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Ultrasound of the abdominal wall hernias

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Samir Haffar

This document discusses the ultrasound evaluation of anterior abdominal wall hernias. It describes the different types of hernias including epigastric, periumbilical, umbilical, inguinal, femoral and incisional hernias. For each type of hernia, it provides ultrasound images demonstrating the normal abdominal wall anatomy and signs of the hernia. It also discusses some pitfalls in hernia evaluation that can be mistaken for hernias, such as atrophied muscles, lymph nodes, hematomas and subcutaneous masses. In summary, the document provides a comprehensive overview of abdominal wall hernia ultrasound evaluation through descriptions and images of normal findings and various hernia types.

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US of anterior abdominal wall hernias Samir Haffar M.D. Assistant Professor of Gastroenterology
Anterior abdominal wall hernias • Types: Anterior abdominal wall hernias Incisional hernias • Pitfalls in hernia evaluation
Anterior abdominal wall hernias -1 Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Epigastric hernia Periumbilical hernia Umbilical hernia Infraumbilical divarication
Anterior abdominal wall hernias -2 Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Inferior epigastric artery & inguinal ligament Direct inguinal hernia Indirect inguinal hernia Femoral hernia Spigelian hernia
Incisional hernias Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Midline vertical incision Lower abdominal Pfannenstiel incision (bikini cut) Subcostal incision
Abdominal wall hernia  Epigastric hernia  Periumbilical hernia  Umbilical hernia  Infraumbilical divarication  Spigelian hernia  Indirect inguinal hernia  Direct inguinal hernia  Femoral hernia  Incisional hernia
Anterior abdominal wall hernias – 1 Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Epigastric hernia Periumbilical hernia Umbilical hernia Infraumbilical divarication
 Epigastric hernia
Epigastric hernia Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Longitudinal sonogram along linea alba No movement during Valsalva maneuver Not unusual for these hernias when small Defect in linea alba Herniated extraperitoneal fat
 Periumbilical hernia
Paraumbilical hernia Rectus abdominis muscle Rectus abdominis muscle Transverse sonogram Defect in linea alba Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Herniated extraperitoneal fat
 Umbilical hernia
Umbilical hernia Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. 4-month-old boy with umbilical hernia Transverse sonogram at umbilicus Umbilical hernia Medial margin of of rectus abdominis Medial margin of of rectus abdominis
 Infraumbilical divarication
Infraumbilical divarication of rectus abdominis Pre-Valsalva sonogram Both rectus abdominus muscles closely approximated to midline Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Pre-Valsalva sonogram Separation of rectus abdominis muscles
Anterior abdominal wall hernias – 2 Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Direct inguinal hernia Indirect inguinal hernia Femoral hernia Inferior epigastric artery
Anterior abdominal wall hernias – 2 Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Inferior epigastric artery & inguinal ligament Direct inguinal hernia Indirect inguinal hernia Femoral hernia Spigelian hernia
Man’s right inguinal region viewed from within abdomen Jamadar DA et al. AJR 2006; 187:185–190 Inferior epigatric artery Rectus abdominal Inguinal ligamentDeep ring Vas deferens Direct inguinal hernia Femoral hernia Spigelian hernia Indirect inguinal hernia
Transducer position to evaluate abdominal wall hernias Jamadar DA et al. AJR 2006; 187:185–190 1- Spigelian hernia 4- Femoral hernia 3- Direct inguinal hernia 2- Indirect inguinal hernia
 Spigelian hernia
Right spigelian hernia Jamadar DA et al. AJR 2006; 187:185–190 Rectus abdominis M Lateral abdominal M Inferior epigastric artery Peritoneal fat stripe Post-Valsalva sonogram Rectus abdominis M Lateral abdominal M Peritoneal fat stripe Pre-Valsalva sonogram
Left spigelian hernia Transverse sonogram along linea semilunaris Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Bowel Rectus abdominis Flank muscle Extraperitoneal fat
 Indirect inguinal hernia
Normal inguinal anatomy Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364. Rt inguinal region – Parallel to & cranial to inguinal ligament Superior pubic ramus
Indirect inguinal hernia Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Rt inguinal region – Parallel & cranial to inguinal ligament Pre-Valsalva maneuver Superior pubic ramus Post-Valsalva maneuver Superior pubic ramus
 Direct inguinal hernia
Direct inguinal hernia Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Rt inguinal region – Parallel & cranial to inguinal ligament Inferior epigastric artery Pre-Valsalva maneuver Fat stripe Post-Valsalva maneuver Inferior epigastric artery
 Femoral hernia
Femoral hernia Superior pubic ramus Pre-Valsalva maneuver Superior pubic ramus Post-Valsalva maneuver Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Rt inguinal region – Parallel & caudad to inguinal ligament
Incisional hernias Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Midline vertical incision Lower abdominal Pfannenstiel incision (bikini cut) Subcostal incision
 Incisional hernia
Incisional hernia Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. 39-year-old woman with right upper quadrant discomfort medial to cholecystectomy incision (hernia) (extraperitoneal fat) (posterior rectus abdominis) Transverse oblique sonogram
Pitfalls in hernia evaluation
Pitfalls in hernia evaluation • Atrophy of anterior abdominal wall muscles • Focal spasm in an abdominal wall muscle • Xiphoid process noticeable after weight loss • Enlarged lymph nodes • Saphenous varix • Hematoma • Focal fluid collection • Subcutaneous endometrioma Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364.
Atrophy of anterior abdominal wall muscles Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364. Appreciated by close proximity of underlying bowel to abdominal wall Centimeter scale to right of image
Prominent xiphoid process Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364. Sagittal midline epigastric sonogram Hypoechoic cartilaginous xiphoid process (X) with ventral curve Tip (arrow) closest to overlying skin & under palpable abnormality
Inguinal lymph nodes Lymph node with fatty hilum Medial to femoral artery (A) & femoral vein (V) Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Sonogram caudad & parallel to inguinal ligament
Saphenous varix Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364. Focal variceal dilation (V) along proximal LSV Just before it traverses cribriform fascia to anastomose with FV V FV LSV Sonogram over proximal LSV
Groin hematoma Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. 25-year-old woman with right groin hematoma Transverse sonogram Heterogeneous, predominantly hypoechoic mass in superficial tissues
Wound abscess Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Longitudinal sonogram Tubular structure Hypoechoic contents Thick & irregular walls Wavy echogenic structure Abdominal wall mesh Prior incisional hernia repair
Subcutaneous endometrioma 34-year-old woman after caesarian section Ill-defined heterogeneous mass with indistinct margins & minimal vascularity superficial to rectus abdominis muscle Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364. Longitudinal sonogram over scar
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Ultrasound of the abdominal wall hernias

