Journal of Ultrasound

https://doi.org/10.1007/s40477-020-00435-0

REVIEW PAPER

Abdominal wall sonography: a pictorial review

Ferdinando Draghi1 · Giulio Cocco2   · Filippo Maria Richelmi1 · Cosima Schiavone2

Received: 23 January 2020 / Accepted: 13 February 2020

© Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB) 2020

Abstract
The anterior abdominal wall, which is composed of three layers (skin and adipose tissues; the myofascial layer; and the deep
layer, consisting of the transversalis fascia, preperitoneal fat, and the parietal peritoneum), has many functions: containment,
support and protection for the intraperitoneal contents, and involvement in movement and breathing. While hernias are often
encountered and well reviewed in the literature, the other abdominal wall pathologies are less commonly described. In this
pictorial review, we briefly discuss the normal anatomy of the anterior abdominal wall, describe the normal ultrasonographic
anatomy, and present a wide range of pathologic abnormalities beyond hernias. Sonography emerges as the diagnostic
imaging of first choice for assessing abdominal wall disorders, thus representing a valuable tool for ensuring appropriate
management and limiting functional impairment.

Keywords  Abdominal wall · Sonography · Abdominal wall sonography

Introduction The pictorial review is based on the combined experience

The anterior abdominal wall is composed of three layers:
skin and adipose tissues; the myofascial layer, consisting
of muscles and their fascial envelopes; and a deep layer,
consisting of the transversalis fascia, preperitoneal fat, and
the parietal peritoneum.
The anterior abdominal wall has many functions, such as
containment, support, and protection for the intraperitoneal
contents and involvement in movement and breathing.
While hernias are often encountered and are well
reviewed in the literature, other abdominal wall pathologies
are less commonly described.
In this pictorial review, we briefly discuss the normal
anatomy of the anterior abdominal wall, describe the nor-
mal ultrasonographic anatomy, and present a wide range of
pathologic abnormalities beyond hernias.
* Giulio Cocco
cocco.giulio@gmail.com
1
Radiology Institute, IRCCS Policlinico San Matteo
Foundation, University of Pavia, Viale Camillo Golgi 19,
27100 Pavia, Italy
2
Unit of Ultrasound in Internal Medicine, Department
of Medicine and Aging Sciences, University of Chieti G
d’Annunzio, Via dei Vestini 31, 66100 Chieti, Italy
of our centers, as indicated by the references in the text, with
a thorough analysis of the literature from the past 18 years
(2001–2019). A systematic search of the literature was per-
formed in PubMed and included original studies and review
articles in English dealing with sonographic descriptions of
the abdominal wall and related disorders. Case reports and
case series were selected according to clinical relevance.
Normal anatomy and sonographic
appearance
The anterior abdominal wall has three layers [1]. The most
superficial layer consists of the skin and adipose tissues. The
middle layer is the myofascial layer, which consists of mus-
cles and their fascial envelopes. The deep layer is formed by
the transversalis fascia, preperitoneal fat, and the parietal
peritoneum [2, 3].
The most superficial layer provides coverage for the
underlying tissues.
The middle myofascial layer has two vertical para-
median muscles, the rectus abdominis (Figs. 1, 2) and its
accessory pyramidal muscle, and three lateral muscles, the
obliquus externus, the obliquus internus, and the transversus
abdominis (Fig. 3).

