in front
Attached to costal margins at sides
Rt. & Lt. parts insert into the central tendon.
HOW DOES THE DIAPHRAGM MOVE WITH
RESPIRATION? HOW DOES THIS AFFECT LOWER
EXTREMITY VENOUS RETURN?
ABSCESS
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The sonographic appearance of an abscess is quite variable. Typically, an abscess is
a complex mass (solid or cystic). Debris, septations and gas can be seen within the
abscess. The boarders of an abscess are typically irregular.
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Gas within the abscess may produce a reverberation (comet-tail) artifact.
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Abscesses typically demonstrate posterior enhancement depending on the cystic
component of the abscess.
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The most reliable findings in patients with abscesses are:
Presence of fever
Increased white blood cell count
ABSCESS:
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Variable appearance on US:
 Generally
hypo to anechoic
 some may contain internal debris.
 Usually has acoustic enhancement.
 Presence of gas produces bright echogenic
reflections and dirty shadow
INTRA-ABDOMINAL ABSCESS
INTRA-ABDOMINAL ABSCESS CT
BILOMA
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Bilomas are extrahepatic collections of extravasated bile. They are caused
by abdominal trauma, gallbladder disease, or biliary surgery.
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Bilomas are predominantly cystic masses located in the right upper
quadrant.
BILOMA:
Extrahepatic collection of extravagated bile.
 Causes: trauma, GB disease, biliary surgery.
 Ultrasound appearance:
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 Anechoic
mass with sharp borders & good through
transmission.
 May contain some debris.
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Located in RUQ or mid abdomen.
BILOMA ON ULTRASOUND
BILOMA ON CT
ASCITES
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Ascites is the excessive accumulation of serous fluid in the peritoneal cavity.
The mechanisms that produce Ascites are complex and incompletely
understood.
Two mechanisms that produce Ascites are:
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Low serum osmotic pressure (protein Loss)
High portal venous pressure
Causes of Ascites include:
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Cirrhosis (most common cause)
Hypoalbuminemia (decreased protein)
Budd-Chiari Syndrome
Heart failure
Cancer
Nephrotic syndrome (protein loss)
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Hypoalbuminemia (low protein) can be the result of liver failure,
nephritic syndrome or malnutrition.
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Transjugular intrahepatic portal systemic shunting (TIPS) can
successfully treat Ascites by lowering portal pressure.
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Ascites is commonly found at the
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Inferior aspect of the right lobe of the liver
Morison’s pouch
Pelvic cul de sac
Paracolic gutters
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Gallbladder wall thickening is frequently seen with Ascites
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Benign Ascites is indicated by freely floating bowel. With
malignant Ascites, the bowel loops are tethered or matted to
the posterior abdominal wall surrounded by complex or
loculated fluid collections.
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Pleural effusion- fluid collection superior to
the diaphragm
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Ascites- Excessive accumulation of serous
free fluid surrounding or interposed between
organs. Collects Inferior to the diaphragm.
Over 90% are due to Cirrhosis, Neoplasm, or
CHF.
Other causes: Hypoalbuminemia, endocrine
disease, Pancreatic Ascites may develop due
to chronic pancreatitis or Pancreatic
pseudocyst.
ASCITES: TRANSUDATIVE VS. EXUDATIVE
Transudative ascites is defined as having less
than 3 g of protein per 100 ml of fluid. It is, as
its name would suggest, a transudate - a result
of raised hydrostatic pressure forcing fluid out
of blood vessels.
 Causes include: cardiac failure.
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Exudate ascites is defined as ascites with a
protein content of greater than 3g protein per
100ml of fluid.
 Possible causes of exudate ascites include:
malignant disease. pyogenic infection.
tuberculosis.
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ASCITES CONT.
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Transudative
 US:
Anechoic region in peritoneal cavity.
 Collects in the most dependent area of the
abdomen
 First seen in the Morrison’s pouch or pouch of
Douglas.
 then seen in Paracolic gutters.
 Freely mobile, bowel loop can be seen floating
within ascites.
ASCITES CONT.