  • 1. US of anterior abdominal wall hernias Samir Haffar M.D. Assistant Professor of Gastroenterology
  • 2. Anterior abdominal wall hernias • Types: Anterior abdominal wall hernias Incisional hernias • Pitfalls in hernia evaluation
  • 3. Anterior abdominal wall hernias -1 Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Epigastric hernia Periumbilical hernia Umbilical hernia Infraumbilical divarication
  • 4. Anterior abdominal wall hernias -2 Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Inferior epigastric artery & inguinal ligament Direct inguinal hernia Indirect inguinal hernia Femoral hernia Spigelian hernia
  • 5. Incisional hernias Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Midline vertical incision Lower abdominal Pfannenstiel incision (bikini cut) Subcostal incision
  • 6. Abdominal wall hernia  Epigastric hernia  Periumbilical hernia  Umbilical hernia  Infraumbilical divarication  Spigelian hernia  Indirect inguinal hernia  Direct inguinal hernia  Femoral hernia  Incisional hernia
  • 7. Anterior abdominal wall hernias – 1 Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Epigastric hernia Periumbilical hernia Umbilical hernia Infraumbilical divarication
  • 9. Epigastric hernia Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Longitudinal sonogram along linea alba No movement during Valsalva maneuver Not unusual for these hernias when small Defect in linea alba Herniated extraperitoneal fat
  • 11. Paraumbilical hernia Rectus abdominis muscle Rectus abdominis muscle Transverse sonogram Defect in linea alba Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Herniated extraperitoneal fat
  • 13. Umbilical hernia Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. 4-month-old boy with umbilical hernia Transverse sonogram at umbilicus Umbilical hernia Medial margin of of rectus abdominis Medial margin of of rectus abdominis
  • 15. Infraumbilical divarication of rectus abdominis Pre-Valsalva sonogram Both rectus abdominus muscles closely approximated to midline Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Pre-Valsalva sonogram Separation of rectus abdominis muscles
  • 16. Anterior abdominal wall hernias – 2 Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Direct inguinal hernia Indirect inguinal hernia Femoral hernia Inferior epigastric artery
  • 17. Anterior abdominal wall hernias – 2 Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Inferior epigastric artery & inguinal ligament Direct inguinal hernia Indirect inguinal hernia Femoral hernia Spigelian hernia
  • 18. Man’s right inguinal region viewed from within abdomen Jamadar DA et al. AJR 2006; 187:185–190 Inferior epigatric artery Rectus abdominal Inguinal ligamentDeep ring Vas deferens Direct inguinal hernia Femoral hernia Spigelian hernia Indirect inguinal hernia
  • 19. Transducer position to evaluate abdominal wall hernias Jamadar DA et al. AJR 2006; 187:185–190 1- Spigelian hernia 4- Femoral hernia 3- Direct inguinal hernia 2- Indirect inguinal hernia
  • 21. Right spigelian hernia Jamadar DA et al. AJR 2006; 187:185–190 Rectus abdominis M Lateral abdominal M Inferior epigastric artery Peritoneal fat stripe Post-Valsalva sonogram Rectus abdominis M Lateral abdominal M Peritoneal fat stripe Pre-Valsalva sonogram
  • 22. Left spigelian hernia Transverse sonogram along linea semilunaris Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Bowel Rectus abdominis Flank muscle Extraperitoneal fat
  • 24. Normal inguinal anatomy Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364. Rt inguinal region – Parallel to & cranial to inguinal ligament Superior pubic ramus
  • 25. Indirect inguinal hernia Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Rt inguinal region – Parallel & cranial to inguinal ligament Pre-Valsalva maneuver Superior pubic ramus Post-Valsalva maneuver Superior pubic ramus
  • 27. Direct inguinal hernia Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Rt inguinal region – Parallel & cranial to inguinal ligament Inferior epigastric artery Pre-Valsalva maneuver Fat stripe Post-Valsalva maneuver Inferior epigastric artery
  • 29. Femoral hernia Superior pubic ramus Pre-Valsalva maneuver Superior pubic ramus Post-Valsalva maneuver Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Rt inguinal region – Parallel & caudad to inguinal ligament
  • 30. Incisional hernias Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Midline vertical incision Lower abdominal Pfannenstiel incision (bikini cut) Subcostal incision
  • 32. Incisional hernia Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. 39-year-old woman with right upper quadrant discomfort medial to cholecystectomy incision (hernia) (extraperitoneal fat) (posterior rectus abdominis) Transverse oblique sonogram
  • 33. Pitfalls in hernia evaluation
  • 34. Pitfalls in hernia evaluation • Atrophy of anterior abdominal wall muscles • Focal spasm in an abdominal wall muscle • Xiphoid process noticeable after weight loss • Enlarged lymph nodes • Saphenous varix • Hematoma • Focal fluid collection • Subcutaneous endometrioma Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364.
  • 35. Atrophy of anterior abdominal wall muscles Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364. Appreciated by close proximity of underlying bowel to abdominal wall Centimeter scale to right of image
  • 36. Prominent xiphoid process Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364. Sagittal midline epigastric sonogram Hypoechoic cartilaginous xiphoid process (X) with ventral curve Tip (arrow) closest to overlying skin & under palpable abnormality
  • 37. Inguinal lymph nodes Lymph node with fatty hilum Medial to femoral artery (A) & femoral vein (V) Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Sonogram caudad & parallel to inguinal ligament
  • 38. Saphenous varix Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364. Focal variceal dilation (V) along proximal LSV Just before it traverses cribriform fascia to anastomose with FV V FV LSV Sonogram over proximal LSV
  • 39. Groin hematoma Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. 25-year-old woman with right groin hematoma Transverse sonogram Heterogeneous, predominantly hypoechoic mass in superficial tissues
  • 40. Wound abscess Jamadar DA et al. AJR 2007; 188 : 1356 – 1364. Longitudinal sonogram Tubular structure Hypoechoic contents Thick & irregular walls Wavy echogenic structure Abdominal wall mesh Prior incisional hernia repair
  • 41. Subcutaneous endometrioma 34-year-old woman after caesarian section Ill-defined heterogeneous mass with indistinct margins & minimal vascularity superficial to rectus abdominis muscle Jamadar DA et al. AJR 2007 ; 188 : 1356 – 1364. Longitudinal sonogram over scar

