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High-resolution ultrasound of spigelian and groin hernias: a closer look at fascial architecture and aponeurotic passageways

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Journal of Ultrasonography

Édition 21 (2021): Edition 84 (January 2021)

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Article Category: review-article

Publié en ligne: 08 mars 2021

Pages: 53 - 62

Reçu: 08 oct. 2020

Accepté: 28 nov. 2020

DOI: https://doi.org/10.15557/jou.2021.0008

Mots clés
hernia, ultrasound, abdominal wall, groin

© 2021 Polish Ultrasound Society. Published by Medical Communications Sp. z o.o.

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Groin anatomy, anterior landmarks. Schematic drawing illustrates the respective arrangement and distal insertions of the anterior abdominal wall muscles (darker grays) and aponeuroses (lighter grays), including the obliquus externus (1) with its lateral (L) and medial (M) columns merging medially with the linea alba (A), the conjoint tendon (void arrowheads) of the obliquus internus (2) and the transversus abdominis (3). The aponeurosis of the obliquus internus is drawn discontinuous to allow cross visualization of the underlying transversus. Note the relationships of the aponeuroses with the rectus abdominis (4). The inguinal ligament (void arrows) gives insertion to the obliquus externus aponeurosis and separates the inguinal (up) from the crural (down) regions. After giving off the inferior epigastric vessels (black arrow), the common femoral artery (a) and vein (v) exit the pelvis crossing underneath the ligament. The femoral canal (asterisk) is a small opening roofed by the inguinal ligament that is reinforced medially by the Gimbernat’s (lacunar) ligament (not shown). The pectineus muscle (5) forms the floor, and the femoral vein its lateral wall. In a more lateral position, the iliacus muscle (6) and the tensor fasciae latae (7) arising from the anterosuperior iliac spine (S) are shown. Medially, the spermatic cord (SC) is seen emerging from the external inguinal ring

Groin anatomy, posterior landmarks (modified from Netter, Atlas of Human Anatomy 2018). Schematic drawing illustrates the anterior abdominal wall from a posterior view. The internal inguinal ring (white arrowhead) is shown as an opening crossed by the spermatic cord (SC). More medially, the femoral artery (a) and vein (v) leave the pelvis through the lacuna vasorum, passing on the undersurface of the inguinal ligament (white large arrow) and lateral to Gimbernat’s (lacunar) ligament (void arrowhead). Cranial to the inguinal ligament, the Hesselbach’s triangle (asterisk) is delimited by the ligament of Henle (void arrow) medially, the Hesselbach’s ligament (white arrowhead) and the inferior epigastric artery (1) and vein (2) laterally. After delimiting the side of the triangle, these vessels pierce the fascia of the rectus abdominis (4) at the level of the Douglas line (thin black arrows). The spigelian fascia (SF) and the sharp and vertically oriented myotendinous junction (spigelian line) of the transversus abdominis (dotted black arrows) are indicated. Laterally, the bulk of the iliopsoas complex (6) leaves the pelvis through the lacuna musculorum. Note the multilayered arrangement of the myofascial planes of the anterior abdominal wall consisting, from depth to surface, of the posterior leaf of the obliquus internus and transversus abdominis aponeurosis (3), the transversus abdominis muscle (5), the obliquus internus (6) and the obliquus externus (7). Star, anterosuperior iliac spine

Douglas line (arcuate line of rectus sheath or linea semicircularis). A, B. Transverse 18–5 MHz US images obtained cranial (
A
) and caudal (
B
) to the Douglas line demonstrate the relationship of the inferior epigastric artery (a) and vein (v) with the aponeurosis of the anterior abdominal wall muscles. A. the obliquus externus and the anterior leaf of the obliquus internus aponeurosis (void arrowheads) run toward the midline crossing over the muscle belly of the rectus abdominis (ReA), whereas the conjoint aponeurosis (white arrowheads) of the transversus and the posterior leaf of the obliquus internus reaches the linea alba passing on the undersurface of the rectus abdominis. B. the inferior epigastric artery (a) and vein (v) are seen running between the fascia transversalis (white arrowhead) and the parietal peritoneum (arrows), given that the aponeuroses of the abdominal wall muscles (void arrowheads) cross over the rectus abdominis (ReA). C. Magnified long-axis 18–5 MHz US image of the inferior epigastric artery demonstrates its passage across the Douglas line (large arrow), with a small collateral branch (narrow arrow) arising at this level. Note the conjoint transversus and the deep leaf of the obliquus internus aponeurosis (arrowheads) running on the undersurface of the rectus abdominis cranial to the line — Douglas line (arcuate line of rectus sheath or linea semicircularis). A, B. Transverse 18–5 MHz US images obtained cranial ( A ) and caudal ( B ) to the Douglas line demonstrate the relationship of the inferior epigastric artery (a) and vein (v) with the aponeurosis of the anterior abdominal wall muscles. A. the obliquus externus and the anterior leaf of the obliquus internus aponeurosis (void arrowheads) run toward the midline crossing over the muscle belly of the rectus abdominis (ReA), whereas the conjoint aponeurosis (white arrowheads) of the transversus and the posterior leaf of the obliquus internus reaches the linea alba passing on the undersurface of the rectus abdominis. B. the inferior epigastric artery (a) and vein (v) are seen running between the fascia transversalis (white arrowhead) and the parietal peritoneum (arrows), given that the aponeuroses of the abdominal wall muscles (void arrowheads) cross over the rectus abdominis (ReA). C. Magnified long-axis 18–5 MHz US image of the inferior epigastric artery demonstrates its passage across the Douglas line (large arrow), with a small collateral branch (narrow arrow) arising at this level. Note the conjoint transversus and the deep leaf of the obliquus internus aponeurosis (arrowheads) running on the undersurface of the rectus abdominis cranial to the line