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Fig. 1  Ultrasound panoramic image of the anterior abdominal wall.
RA rectus abdominis, EO external oblique, IO internal oblique, TA
transversus abdominis, LA linea alba, LS semilunar line
Fig. 2  Ultrasound panoramic image of the rectus abdominis. The
rectus abdominis muscle extends from the last costal cartilage to the
upper edge of the pubis. It is composed of several muscular bodies
separated by 3 or 4 tendinous intersections
Fig. 3  Ultrasound panoramic image of the lateral abdominal wall.
Laterally, the external oblique (EO), internal oblique (IO), and trans-
versus abdominis (TA) muscles extend from the lateral edge of the
rectus to the flanks with three overlapping layers
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Journal of Ultrasound
The rectus abdominis muscles extend from the last costal
cartilage to the upper edge of the pubis (Fig. 2). They are
composed of several muscular bodies separated by three or
four tendinous intersections.
The pyramidal muscles are small and variable triangular
muscles, localized between the pubis and the linea alba.
Laterally, the external oblique, the internal oblique, and
the transversus abdominis muscles extend from the lateral
edge of the rectus to the flanks with three overlapping lay-
ers (Fig. 3).
The aponeuroses of these muscles form the rectus sheaths,
enveloping the right and left rectus muscles and forming the
linea alba [4, 5]. In the superficial part, the sheath extends
over the entire abdominal wall, at the back, and it stops at
its lower part and forms a fibrous arch: the arcuate line. It
has a variable position but is often localized in the upper
second quarter of the umbilical–pubic distance. The linea
alba opposes the diastasis of the rectus abdominis muscles.
At the lateral edge of the rectus abdominis, the semilunar
line marks the interface with the oblique muscles (Fig. 1).
The deep layer of the anterior abdominal wall, formed
by the transversalis fascia, preperitoneal fat, and the pari-
etal peritoneum, is quite elastic and covers and protects the
underlying viscera.
The skin of the anterior abdominal wall is vascularized by
arteries (the perforating arteries) that arise from the superior
and inferior epigastric arteries, pass through the body of
the rectus abdominis muscles, perforate the aponeurosis of
the sheath, and with an oblique course go to vascularize the
subcutaneous fatty tissue.
Additionally, small tributaries of the lower six internal
intercostal arteries contribute to the blood supply of the rec-
tus abdominis muscle and rectus sheath [6].
The arteries run with the superior and inferior epigastric
veins. Deep lymphatics travel with the epigastric veins.
The ventral rami of the spinal nerves supply the rec-
tus abdominis muscles and sheath. The thoracoabdominal
nerves, arising from the T7–T11 spinal segments and the
subcostal nerve (T12), innervate the rectus abdominis mus-
cle. The subcostal nerve innervates the pyramidalis muscle
[7].
Abdominal wall hernias
Muscles and tissues provide strength to the abdominal wall
to hold all the contents of the abdominal cavity. Sometimes,
there is an opening in the abdominal wall, allowing what is
inside to push through to the outside; this is called a hernia.
Some hernias occur in natural openings in the abdomi-
nal wall (umbilical, paraumbilical, and Spigelian hernias)
(Table 1) that allow body structures to go from the inside to
the outside of the abdomen.
Journal of Ultrasound
Table 1  Abdominal hernia Umbilical
anatomy
Paraumbilical
Spigelian
Incisional parastomal
Fig. 4  Umbilical hernia. Ultrasonography shows ascites (arrows)
caused by liver failure through a defect (caliper) in adults with chron-
ically elevated intra-abdominal pressure
Umbilical hernias occur in the abdominal wall near the
umbilicus. True umbilical hernias are common in otherwise
healthy infants. The sac protrudes through the remnant of the
vitellointestinal duct that has failed to cicatrize, usually as
a result of neonatal sepsis. True umbilical hernias can also
be seen in adults with chronically elevated intra-abdominal
pressure, such as ascites caused by liver failure (Fig. 4),
chronic ambulatory peritoneal dialysis, or slowly enlarging
intraperitoneal masses.
Paraumbilical hernias (Fig. 5) typically occur in corpulent
women between the ages of 35 and 50. They usually occur
through a defect in the linea alba just cranial to the umbilical
cicatrix, from where they extend anteroinferiorly into the
umbilicus [8, 9].
A Spigelian hernia is a protrusion through the Spigelian
fascia. The hernia is often interparietal and frequently has
no mass at physical examination.
When people have undergone abdominal surgery, some-
times the incisions where the abdominal cavity was entered
do not heal well, and a hernia can form in this location; this
is known as an incisional hernia. Incisional hernias occur
in approximately 10% of all anterior abdominal wall clo-
sures. They are more common in obese and elderly patients
and are associated with persistent postoperative coughing
and abdominal distension. The abdominal wall closure is