Exudative
 Due
to inflammation and malignancy.
 US: May have Septations, Echogenic debris,
loculation of fluid, matted bowel loops.
 Loculated ascites: is no compressible, does not
move with change of position.
 DD: Abscess, cystic Neoplasm, hematoma,
lymphocele.
ASCITES
Urine ascites: results from renal transplant,
pt. on chronic hemodialysis.
 Bloody Ascites: caused by ruptured Ao,
ruptured ectopic pregnancy…
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ASCITES IN SEVERAL ABDOMINAL
COMPARTMENTS
IMAGE OF BENIGN ASCITES
MALIGNANT ASCITES
LYMPHOCELE
Lymphoceles are complications of
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Renal transplantation
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Gynecologic surgery
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Vascular Surgery
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Urological Surgery
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Caused by leakage of lymph from a renal allograft (transplant) or by a
surgical disruption of the lymphatic channels.
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Differential diagnosis includes any fluid collection such as loculated Ascites,
Urinoma, hematoma, or abscess. The presence of internal echoes within the
collection is more consistent with an abscess or hematoma than with a
Lymphocele.
LYMPHOCELE
A lymph–filled cystic mass with no epithelial
lining.
 Causes:
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 Complication
of surgery ( involving-vascular,
urological, gynecological, renal.)
 Leak by surgical disruption of the lymph.
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US: round,/elliptical, anechoic, septations seen
frequently, w/ good through transmission
LYMPHOCELE.
URINOMA
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An Urinoma is a collection of urine which is located outside of the kidney or
bladder. Urinomas are caused by renal trauma, renal surgery, or from an
obstructing lesion.
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Most commonly associated with
Renal transplantation.
Posterior urethral valve obstruction
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My accumulate directly after a renal transplant due to an anastomotic leak
of the ureter.
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Its sonographic appearance is similar to a Lymphocele.
URINOMA:
A collection of urine, located outside the kidney
or bladder due to an obstructing lesion.
 Causes : Renal trauma, renal surgery, renal
transplant.
 US: elliptical anechoic mass located in
perinephric space.
 DD: Lymphocele.

A URINOMA
PSEUDOMYXOMA PERITONEI
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The filling of the peritoneal cavity with mucinous material and
gelatinous Ascites. Tumor implants are found on the peritoneal
surfaces. Bowel loops will be matted to the posterior abdominal
wall.
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Caused by metastasis or rupture of a mucinous
cystadenocarcinoma of the ovary or mucinous tumor of the
appendix. This is referred to as malignant Ascites.
AN ULTRASOUND IMAGE OF A PSEUDOMYXOMA
PERITONEI
A CT SCAN OF A PSEUDOMYXOMA PERITONEI.
HEMATOMAS
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A hematoma is a collection of blood which is usually confined to an organ,
tissue or space.
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The ultrasound appearance of hematomas is variable and depends on the
age of eth collection.
Fibrin invasion causes hematomas to appear hyperechoic. Gradual
hemolysis eventually creates an anechoic appearance. Organization of clot
or fragmentation of the clot will produce irregular echoes. Calcifications are
often associated with longstanding hematomas.
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A decrease in the hematocrit level indicates the presence of a hematoma.
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Hematocrit is the volume of red blood cells fond in 100 ml of blood. Blood
spillage outside the circulatory system will result in a decreased hematocrit
AN NEW HEMATOMA – TENNIS LEG
AN OLD HEMATOMA- TRANSPLANTED KIDNEY
HEAMTOMA- ECHOFILLED
LYMPHOMA
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Lymphoma encompasses two groups of neoplasms:
Non-Hodgkin Lymphoma (NHL)
Hodgkin disease
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Both Hodgkin’s lymphoma and non-Hodgkin’s lymphoma are a type of
cancer that begins in a subset of WBCs called lymphocytes, which are an
important part of the immune system.
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The main difference between Hodgkin’s and non-Hodgkin’s is in the specific
lymphocyte each one involves.
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If a Reed-Sternberg cell is detected, the lymphoma is classified as
Hodgkin’s. If the RS cell is not seen, then it is Non-Hodgkin’s, and the
treatment and outcome for each type can be quite different.
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Lymph nodes sonographically appear as an anechoic/hypoechoic mass
containing a central echogenic foci. Lymph tissue is not associated with
acoustic enhancement.
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The SANDWICH or MANTLE sign is the presence of peri-vessel lymphoma.
Lymphomatous nodules typically cluster anterior and posterior to linear
structures such as the aorta or the Superior Mesenteric Artery. This finding
can be clinically important as it is found more frequently with non-Hodgkin
lymphoma than with Hodgkin’s lymphoma.
Findings associated with non-Hodgkin lymphoma
include:
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Peripheral lymphadenopathy
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Splenomegaly
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Hepatomegaly
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Cytopenia – A reduction in the number of blood cells.
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Abdominal mass causing bowel obstruction
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Hydronephrosis due to retroperitoneal nodes.
NORMAL LYMPH NODES
THE SANDWICH (MANTLE) SIGN
THORAX (NON-CARDIAC CHEST)
Ultrasound imaging is utilized in the thorax for:
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Identifying a pleural effusion
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Identifying solid pleural masses
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Identifying a pneumothorax
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Localization for Thoracentesis
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Localization of pleural fluid is performed with the patient in a sitting
position. A dorsal intercostals space is marked so that a puncture can easily
access the fluid away from the diaphragm