Spigelian line and fascia. A. Transverse 18–5 MHz US image demonstrates the relationship of the obliquus externus (a), obliquus internus (b), transversus abdominis (c) and their corresponding aponeuroses (white arrowheads, void arrowheads and thin white arrows respectively) with the rectus abdominis (ReA). The spigelian line (large white arrow) represents the level of the myotendinous junction of the transversus abdominis, whereas the spigelian fascia (SpF) consists of the transversus aponeurosis between the spigelian line and lateral border of the rectus abdominis (ReA). B. Transverse 22–8 MHz US image obtained distal to the Douglas line shows the flat aponeuroses of the obliquus externus (void arrowheads), obliquus internus (white arrowhead) and transversus abdominis (thin white arrow) as they cross over the rectus abdominis

Spigelian hernia. A. Schematic drawing illustrates a small bowel loop (void arrow) herniating through the spigelian fascia (black arrow). After crossing the transversus abdominis (1) and the obliquus internus (2), the hernia sac expands deep to the obliquus externus aponeurosis (3). ReA, rectus abdominis. B. Axial CT scan in a patient with recurrent episodes of abdominal pain and discomfort demonstrates a spigelian hernia (asterisk), protruding through a cleft in the spigelian fascia (arrowheads). The intact obliquus externus aponeurosis (void arrows) bounds the herniation, making it occult at physical examination. More laterally, the flat bellies of the transversus abdominis (1), obliquus internus (2), and obliquus externus (3) are seen

Inguinal region and Hesselbach’s triangle. Schematic drawing offers a closer look of the anatomical structures surrounding the spermatic cord (SC) in the inguinal canal. In this drawing, the aponeuroses of the obliquus externus (1) and the conjoint ones of the obliquus internus (2) and transversus abdominis (3) are artificially displaced by pins for better visualization of the field of interest. The spermatic cord (SC) is depicted between the internal (curved arrow) and external (arrowhead) inguinal rings, travelling across the aponeurotic layers and close to the inguinal ligament (void arrows). Note the Hesselbach’s triangle (star), the base of which is lateral and formed by the inferior epigastric vessels (black arrow)

Inguinal ligament. Oblique extended field-of view 18–5 MHz US image oriented between the anterosuperior iliac spine and the pubic tubercle (asterisk) demonstrates the inguinal ligament (white arrowheads) in its long-axis as it crosses the groin. The inguinal ligament bridges two wide passageways separated by the iliopectineal ligament (not shown). The lateral (lacuna musculorum) is crossed by the tendon (1) and most distal part of the myotendinous junction (2) of the psoas, the medial (3) and lateral (4) components of the iliacus, the femoral (n) and lateral femoral cutaneous nerves. The medial (lacuna vasorum) houses the femoral artery (a) and vein (v), the pectineus muscle (5), and the ligament of Cooper (void arrow) that is an extension of the inguinal ligament inserting into the pubic ramus and forming the floor of the femoral ring (star)

Inguinal canal: internal inguinal ring level. Transverse 18–5 MHz US image demonstrates the spermatic cord (large void arrows) emerging from the internal inguinal ring lateral to the external iliac artery (a) and vein (v). Several structures can be recognized inside the inguinal canal, including arteries (1), veins (2), and small superficial groin nerves (narrow arrows). Whereas the genital branch of the genitofemoral nerve travels from the internal to the external inguinal ring, thus crossing the whole inguinal canal, it is worth considering that the ilioinguinal nerve does not enter the canal through the internal ring and crosses only part of it. The inferior epigastric artery (white large arrow) runs in a more medial position relative to the internal inguinal ring, on the undersurface of the rectus abdominis (ReA)