Herniation through the umbilicus
Herniation through the linea alba
Herniation in the Spigelian aponeurosis between the linea
semilunaris and the lateral border of the rectus muscle
Herniation through an incisional site or adjacent to a stoma
Fig. 5  Paraumbilical hernia. Ultrasonography shows preperitoneal fat
(A: caliper) through a defect (B: caliper) in the linea alba, just cranial
to the umbilical cicatrix. These hernias typically occur between 35
and 50 years of age. RA rectus abdominis
Fig. 6  Umbilical hernia. Ultrasonography shows omental fat (A: cali-
per) through a defect (B: caliper) in the linea alba
particularly prone to dehiscence after peritonitis. Hernias
occur more commonly through incisions in the hypovas-
cular linea alba than through transverse muscle-splitting
approaches [10, 11].
A parastomal hernia is an incisional hernia in which the
bowel loops herniate through the abdominal wall defect that
was created for the stoma.
Mesentery (Fig. 6), bowel (Fig. 7), and fat are the most
common hernia contents, but solid organs may also herniate
through abdominal wall defects.
Abdominal wall hernias are common surgical problems,
usually managed without radiologic evaluation, so most
imaging of hernias is probably incidental to the investigation
of an unrelated clinical problem. However, physical exami-
nation alone can be difficult and unrewarding if the patient is
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Fig. 7  Incisional hernia. Ultrasonography shows bowel loops (A: cal-
iper) through a defect (B: caliper) of the abdominal wall
obese, if the hernia is small, or if the hernia arises in a rare
anatomic location. The use of computed tomography (CT),
ultrasound, and magnetic resonance imaging (MRI) for the
investigation of abdominal wall hernias is well documented.
Each of these imaging techniques has been shown to be more
sensitive and specific than physical examination in the detec-
tion of difficult hernias in difficult patients [12–19].
The advent of noninvasive cross-sectional imaging tech-
niques has lowered the clinician’s threshold for investigating
diagnostically challenging patients.
Ultrasound has a high sensitivity (85–92.7%) and speci-
ficity (81.5–93.8%) for detecting abdominal wall hernias.
It is also relatively cheap, widely available, and safe and is
therefore becoming the first-line imaging tool in many cent-
ers. Real-time imaging with ultrasound allows assessment
of the patient in several positions and maximizes the chance
of showing the hernia while the patient performs a Valsalva
maneuver [20, 21].
CT has a reported sensitivity of 83% (and a specificity of
67–83%) and is also being more widely used to investigate
hernias. It is limited by the necessary supine position of the
patient and the lack of real-time imaging, which is prohib-
ited by the large doses of ionizing radiation involved. It is,
however, particularly useful when ultrasound is limited by
the patient’s obesity or when the size of the hernia precludes
accurate sonographic assessment of the relevant anatomy
[22].
MRI is relatively expensive and less available in most
centers, but it is capable of showing exquisite anatomic detail
without the need for ionizing radiation. Direct comparison
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Journal of Ultrasound
of MRI and ultrasound has shown that they are comparably
sensitive techniques (94.5% and 92.7%, respectively) [23].
The most common complications of abdominal wall
hernias are bowel obstruction secondary to the hernia,
incarceration, and strangulation. Presenting symptoms may
include abdominal pain, vomiting, and distention. Physical
examination may reveal a firm, tender abdominal wall mass.
Abdominal distention, dehydration, or peritoneal signs even-
tually become manifest [24].
In the United States, complications related to external
hernias represent one of the most common reasons for emer-
gent surgery performed in patients over 50 years old [25,
26, 27].
Over one million hernia repairs are performed annually.
Surgical correction of hernias is currently the major opera-
tion most frequently performed by general surgeons in the
United States and the second most common abdominopelvic
surgery after cesarean section [28].
To prevent acute complications, external hernias are usu-
ally repaired electively [29].
Repair of abdominal wall hernias with synthetic patches
was first described in 1962. Since then, these patches have
been widely used, and the various procedures using mesh in
abdominal wall repair have become a commonplace treat-
ment. Several reports have shown that compared with simple
sutures, mesh is superior, with significantly reduced recur-
rence rates [30–32].
Materials from which the mesh is manufactured are usu-
ally derived from polypropylene or polytetrafluoroethylene
and typically function by providing a bridge across deficient
tissues. The mesh is incorporated into the adjacent tissues
and should restore the structure and function of the abdomi-
nal wall [33].
Diastasis of the rectus abdominis muscles
Traction of the rectus abdominis muscles can lead to a wid-