Solid pleural masses and loculated thoracic fluid are typically seen fixed
away from the diaphragm, opposed to free fluid that accumulated in the
recesses of the diaphragm.
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A pneumothorax is identified with the absence of gliding of the parietal and
visceral pleura and the presence of a comet tail artifact between these
layers. This exam is typically performed with a trauma patient. With the
patient in a supine position, air can be located on the anterior medial
location of the thorax.
PLEURAL EFFUSION
BAKER’S CYST
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A Baker’s cyst is a collection of synovial fluid in the popliteal fossa. It is
commonly located in the medial aspect of the popliteal fossa. They may also
extend downward into the calf muscles.
Causes include
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Rheumatoid arthritis

Osteoarthritis

Overuse of the knees

Symptoms may be mistaken for deep venous thrombosis due to pain and
swelling behind the knee and the upper calf.
AN IMAGE OF A BAKER’S CYST
RECTUS SHEATH HEMATOMA

The rectus Abdominis muscles are two longitudinally oriented muscles
extending from the Xiphoid process to the pubic bone. They are encased in a
sheath anteriorly and posteriorly. These sheaths join at the midline to form
the LINEA ALBA.

The Anterior and posterior rectus sheath extend from the costal margin to
the arcuate line (Semi-circular line), which is located midway between the
umbilicus and the symphysis pubis, where the posterior wall of the sheath
ends.
RECTUS SHEATH HEMATOMA

Posttraumatic
 Direct
trauma; surgery
 Sudden vigorous abdominal contraction- seizure,
coughing, sneezing

Spontaneous
 Anticoagulants
therapy is the most common cause
of S. rectus sheath hematoma
 Bleeding disorders
 pregnancy
RECTUS SHEATH HEMATOMA
CONT.
US
Appearance: Depends on the relation
to Arcuate line, Age and the transducer.
 Above
Arcuate line hematoma is ovoid, does not
cross midline.
 Below Arcuate line can spread across and even to
pelvis, forming large mass, compressing the urinary
bladder.
HEMATOMA:

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
Collection of blood , usually confined to an organ, tissue, space.
Causes:
 Trauma or surgery- most common in pt. on anticoagulant.
 Hemophiliacs, leukemic.
US- variable depending on the age of the bleed:
 Fresh is more echogenic
 Old is anechoic,
 Between these stages clot can be inhomogeneous.
 Very old H. can become hypoechoic because of continued clot lysis,
or have calcification.
 Subcapsular H. retain the shape of the organ they surround.
 Peritoneal H. can be ovoid or crescent.
Lab.-There is a drop in patients hematocrit level.