Inguinal canal: middle third and external inguinal ring levels. A. Short-axis 18–5 MHz US scan shows the proximal third of the spermatic cord (dotted line) travelling inside the inguinal canal at the level of origin of the inferior epigastric vessels (arrows) from the external iliac artery (a) and vein (v). Hesselbach’s triangle appears as a fat-filled area (asterisk) between the lateral border of the rectus abdominis (ReA) and the inferior epigastric vessels, where no structures other than the fascia transversalis restrain the abdominal content from protruding. The distal aponeurosis (white arrowheads) of the obliquus externus is shown bridging over the inguinal canal. B. Short-axis 18–5 MHz US obtained at the level of the pubic tubercle (asterisk) demonstrates the spermatic cord (dotted line) approaching the external inguinal ring deep to the aponeurosis of the obliquus externus (void arrowheads). More medially, the insertion of the rectus abdominis (ReA) reinforced by fibers from the adductor longus and the contralateral obliquus externus appears as an echogenic band overlying the pubis

Direct and indirect inguinal hernias. A. Schematic drawing of the groin illustrates the portals of direct (a) and indirect (b) inguinal hernias (modified from Netter, Atlas of Human Anatomy 2018). The indirect hernia runs across the whole inguinal canal (6), travelling from the internal (void arrowheads) to the external (black arrowheads) inguinal rings and displacing the spermatic cord (SC) on the side. The relationship of the inguinal canal with the series of local aponeurotic layers related to the fascia transversalis (1), transversus abdominis (2), obliquus internus (3) and obliquus externus (4) is illustrated. The direct hernia is seen forcing a passage through the fascia transversalis, in an area where this latter is not supported by any reinforcing structures, and expanding outside the inguinal canal, on the lateral side of the rectus abdominis (5). Void arrow, inguinal ligament. B, C. Oblique axial reformatted CT images from two different patients demonstrate the different pathways of direct (
B
) and indirect (
C
) inguinal hernias. B. The neck (asterisk) of the indirect hernia enters the canal external to the inferior epigastric artery (white arrowhead) and vein (void arrowhead). The spermatic cord (thin arrow) is displaced on the side of the canal. Arrow, groin lymph node. C. The neck (asterisk) of the direct hernia is seen expanding medial to the inferior epigastric artery (white arrowhead) and vein (void arrowhead). B, C. The relationship between the external iliac artery (a) and vein (v) and the hernia portals are also illustrated — Direct and indirect inguinal hernias. A. Schematic drawing of the groin illustrates the portals of direct (a) and indirect (b) inguinal hernias (modified from Netter, Atlas of Human Anatomy 2018). The indirect hernia runs across the whole inguinal canal (6), travelling from the internal (void arrowheads) to the external (black arrowheads) inguinal rings and displacing the spermatic cord (SC) on the side. The relationship of the inguinal canal with the series of local aponeurotic layers related to the fascia transversalis (1), transversus abdominis (2), obliquus internus (3) and obliquus externus (4) is illustrated. The direct hernia is seen forcing a passage through the fascia transversalis, in an area where this latter is not supported by any reinforcing structures, and expanding outside the inguinal canal, on the lateral side of the rectus abdominis (5). Void arrow, inguinal ligament. B, C. Oblique axial reformatted CT images from two different patients demonstrate the different pathways of direct ( B ) and indirect ( C ) inguinal hernias. B. The neck (asterisk) of the indirect hernia enters the canal external to the inferior epigastric artery (white arrowhead) and vein (void arrowhead). The spermatic cord (thin arrow) is displaced on the side of the canal. Arrow, groin lymph node. C. The neck (asterisk) of the direct hernia is seen expanding medial to the inferior epigastric artery (white arrowhead) and vein (void arrowhead). B, C. The relationship between the external iliac artery (a) and vein (v) and the hernia portals are also illustrated

Femoral ring and femoral canal. A, B. Transverse 18–5 MHz US images demonstrate the anatomical boundaries of the femoral ring (star) and canal (dotted line). The femoral ring forms the gate between abdomen and thigh. It is delimited by the Cooper’s ligament (void arrows) posteriorly and the inguinal (white arrowheads) and Gimbernat’s ligaments (thin white arrow) anteromedially. Soon after crossing the ring, the femoral canal lies anterior to the pectineus (asterisk) and medial to the femoral artery (a), vein (v) and branches of the femoral nerve which are invested by the femoral sheath to form a neurovascular compartment in continuity with the lacuna vasorum

Femoral hernia. A. Schematic drawing of the groin illustrates a small bowel loop (white arrows) crossing the femoral ring and expanding in the femoral canal, between the Gimbernat’s ligament (white arrowheads), the inguinal ligament (black arrow), and the femoral vein (v). The femoral artery (a) runs more laterally in the lacuna vasorum, alongside the iliopectineal ligament (black arrowhead). In a more external position, note the lacuna musculorum (LM). 1, inferior epigastric artery; 2, inferior epigastric veins; obt, obturator foramen. B. Oblique axial reformatted CT in a patient who had acute intestinal obstruction demonstrates a distended bowel loops (b) herniating inside the femoral canal. The bulk of the hernia content compresses the adjacent femoral vein (white arrowheads), whereas the femoral artery (void arrowhead) remains unaffected. Asterisk, contralateral femoral canal

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