ening of the linea alba, causing a clinical condition known as
diastasis of the rectus abdominis muscles (DRAM).
DRAM is characterized by thinning and widening of the
linea alba, combined with laxity of the ventral abdominal
musculature. This causes the midline to “bulge’’ when intra-
abdominal pressure is increased. This clinical condition is
often seen in pregnancy [34, 35].
According to the Beer classification, DRAM is defined
as an interrectus distance (IRD) of 22 mm or more, assessed
three centimeters above the umbilicus. This measure must
be taken in a relaxed state of the patient, avoiding traction
that can make muscles to get closer to each other. DRAM
is frequently misclassified as a primary ventral hernia,
although the musculofascial continuity of the midline and
Journal of Ultrasound
the subsequent absence of a true hernia sac is what sets
DRAM apart from a ventral hernia [36].
Although the association is not definitive, the presence,
size, and duration of DRAM have been linked to pelvic and
low back pain [37, 38].
DRAM has been found to weaken abdominal muscles
[39] and disturb their functions in lumbopelvic stability; it
has also been associated with pelvic floor dysfunction [40].
In clinical practice, measurement of DRAM width is
often performed to screen for the presence of clinically
important DRAM, determining whether a widening is over
or under an accepted cut-off value [39, 41, 42].
Ultrasound and calipers are satisfactory tools for DRAM
measurement. This has been supported by empirical results
[43] and further calculations of diagnostic accuracy values
based on these results [44].
Ultrasound has been most widely researched with regard
to its reliability and has shown to be a reliable method when
images were taken by experienced sonographers. Calipers
also seem a reliable method for measuring DRAM width
(Fig. 8) [45].
For clinical out- and in-patient services and many
research purposes, CT and MRI scans are not feasible meth-
ods for measuring DRAM width. Also, insufficient evidence
was found for them to be considered “gold standard” as often
claimed [46, 47].
Fig. 8  Diastasis of the rectus abdominis muscles (a, b). Diastasis of
the rectus abdominis muscles is defined as an interrectus distance
of 22  mm or more (a calipers), assessed three centimeters above
the umbilicus. This measure must be taken in a relaxed state of the
patient, avoiding traction that can make muscles to get closer to each
other. b Ultrasound panoramic image. RA rectus abdominis, LA linea
alba
DRAM is mostly treated conservatively, with or without the
help of a physiotherapist [48].
In case of severe functional or cosmetic impairment, the
patient can be referred to a plastic or general surgeon. If surgi-
cal treatment is considered, several techniques, ranging from
laparoscopic, endoscopic, hybrid, and open repairs, are avail-
able. Currently, there is no consensus on the preferred surgical
management of DRAM [49].
Atrophy of the abdominal wall muscles
Muscle atrophy is the loss of muscle mass, which can be
caused by aging, malnutrition, immobility, medications, and
a wide range of injuries or diseases that impact the musculo-
skeletal or the nervous system.
The most frequent cause is advancing age, which brings
progressive loss of muscle strength, muscle mass, and muscle
quality, resulting in a condition known as sarcopenia. Age-
related muscle atrophy has been associated with a decrease
in motor function. Atrophy in particular was associated with
chronic bed rest and is more marked in the antigravity muscles,
such as back and abdominal muscles [50–52].
Furthermore, atrophy of the abdominal wall muscles is a
significant side effect of laparotomy, which, despite the wide-
spread use of laparoscopy, is still frequently required and per-
formed. In a study, chevron incisions were found to result in
more atrophy compared with midline incisions [53].
The etiology is twofold: physical transection and remod-
eling of muscle fibers and, more importantly, direct transection
of the intercostal nerves. Management of patients with symp-
tomatic abdominal wall atrophy is supportive only.
In our experience, atrophy of the muscles of the abdomi-
nal wall is also frequent in obese persons, and it represents a
problem for bariatric surgery.
Regardless of the cause, muscle atrophy is characterized by
the replacement of muscle tissue with fat and fibrous tissue.
Atrophy of the abdominal wall muscles can be objecti-
fied by measuring muscle thickness. On ultrasound images,
infiltration of fat and fibrous tissue increases muscle echo
intensity and increases interface and attenuation, and the
muscles become whiter (Fig. 9) [54, 55].
Sarcopenia, myosteatosis, and impaired aerobic fitness
(objectively measured by reduced oxygen uptake) have been
associated with poor postoperative outcomes and survival
[56].
Hematomas and injuries of the abdominal
wall intrinsic muscles
Hematomas of the abdominal wall muscles are frequent
in patients under anticoagulant treatment. The muscular
sheath prevents their extension, but the pressure causes acute
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 Journal of Ultrasound

