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Spigelian hernias are said to be a rare condition of the elderly population, usually arising below the arcuate line. Local experience has led us to challenge these commonly held beliefs. Operations for Spigelian hernia from 2006–2016 were identified from the Edinburgh Lothian Surgical Audit computerised database and case notes were reviewed. One hundred and one patients underwent surgery for 107 Spigelian hernias in the 10-year period. The female-to-male ratio was 2:1. Ages ranged from 32 to 88 with a median of 64 years. Sixty-five operations were done open and 42 were laparoscopic. Twelve of the 27 for which the precise anatomic location was recorded were situated above the arcuate line. Twenty-nine hernias had small defects and comprised interstitial fat only with no peritoneal sac. Ages in this group ranged from 32 to 80 (median = 48 years). All presented with intermittent local pain and/or swelling, although in three patients the hernias were impalpable. Those three also underwent ultrasound, CT and/or laparoscopy, but the hernias were only identified after open surgical exploration. The remaining 78 cases had peritoneal sacs of varying size with defects up to 9 cm across, and all were identified on imaging and/or laparoscopy. Ages ranged from 38 to 88 (median = 67 years; p

The aim of the research was to determine the incidence, significance, and anatomy of spermatic cord and round ligament lipomas. Between 2000 and 2010 we evaluated 969 consecutive patients with 1,070 indirect inguinal hernias, who underwent open repair. A total of 22 lipomas of the spermatic cord or round ligament were identified and resected in 22 patients. No neoplastic changes confirmed in histopathologic examinations of the specimens were reported. Lipomas of the cord and round ligament occur with a considerable incidence. We believe that even if there is no peritoneal sac, the herniation of extraperitoneal fat through the inguinal canal should be counted as an inguinal hernia, and it requires adequate treatment.

PURPOSE: To study the feasibility of three-dimensional (3D) whole-body, head-to-toe, water/fat resolved MRI, using continuously moving table imaging technology. MATERIALS AND METHODS: Experiments were performed on nine healthy volunteers, acquiring 3D whole-body head-to-toe data under continuous motion of the patient table. Two different approaches for water/fat separation have been studied. Results of a three-point chemical shift encoding and a spectral presaturation technique were compared with respect to image quality and performance. Furthermore, fast, low-resolution, whole-body water/fat imaging was performed in two minutes total scan time to derive patient-specific parameters such as the total water/fat ratio, the intraperitoneal/extraperitoneal fat ratio, and the body mass index (BMI). RESULTS: Good water/fat separation with decent image quality was obtained in all cases. The three-point chemical shift encoding approach was found to be more efficient with respect to signal-to-noise ratio (SNR) and acquisition time. CONCLUSION: Whole-body water/fat sensitive MRI using continuous table motion is feasible and could be of interest for clinical practice. Some improvements of the method are desirable.

Whereas interstitial hernias of infancy are a result of congenital abnormalities, those in adults have been blamed on anatomical banding. Many of the latter are associated with systemic, genetic, or acquired connective tissue disease, however. This results in attenuated aponeuroses, ruptured tendons, and atrophied fascia from collagen malformation and destruction. Muscle contractility is compromised by loss of connective tissue septae, reducing capillary density. The result is wasting and disaggregation, which explains interstitial defects filled with herniated extraperitoneal fat, which account for 1% of primary inguinal herniae. These were originally described in the transversus and internal oblique musculature by Hessert (Surg Gyn Obstet 16:566–568, 1913). Similar slits are seen with Spigelian herniae, all of which are interstitial. This hypothesis, if proven, would imply treatment of the pervasive co-morbidity with the protrusions.

Fatty tissue within the internal cremasteric fascia is frequently encountered during hernia surgery, and it is called a cord lipoma in the surgical literature. Between 1997 and 2001, 128 consecutive patients with 139 indirect inguinal hernias, who underwent open repair, were evaluated. A total of 100 lipomas of the spermatic cord or round ligament were identified and resected in 92 patients. There were no reported neoplastic changes noted in histopathologic examinations of the specimens. The incidence of cord lipoma associated with indirect inguinal hernia was 72.5%. Average body mass index (BMI) was 25.7 in patients with lipoma and 24.6 in patients without lipoma ( P=0.048). The incidence of cord lipoma in large hernias (Nyhus Type II and IIIb) was higher in our patients ( P0.005). It can be clearly seen during laparoscopic exploration of the preperitoneal space that cord lipoma is a continuation of extraperitoneal fat tissue. We believe that even if there is no peritoneal sac, the herniation of extraperitoneal fat through the inguinal canal should be counted as an inguinal hernia, and it requires treatment.