A rectus sheath hematoma is a result of a tear in the epigastric vessels or
the muscle fibers of the rectus abdomens.
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A rectus muscle hematoma superior to the arcuate line is confined between
the anterior and posterior sheaths and should not move across eth midline
due to the linea alba.

A rectus muscle hematoma inferior to the arcuate line will extend into the
pelvis mimicking pelvic pathology causing external compression on the
urinary bladder.
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As with all hematomas, the sonographic appearance is variable depending
on the age of the bleed.
Rectus Sheath hematomas occur in a variety of conditions such as:

Trauma

Pregnancy

Surgical Injury

Anticoagulation therapy

Long term steroid therapy

Heavy physical actively

Violent coughing
CT IMAGE OF A RECTUS SHEATH HEMATOMA
CLINICAL ASSESSMENT OF A RECTUS SHEATH
HEMATOMA
RSH- ULTRASOUND
ABDOMINAL WALL NEOPLASMS
Uncommon
 Desmoid tumor:
 Most
common benign tumor.
 Arises from fascia or aponeurosis of muscle.
 Seen commonly in people with history of
previous abd. surgery.
 70% seen between age of 20-40 years. 3:1
female preponderance

Other Benign tumors are; Neuroma, Lipoma,
Neurofibroma
ABDOMINAL WALL NEOPLASMS CONT.
Metastatic Melanoma: Is the most common
malignant subcutaneous nodule.
 Other malignancies may locally invade from
pleura, peritoneum, diaphragm (mesothelioma,
rhabdomyosarcoma, fibrosarcoma), or intraabdominal organs like colon.
 Mets from: lymphoma, CAs of lung, breast,
ovary and colon are less common

HERNIAS
Inguinal
 Ventral
 Spigelian
 Lumbar
 Incisional
 Femoral

TYPES OF HERNIAS
WHAT IS AN INGUINAL HERNIA?

An inguinal hernia occurs when tissue pushes
through a weak spot in your groin muscle. This
causes a bulge in the groin or scrotum. The
bulge may hurt or burn.
INGUINAL HERNIA


Occurs in the inguinal canal which extend from the deep
inguinal ring (a defect in the transversalis m. fascia ant.
To the femoral vessels and above the inguinal ring) to
the superficial Inguinal ring (an opening in the
aponeurosis of the ext. oblique m.)
Inguinal hernias can be direct or indirect and US can not
distinguish them, but it can distinguish them from other
inguinal canal pathologies.


ex. undescended testicles, varicoceles.
Both direct and indirect inguinal hernias can extend into
the scrotum.
SYMPTOMS

The main symptom of an inguinal hernia is a bulge in
the groin or scrotum. It often feels like a round lump.
The bulge may form over a period of weeks or months.
Or it may appear all of a sudden after you have been
lifting heavy weights, coughing, bending, straining, or
laughing. The hernia may be painful, but some hernias
cause a bulge without pain


Most inguinal hernias occur because an opening in
the muscle wall does not close as it should before
birth.
That leaves a weak area in the belly muscle. Pressure
on that area can cause tissue to push through and
bulge out. A hernia can occur soon after birth or much
later in life

The diagnosis of inguinal hernia is usually based on
the patient’s medical history and a physical exam.
Tests such as ultrasound and CT scans are not usually
needed to diagnose an inguinal hernia. In most cases,
a doctor can identify an inguinal hernia during
a physical exam.
THE INFERIOR EPIGASTRIC ARTERY
INDIRECT INGUINAL HERNIA

Exits through the deep inguinal ligament ring
and is lateral to the Inferior Epigastric Artery
and courses through the inguinal canal.
INDIRECT
DIRECT INGUINAL HERNIA
Protrudes through a weakened inguinal canal
floor medial to the Inferior epigastric artery.
DIRECT
DIRECT VS. INDIRECT
INGUINAL HERNIA CONT.