Fig. 9  Muscular atrophy in
an obese patient (a, b). On an
ultrasound image, the infiltra-
tion of fat and fibrous tissue
increases muscle echo intensity
(a) and increases interface, and
the muscles become whiter (b
ultrasound panoramic image).
There is marked hypertrophy
of the subcutaneous adipose
tissue. RA rectus abdominis, LA
linea alba

pain. They are more or less hypoechoic masses (Fig. 10),
sometimes pure liquid. Simple monitoring is the rule in the
absence of hemodynamic repercussions.
Intrinsic muscle injuries of the abdominal wall are rather
rare but have been described in several studies. They occur
due to the contraction and simultaneous elongation of the
muscles, leading to the destruction of myofibers [57].
Athletes of some sports are most frequently affected
by intrinsic muscle injuries of the abdominal wall. These
players often have asymmetrical hypertrophy of the muscle
on the side opposite to the dominant arm, and the tears are
almost always on the contralateral side of the dominant arm
[58]. Usually, tennis players complain of sudden-onset pain
and point tenderness that generally occur during service

Fig. 10  Hematoma of the rectus

abdominis muscle. a Transverse
ultrasound scan. b Longitudinal
ultrasound scan. Hematoma:
arrows. RA rectus abdominis

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Journal of Ultrasound

and smash in the side opposite to the dominant arm, and

the injuries often affect the rectus abdominis muscle [59].
Volleyball and handball players make similar biomechani-
cal movements, and the injuries usually affect the rectus
abdominis muscle on the nondominant side. The injury
mechanism is indirect at the time of the flexion/extension
transition when players serve or attack in the case of vol-
leyball or throw in the case of handball [60, 61]. In baseball
players, the abdominal muscles (the internal and external
oblique, rectus, and transversus abdominis muscles) play
an important role in pitching and hitting. Proper abdominal
muscle activation during throwing and swinging is crucial
for generating optimal ball velocity and bat speed.
Injuries contralateral to the dominant arm are more
common and usually affect the internal/external oblique
muscle [62]. For similar reasons, hockey players’ tears fre-
quently affect the oblique muscles [63]. In these sports, the
abdominal muscle injuries involve similar sequences and
are produced during brusque flexoextension movements
and rotations of the trunk during eccentric contraction or
concentric–eccentric transitions in the serve or attack in
volleyball, the serve in tennis, the batting in baseball, the
throwing of the ball in handball, or the hitting of the hockey
puck; the injuries start in the legs and transfer to the trunk,
the shoulder, and the arm [61]. Fig. 11  Intrinsic muscle injuries. Tears appear as a disruption of the
Sports that involve hitting or throwing a ball with the normal fibrillar pattern (arrows). a Longitudinal ultrasound scan, b
use of the upper limbs can lead to injuries to the abdomi- transverse ultrasound scan and presence of fluid collections
nal wall muscles. Ultrasound examination of a patient with
suspected muscle injury should always be preceded by an
accurate reporting of the patient’s medical history, includ-
ing the mechanism of injury, symptoms, possible pain, and or pelvic peritoneum, but it rarely arises in extrapelvic
loss of strength. sites, such as surgical scars [66].
Careful clinical evaluation may reveal the presence Nowadays, surgical scar endometriosis following
of morphological alterations, such as a subcutaneous obstetric and gynecological procedures is more frequent
hematoma. due to an increasing number of caesarian sections world-
Ultrasound scanning of the abdominal muscles should be wide [67]. Endometriosis of the abdominal wall (AWE)
transverse and longitudinal from the proximal attachment can affect the cutaneous–subcutaneous (Fig. 12) or intra-
to the distal attachment, including the myotendinous junc- muscular tissues (Fig. 13).
tion and enthesis. On sonography (Fig. 11), the muscle tear The occurrence of symptoms and the growth of the
appears as a disruption of the normal echogenic fibrillar pat- endometriosis depend on estrogen stimulation, so a peri-
tern and the presence of anechoic clefts and irregular linear odic increase in pain intensity associated with menstrua-
bands with or without fluid collections [64]. tion can occur [66].
Abdominal wall endometriosis (AWE) is often misdi-
agnosed with several other pathological conditions, such
Abdominal wall endometriosis as desmoid tumors, lymphomas, hernias, metastatic car-
cinomas, sarcomas, and hematomas [68].
Endometriosis is the presence of endometrial glands and Several studies found the time interval between sur-
stroma outside the endometrial cavity. The ectopic tissue gery and clinical presentation to be between 3 months and
is responsive to ovarian hormonal stimulation and prolifer- 10 years [69].
ates when stimulated by cyclic estrogens, thus seeming to The physiopathological processes underlying endome-
“menstruate.” triosis are unclear, and three theories (tubal regurgitation,
Endometriosis was first described by Rokitansky [65]. It celomic metaplasia, and vascular spread) have been pos-
generally occurs in pelvic sites, such as the ovaries, bowel, tulated to explain it [70].

