The targeted sonographic evaluation of this region confirms that these structures are bowel loops which extend through the anterior-medial abdominal wall. Traumatic abdominal wall hernias are understood to result from a blunt force applied to the abdomen over large enough of an area to prevent the penetration of the skin.
Abdominal radiograph demonstrates a distended appearance of the abdomen, while the ultrasound image confirms the presence of ascites fluid. There is soft tissue density isodense to bowel herniating through the left anterior abdominal wall lateral to the left rectus abdominus muscle, with scattered foci of air within the resulting subcutaneous soft-tissue density structure. Spigelian hernias occur along the semilunar line (which transverses a vertical space along the lateral rectus abdominus border from the costal margin to the pubic symphysis), particularly where this line intersects the arcuate line.

Traumatic Spigelian hernia is very rare, particularly in the pediatric population, and ultrasound can be very helpful (as it was in this case) to confirm the findings. The patient may have signs of peritonitis, and ultrasound demonstrates either free ascites fluid or loculated subhepatic fluid.
The etiology is thought to be either due to distal obstruction due to stones or stenosis, or a congenital weakness in the wall of the duct predisposing to spontaneous perforation.
Treatment with drainage and decompression by cystostomy is performed to allow spontaneous closure of the defect.
The hepatobiliary scan can differentiate this condition from other causes of prolonged neonatal jaundice by demonstrating the flow of bile into the peritoneal cavity.

In contrast, biliary atresia results in complete lack of excretion of tracer from the liver.
Neonatal hepatitis typically demonstrates excretion, often delayed, into the gastrointestinal tract.

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