Subscribe to RSS

DOI: 10.1055/s-0045-1806838
Unraveling Posterior Rectus Sheath Hernia: Multimodality Imaging with Intraoperative Correlation
Dear Editor, we present here a case of a 55-year-old male with complaints of acute abdominal pain, localized predominantly in the right upper quadrant, nonradiating in nature associated with two to three episodes of emesis. He had a past surgical history of laparoscopic cholecystectomy done 4 years ago. His vitals and blood counts were normal. On examination, a focal irreducible hard lump of size approximately 3 × 4 cm was noted about 2 to 3 cm above from the umbilicus in the right paramedian location, which was tender, nonmobile, and nonpulsatile in nature. No other associated features were noted. Differential of acute etiology concerning with the liver and head of pancreas were considered with a suspicion of tumor. To characterize the lesion, ultrasound (USG) abdomen was performed, which showed bulky right rectus sheath compartment with herniating bowel loops and omentum through a defect of about 2.5 cm size in the right posterior rectus sheath in the supraumbilical location, as shown in [Fig. 1A–C]. The visualized afferent bowel loops were normal in caliber and echogenicity with no fluid in the hernial sac, as show in [Fig. 1D]. Thus, suggesting no symptoms of obstruction. However, patient's pain aggravated to severe extent the next day, with bloating and nonpassage of flatus, and was suspected to have developed obstruction. To confirm USG findings, a contrast-enhanced computed tomography (CT) abdomen was done, which illustrated similar findings, as shown in [Fig. 2A] and [B].




Patient was taken up for surgery immediately, during which ileal bowel loops and omental fat were seen between the right rectus abdominis muscle and posterior rectus sheath, as in [Fig. 2C] and [D]. Bowel loops were reduced and defect repaired with a mesh. Postoperatively, patient was stable and discharged after 4 days.
This case emphasizes the role of USG in diagnosing posterior rectus sheath hernia. It has been proposed that the individuals who develop this hernia have some sort of muscle weakness present earlier, which is further accentuated due to surgical incision/ trauma to the rectus abdominis muscle.[1] [2] Other predisposing factors are increased abdominal pressure caused by obesity, ascites, and other causes.[1] [3] Due to rarity of this condition, not many of the clinicians and radiologists are aware, consequently, such cases are usually neglected, or worked up as abdominal lumps, until they show up in emergency as complicated hernia with small bowel obstruction, incarceration, strangulation, bowel ischemia/infarction, or bowel perforation.[1] [2] A timely diagnosis, as in our case, is cardinal for better prognosis, and having a high degree of suspicion is key in making the diagnosis. A well-aware radiologist with high level of suspicion in a case presenting with complaints and potential risk factors as discussed, can make a working diagnosis of this condition. A CT scan can be performed when in doubt, as it is more sensitive than USG in the identification of posterior rectus sheath defect.
#
Conflict of Interest
None declared.
Acknowledgments
None.
Ethics Approval
None.
Consent to Participate
Informed written consent was taken from the participant.
Consent for Publication
Informed written consent was taken from the participant.
Availability of Data and Material
Data sharing is not applicable to this article as no data sets were generated or analyzed during the current study.
Competing Interests
The authors declare that they have no competing interests.
Authors' Contributions
R.S. and L.B. performed the clinical evaluation. R.S. and L.B. performed USG and CT study along with postprocessing. R.S. and L.B. evaluated the imaging studies and reached to a diagnosis. R.S. and L.B. performed the literature search and prepared the manuscript. L.B. prepared the images and figure legends. All authors reviewed and edited the manuscript. All authors read and approved the final manuscript.
-
References
- 1 Aguirre DA, Santosa AC, Casola G, Sirlin CB. Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics 2005; 25 (06) 1501-1520
- 2 Losanoff JE, Basson MD, Gruber SA. Spontaneous hernia through the posterior rectus abdominis sheath: case report and review of the published literature 1937-2008. Hernia 2009; 13 (05) 555-558
- 3 Ng CW, Sandstrom A, Lim G. Spontaneous posterior rectus sheath hernia: a case report. J Med Case Rep 2018; 12 (01) 96
Address for correspondence
Publication History
Article published online:
27 March 2025
© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India
-
References
- 1 Aguirre DA, Santosa AC, Casola G, Sirlin CB. Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics 2005; 25 (06) 1501-1520
- 2 Losanoff JE, Basson MD, Gruber SA. Spontaneous hernia through the posterior rectus abdominis sheath: case report and review of the published literature 1937-2008. Hernia 2009; 13 (05) 555-558
- 3 Ng CW, Sandstrom A, Lim G. Spontaneous posterior rectus sheath hernia: a case report. J Med Case Rep 2018; 12 (01) 96