Direct
 Protrudes
through a weakened inguinal canal floor
medial to the IEA (Inferior epigastric artery).

Indirect
 Exits
via deep inguinal ligament ring(lat to IEA) &
courses through the inguinal canal.
PROTOCOL

Ultrasound examination of the inguinal region with the patient in the supine
and upright positions and with the Valsalva maneuver has been reported to
have a diagnostic sensitivity and specificity of greater than 90 percent.

The ultrasound examination may also be helpful in differentiating an
incarcerated hernia from a pathologic lymph node or other cause of a firm,
palpable mass.
WHAT IS AN INGUINAL HERNIA?

An inguinal hernia occurs when tissue pushes
through a weak spot in your groin muscle. This
causes a bulge in the groin or scrotum. The
bulge may hurt or burn.
WHAT ARE THE SYMPTOMS?

The main symptom of an inguinal hernia is a
bulge in the groin or scrotum. It often feels like
a round lump. The bulge may form over a
period of weeks or months. Or it may appear all
of a sudden after you have been lifting heavy
weights, coughing, bending, straining, or
laughing. The hernia may be painful, but some
hernias cause a bulge without pain
WHAT CAUSES AN INGUINAL HERNIA?

Most inguinal hernias happen because an
opening in the muscle wall does not close as it
should before birth. That leaves a weak area in
the belly muscle. Pressure on that area can
cause tissue to push through and bulge out. A
hernia can occur soon after birth or much later
in life
RIGHT INGUINAL HERNIA
EXAMS & TESTS
The diagnosis of inguinal hernia is usually
based on the patient’s medical history and a
physical exam.
 Tests such as ultrasound and CT scans are not
usually needed to diagnose an inguinal hernia.
In most cases, a doctor can identify an inguinal
hernia during a physical exam.

INDIRECT INGUINAL HERNIA

exits through the deep
inguinal ligament ring and is
lateral to the inferior
epigastric artery and courses
through the inguinal canal.
DIRECT INGUINAL HERNIA

protrudes through a
weakened inguinal canal
floor medial to the Inferior
epigastric artery.

Difference between direct
and indirect cannot be seen.
INDIRECT & DIRECT INGUINAL HERNIA
LEFT INGUINAL HERNIA
HERNIAS
WITH RELATION TO ULTRASOUND
Ultrasound may be ordered to diagnose a hernia or
to characterize the contents of a hernia and
determine its reducibility.
 The ultrasound examination is dynamic because it
is performed in real time, showing motion live, and
because it can be performed while the patient is
lying on his/her back or standing upright.
 It can also be performed when the patient is
breathing quietly or straining vigorously.
 Ultrasound can be performed while the hernia is
being compressed with the ultrasound transducer.

CT and MR scans, on the other hand, can only be
done with the patient lying on his/her back and
generally without straining.
Because of the ability of ultrasound to show motion
during dynamic maneuvers, ultrasound has several
advantages over more expensive CT and MR scans
in evaluating for groin and anterior abdominal wall
hernias.
•Ultrasound, like CT and MR, can show larger nonreducible hernias, but can also smaller show
reducible hernias that CT and MR cannot show.
•Because ultrasound images show real time motion,
we can see reducible hernias moving in and out
during dynamic maneuvers.
•During the ultrasound examination, any hernia that is
found can be compressed with the ultrasound probe to
determine if the hernia is reducible or tender. CT and
MR, on the other hand, even when they show a hernia,
cannot determine whether the hernia is tender.
Tenderness is important, because hernias are so
common, that we often find “incidental” small hernias
that are not the cause of the patient’s pain. If a hernia
is tender when compressed by the ultrasound probe, it
is far more likely that the hernia is, indeed, the cause
of pain, and not merely a common incidental finding.
LONG