Laparoscopic repair of ventral abdominal wall hernias involves intraperitoneal placement of a mesh, which may lead to adhesion formation and bowel fistulation. The first series of selected patients with ventral abdominal wall hernias treated laparoscopically by extraperitoneal placement of a polypropylene mesh is presented. Thirty-four patients (24 women and 10 men; median age, 52 years [range, 34-70]) were selected from among 122 patients undergoing laparoscopic ventral hernia repair. Of these patients, 18 had a primary ventral abdominal wall hernia and 16 had an incisional hernia. After reduction of sac contents and adhesiolysis intraperitoneally, a large flap of peritoneum (with extraperitoneal fat, fascia, and posterior rectus sheath where present) was raised to accommodate a suitably sized polypropylene mesh, which was then covered again with the peritoneal flap at the end of the procedure. Intraoperatively, apart from circumcision of the hernial sac at the neck, a total of 24 iatrogenic peritoneal tears occurred in 20 patients, mainly at the site of the previous scar. In two patients, it was observed that greater than 25% of the mesh was exposed after the procedure. The median (+/-SD) duration of hospitalization postoperatively was 1 day (+/-0.56). One patient's hernia recurred 4 months after surgery, and one patient's infected mesh was removed 8 months after surgery. Laparoscopic extraperitoneal placement of a mesh is feasible and appears to be an advance over laparoscopic intraperitoneal mesh placement for ventral abdominal wall hernias in selected patients. However, longer follow-up and controlled clinical trials will be necessary before any firm conclusions can be drawn.

Magnetic resonance (MR) imaging has an increasing role in evaluating soft-tissue masses of the extraperitoneal spaces. Since the MR imaging features of most soft-tissue masses are nonspecific, prediction of a specific histologic diagnosis remains a challenge for the radiologist. However, there are certain specific MR imaging appearances that are helpful for more accurate diagnosis. Some histologic components, such as myxoid stroma, collagen fibers, calcification, and fat, have characteristic MR imaging features. Recognition of these features can assist the radiologist in limiting the differential diagnosis. Dynamic enhancement patterns can reflect the vascularity of masses and may be useful in diagnosis, especially in differentiating benign from malignant soft-tissue masses. Familiarity with specific signs and knowledge of diagnostic pitfalls are also important for shortening the list of differential diagnoses. Specific signs are the target sign, the bowl of fruit sign, a whorled appearance, a flow void, speckled enhancement, associated lymphadenopathy, and extension into the intervertebral foramen. Diagnostic pitfalls are as follows: a myxoid stroma simulating cystic degeneration and necrosis, collagen fibers simulating hemorrhage, a fat component simulating extraperitoneal fat, extensive intratumoral hemorrhage simulating hematoma, benign masses mimicking malignant ones, malignant masses mimicking benign ones, and peritoneal lesions mimicking extraperitoneal masses.

Objectives To study the clinical anatomy of the transversalis fascia (TF) and to explore the intertransversalis fascia approach in urologic laparoscopic operations (ULOs). Design Prospective study. Setting Two academic hospitals. Other Participants Data from 1217 urologic laparoscopic or open operations and 10 laparoscopic hernia repairs were analyzed between January 1, 2009, and April 30, 2011. Findings from 3 fresh autopsies were also included. Main Outcome Measures The anatomy of the TF was studied and the intertransversalis fascia approach was explored in ULOs; furthermore, they were proved in the open operations and fresh autopsies. Photographs were taken from the intertransversalis fascia approach in ULOs, micrographs were obtained to examine the microscopic structure of the TF, and the color atlas of TF anatomy (cross and sagittal sections) was drawn. Results The TF is a general plane of connective tissue lying between the inner surface of the transversus abdominis and the extraperitoneal fat. It can be divided into 2 layers (superficial and deep), with an amorphous fibroareolar space between them. The intertransversalis fascia approach in ULOs is the approach between the 2 layers of the TF. Conclusions The intertransversalis fascia approach is described for the first time, to our knowledge. Surgeons can obtain a clean, clear, and bloodless operating space in ULOs using the intertransversalis fascia approach.