Editor's Notes

  • #6: Subcostal incision skinincisionshorter than deeper incision with extension along line of incision both medially and laterally. There is potential for hernia (ovals).Midline vertical incisionSuture perforations (circles) site for incisional hernias (curved arrow).Lower abdominal Pfannenstiel incision (bikini cut)Bikini cut is curvilinear cutaneous and subcutaneous incision (A), but vertical component of incision is between rectus abdominis muscles, with potential for incisional hernia (vertical rectangle).
  • #25: Sonogram of inguinal region parallel and cranial to inguinal ligament Spermatic cord (C), external iliac artery (A), inferior epigastric artery (E), femoral vein (V), and superior pubic ramus (curved arrow).
  • #26: Pre-Valsalva maneuver sonogramHernia not visible, external iliac artery (A), inferior epigastric artery (E), and superior pubic ramus (curved arrow).Post-Valsalva maneuver sonogram External iliac artery (A), inferior epigastric artery (E), dilated external iliac vein (V), superior pubic ramus (curved arrow), and indirect inguinal hernia (H) originating from lateral to external iliac artery (arrowhead) and traversing inguinal canal from lateral to medial. (Left = lateral)
  • #28: Pre-Valsalva maneuver sonogram Hernia not visible, peritoneal fat stripe (straight arrows) medial to inferior epigastric artery (curved arrow).Post-Valsalva maneuver sonogramDirect inguinal hernia deforming peritoneal reflection (straight arrows) medial to inferior epigastric artery (curved arrow). Left is lateral, right is medial.
  • #30: Pre-Valsalva maneuver sonogram Hernia not visible, femoral artery (A), femoral vein (V), and superior pubic ramus (curved arrow).Post-Valsalva maneuver sonogram Dilated femoral vein (V) lateral to femoral hernia (arrows). Superior pubic ramus (curved arrow) is also seen.
  • #31: Subcostal incision skinincisionshorter than deeper incision with extension along line of incision both medially and laterally. There is potential for hernia (ovals).Midline vertical incisionSuture perforations (circles) site for incisional hernias (curved arrow).Lower abdominal Pfannenstiel incision (bikini cut)Bikini cut is curvilinear cutaneous and subcutaneous incision (A), but vertical component of incision is between rectus abdominis muscles, with potential for incisional hernia (vertical rectangle).