Distal inguinal canal
Epididymal head
Testicle-Medial, Mid, Lateral
Epididymal tail
Measure length pole to pole
PROTOCOL
TRANS




Epididymal head
Testicle- Upper, Mid, Lower
Epididymal tail
Measure transverse and AP
PROTOCOL







Color Doppler each testicle in longitudinal
Make sure to use same color gain throughout study
Measure all masses and cysts and large hydroceles in 3
dimensions
Suspected Inguinal Hernia- Scan up into inguinal canal.
Look for loops of bowl or herniate knuckles of
mesenteric fat
Undescended Testicles- Scan both hemiscrotum. If
testicles are absent, scan inguinal canals up into pelvis.
Valsalva may show hernia
Annotate ALL images
ULTRASOUND

Ultrasound examination of the inguinal region with
the patient in the supine and upright positions and
with the Valsalva maneuver has been reported to
have a diagnostic sensitivity and specificity of
greater than 90 percent.

The ultrasound examination may also be helpful in
differentiating an incarcerated hernia from a
pathologic lymph node or other cause of a firm,
palpable mass.
PATIENT PREP FOR INGUINAL HERNIA REPAIR

Patients will have standard preoperative blood
and urine tests, an electrocardiogram and a chest
x ray to make sure that the heart, lungs, and major
organ systems are functioning well. A week or so
before surgery, medications may be discontinued,
especially aspirin or anticoagulant drugs. Starting
the night before surgery, patients must not eat or
drink anything. Once in the hospital, an IV may be
placed into a vein in the arm to deliver fluid and
medication during surgery. A sedative may be
given to relax the patient
VENTRAL HERNIA

Acquired
 Obese,

elderly, previous trauma, surgery
Congenital
 Gastroschisis
 isolated,
 Rt
side of the umbilical cord
 Omphalocele
 Three
times more common
 Mid Line at the site of umbilical cord insertion
 Covered with a membrane
 Associated with other organ malformations
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Gastroschisis- Umbilical cord inserts normally into the fetal abdomen
(short arrow), adjacent to non-dilated exteriorized bowel (long arrow).
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Gastroschisis- Exteriorized bowel loops (arrow), partly separated by
fluid and not covered by a membrane.
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Omphaloceles occur in approximately 1:4,000 live births, and
include a spectrum of midline defects that range from large (usually
containing liver and bowel) to small (which may contain only 1 or 2
bowel loops).
The exteriorized viscera are contained by an amnio-peritoneal
membrane, and the umbilical cord inserts midline into the sac.
Features most predictive of prognosis are other serious
malformations (expected in 50% to 75% of affected fetuses,
including cardiac malformations in 30% to 35%) and chromosomal
abnormalities (approximately 10% to 20%), mainly Trisomies 18
and 13.
Although "bowel-only" omphaloceles are generally smaller, less
conspicuous sonographically, and often easier to repair postnatally,
the rate of chromosomal abnormalities (perhaps 70% to 80%) is 8
to 10 times higher than that found in fetuses in whom the
omphaloceles contain liver within herniated sac.
Be aware that small bowel-only omphaloceles may contain only one
or two loops of bowel that have migrated into the cord so that the
abnormality may not be recognized solely by examination of the
cord insertion into the fetal abdomen. Thus, examination of the
umbilical cord beyond the fetal abdomen for several centimeters is
prudent.
ULTRASOUND IMAGE DEMONSTRATING
OMPHALOCELE CONTAINING LIVER(L)
THE SPIGELIAN LINE
SPIGELIAN HERNIA
The only spontaneous hernia of the lateral
abdominal wall.
 Due to a defect in the layers of flat broad
tendons of transversus abdominis muscle
lateral to the rectus sheath.
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FEMORAL HERNIA
Patients have groin pain and no palpable mass.
 The mass is demonstrated medial to the
femoral vein.
 Differential Diagnosis: Hematoma,
Pseudoaneurysm, AV fistula, Lipoma, Lymphnode, saphenous varices.
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