Eighteen cases of urachal abscess were studied with sonography. Their configurations were cone shaped in 11 cases, tubular in 4, curved club shaped, and oval and irregular in one each. Their complications, such as intraperitoneal spread, chronic cystitis, and adhesion to the omentum or the colon, could also be suggested by ultrasonography. Gas was found in 50% of the lesions, which were all larger than 1 cm in diameter. An abscess smaller than 1.2 cm in diameter (which can be as long as 5 cm) can be treated with antibiotics or incision and drainage without total excision. A lesion within the extraperitoneal fat space of abdominal wall at the midline below umbilicus suggests the diagnosis of urachal abscess in cases of umbilical discharge and/or when the lesion extends to the umbilicus.

A lumbar hernia usually involves protrusion of extraperitoneal fat or bowel through an area of weakness in the posterolateral abdominal wall bounded superiorly by the 12th rib, inferiorly by the iliac crest, posteriorly by the erector spinae muscle, and anteriorly by the posterior border of the external oblique muscle. Most are due to an acquired nontraumatic or congenital cause. Acute blunt abdominal trauma is a rare cause of lumbar hernia; to our knowledge, the CT diagnosis of this variety has not been reported. Since 1985, approximately 850 patients have undergone emergent abdominal CT for evaluation of acute abdominal trauma at our hospital; in seven of these patients, a traumatic lumbar hernia was diagnosed prospectively. In three patients, CT showed a flank hematoma with herniation of bowel through the lumbar triangle. CT showed pelvic fractures in three other patients, accompanied by herniation of bowel in one patient, herniation of extraperitoneal fat in another, and herniation of extraperitoneal fat and blood in the third. One patient had both a flank hematoma and a pelvic fracture with herniation of bowel. Acute traumatic lumbar hernia is a rare but significant abnormality that should be considered in patients with blunt abdominal trauma, especially in those with large flank hematomas and pelvic fractures. The hernia contents, associated injuries, and disrupted muscle layers are all well demonstrated on CT.

Medial displacement of the liver was observed in 35 cases of ascites using plain radiographs, total-body opacification, tomography, radionuclide imaging, peritoneography, and∕or ultrasonography. In 16 cases the displaced liver was seen on plain radiographs. Separation of the liver and kidney was seen on ultrasonograms in every case; it was increased by addition of increments of fluid in patients undergoing peritoneal dialysis. Since the liver is surrounded by fluid, an interface between it and the extraperitoneal fat cannot account for the displacement seen on plain radiographs: rather, this is the result of a difference in density between liver and fluid.

Extraperitoneal perforations of the gastrointestinal tract, although uncommon, may be fatal if not recognized.The clinical and roentgen features of 5 cases of extraperitoneal perforation are described. In all, one or more of the following roentgen signs were seen: extraperitoneal gas, obliteration of normal extraperitoneal fat lines, and abnormal position of nasogastric tube. Usually an alert roentgenologist will be able to provide the diagnosis earlier than can the clinician.

To determine the radiographic signs of ascites, roentgenograms of 200 normal children and 29 children with ascites were studied. Many of the indirect radiographic signs are related to the development of the extraperitoneal fat pads. These include visualization of the hepatic angle and flank stripe widening, and nonvisualization of the psoas and splenic outlines. These signs may not be present due to lack of extraperitoneal fat pad development. However, radiographic diagnosis is usually possible by direct signs of intraperitoneal fluid such as visualization of the lateral liver border, “dog ears” in the pelvis, and measurable widening of the flank stripe to colon distance.

Recognition of the presence or absence of intraperitoneal fluid may be of considerable importance in the evaluation of abdominal disease. The indebtedness of radiologists to the work of Laurell (4, 5) and Frimann-Dahl (3) is difficult to overestimate. There are times, however, when the signs described are hard to apply. Frimann-Dahl was quick to point out the difficulties when the bowel is fluid-filled, when it is distended by a combination of gas and fluid, and even when it is relatively devoid of gas. Because of these problems we have sought a more usable technic of determining the presence or absence of peritoneal fluid. A further consideration of the anatomy of the flank has led us to the lower and lateral margins of the liver, the hepatic angle. Evaluation of the Flank Stripe The roentgen anatomy of the extraperitoneal and muscle plane fat has been described by both Laurell and Frimann-Dahl. These and other authors further state that the intra-abdominal viscera indent and mold the extraperitoneal fat...

The anatomy of the extraperitoneal fat has been described in detail previously. Visualization of the cephalic extension of the extraperitoneal fat can localize the diaphragm on its undersurface. The extraperitoneal perivisceralfat pad is limited in its cephalic extent by the insertion of the diaphragm. Laterally, the point of insertion of the lateral aspect of the diaphragm may be ascertained because at this point the so-called flank fat ends. Medially the crus of the diaphragm can be clearly identified as an extension of soft tissue density from the superior portion of the psoas margin.