Diagnosis of inguinal region hernias with axial CT: the lateral crescent sign and other key findings.

Differentiation of direct inguinal hernias, indirect inguinal hernias, and femoral hernias is often difficult at clinical examination and presents challenges even at diagnostic imaging. With the advent of higher-resolution multidetector computed tomography (CT), the minute anatomic detail of the inguinal region can be better delineated. The authors examine the appearance of these hernias at axial CT, as the axial plane remains the diagnostic mainstay of evaluation of acute abdomen. They review and label key anatomic structures, present cases of direct and indirect inguinal hernias and femoral hernias, and demonstrate their anatomic differences on axial images. Direct inguinal hernias protrude anteromedial and inferior to the course of the inferior epigastric vessels, whereas indirect inguinal hernias protrude posterolateral and superior to the course of those vessels. The proposed lateral crescent sign may be useful in diagnosis of early direct inguinal hernias, as it represents lateral compression and stretching of the inguinal canal fat and contents by the hernia sac. Femoral hernias protrude inferior to the course of the inferior epigastric vessels and medial to the common femoral vein, often have a narrow funnel-shaped neck, and may compress the femoral vein, causing engorgement of distal collateral veins. Familiarity with these anatomic differences at axial CT, along with the lateral crescent sign of direct inguinal hernias, may help the radiologist better assist the clinician in accurate diagnosis of the major types of hernias of the inguinal region. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.312105129/-/DC1.

Pancreatic cystic neoplasms.

Cystic neoplasms of the pancreas have been recognized for almost 2 centuries, but the principles of management continue to evolve. Clinicians have a better understanding now of the diverse pathologies and behaviors of cystic neoplasms, and can characterize them more precisely into benign, malignant, and of uncertain potential in their manifestations. Treatment is dependent on accurate diagnosis and tailored to the potential aggressiveness of the lesion, the surgical fitness of the patient, and the probability of effecting long-term palliation or survival of the patient. In this article the authors review the classification based on the World Health Organization classification and the latest evidence-based literature of cystic neoplasms, and present their considerations for surgical management of the various lesions. A better understanding of the biologic potential of cystic neoplasms such as intraductal papillary mucinous neoplasms allows for a more patient-specific evidence-based management plan.

Complications of gallstones: the Mirizzi syndrome, gallstone ileus, gallstone pancreatitis, complications of "lost" gallstones.

Gallstones cause various problems besides simple biliary colic and choplecystitis. With chronicity of inflammation caused by gallstone obstruction of the cystic duct, the gallbladder may fuse to the extrahepatic biliary tree, causing Mirizzi syndrome, or fistulize into the intestinal tract, causing so-called gallstone ileus. Stones may pass out of the gallbladder and travel downstream through the common bile duct to obstruct the ampulla of Vater resulting in gallstone pancreatitis, or pass out of the gallbladder inadvertently during surgery, resulting in the syndromes associated with lost gallstones. This article examines these varied and complex complications, with recommendations for management based on the literature, the data, and perhaps some common sense.

Uncinatectomy: a novel surgical option for the management of intraductal papillary mucinous tumors of the pancreas.

An intraductal papillary mucinous tumor (IPMT) is a rare cystic lesion of the pancreas, comprising only 1% of all pancreatic exocrine neoplasms. The prognosis for these lesions is typically favorable as compared with invasive ductal carcinomas. Nevertheless, the management of IPMTs involves surgical resection due to their malignant potential. When located in the pancreatic head, the conventional treatment for IPMT is pancreatoduodenectomy. Some authors have advocated limited pancreatectomy for low-grade IPMTs of the pancreas, thereby decreasing the morbidity of more extensive resection. In this report, we describe our technique of minimal pancreatectomy, whereby the uncinate process and associated branch duct were completely extirpated while preserving remainder of the pancreatic head, duodenum, and pancreatic ducts. The case presented underscores the feasibility and advantages of minimal pancreatic resection in the management of such tumors.

Radical gastrectomy for cancer of the stomach.

Carcinoma of the stomach remains one of the most common causes of cancer deaths in the world. The only treatment to offer hope for cure or long-term palliation is surgery. Optimal surgical resection requires an adequate margin of normal tissue around the tumor,dissection of perigastric lymph nodes, and en-bloc removal of organs involved by direct extension. Extended lymphadenectomy has not been shown to offer survival advantage in the West.