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 Journal of Ultrasound

Fig. 12  Endometriosis of subcutaneous tissues. B-mode ultrasound shows a hypoechoic mass inside the subcutaneous tissues (a) with intral-
esional vascular signals with color Doppler ultrasound (b) and a hard pattern with strain elastosonography (c)

Fig. 13  Endometriosis of muscular tissues. B-mode ultrasound shows a hypoechoic mass inside the muscular tissues (a), with a hard pattern
with strain elastosonography (b)

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Journal of Ultrasound
A widely accepted explanation for the presence of endo-
metriosis in unusual sites (e.g., the lungs, the brain, and inci-
sional scars) is that endometrial cells are transported through
hematogenous, lymphatic, or iatrogenic routes [70]. Some
authors suggested that natural killer activity and/or altered
peritoneal macrophage maturation may play a role in its
pathogenesis [71].
Health care providers should suspect cutaneous endo-
metriosis in any women with pain and a lump in the inci-
sional scar after pelvic surgery [72]. Cesarean section (CS)
is the most common surgery performed around the world;
the World Health Organization (WHO) suggests a cesarean
rate of 5–15%, but the worldwide percentage is higher [73].
Generally, abdominal wall endometriosis is confined to the
peritoneal surface, and it is mainly associated with cesarean
section (incidence 1–2%), but it may also result from a previ-
ous surgical procedure [69].
The pathogenesis of endometriosis is complex, and AWE
is believed to be the result of mechanical iatrogenic implan-
tation, through the direct inoculation of the abdominal fascia
and/or subcutaneous tissue with endometrial cells during
the surgical intervention, which, under estrogen stimulation,
become active and expand [70].
Some authors have examined factors contributing to CSE
and defined possible causes, including the easy separation
and transport of endometrial cells by the amniotic fluid flow
into the pelvic cavity after hysterotomy; the large amount of
endometrial cells spreading into the pelvis before hyster-
otomy closure, which can become trapped in the wound; and
the nurturing role of blood and hormones after inoculation
of the cells, allowing them to grow and develop into subcu-
taneous masses [74].
It is important to highlight that a higher incidence is
reported after early hysterotomy (end of the second or begin-
ning of the third trimester), as the early decidua seems to
have more pluripotential capabilities, potentially resulting
in enhanced cellular replication producing endometriosis
[73]. Endometriosis guidelines report that only histologi-
cal examination can provide the definitive confirmation of
the diagnosis [75]. However, medical history together with
a gynecological examination has a combined sensitivity of
around 80% for diagnosing endometriosis. As evidenced in
our cases, patients are referred to medical examination due
to the presence of abdominal/pelvic pain that often has no
clear and immediate anatomical and pathological explana-
tions; therefore, a diagnosis of irritable bowel or functional
disorder is often wrongly reached.
Table 2  Vascular anomalies
Vascular tumors Hemangiomas, hemangioendotheliomas, angiosarcomas
Vascular malformations Slow flow (capillary, venous, and lymphatic) and fast flow (arterial and arteriovenous) anomalies
As previously mentioned, endometriosis location can be
variable and widespread; the qualitative assessment of pain
often shows a close relationship with the menstrual cycle,
and this represents the main clue for the diagnosis of endo-
metriosis [75].
B-mode ultrasound images with a high-frequency linear
probe can identify the presence of endometriosis foci inside
the superficial tissues of the abdominal wall showing the
hypoechoic nodule located inside the tissues (cutaneous,
subcutaneous, or muscular) (Figs. 12a, 13a). Fine intrale-
sional vascular spots are depicted with color-power Doppler
(Fig. 12b), and a hard pattern of the mass is identified with
the elastosonography strain modality (Figs. 12c, 13b) [76].
Vascular malformation of the abdominal
wall
Vascular anomalies may be isolated or multiple and rarely
affect the abdominal wall.
In 1982, Mulliken and Glowacki created the first classi-
fication based on the normal development, cellular kinetics,
and histopathology of vascular abnormalities. Endothelial
malformations are biologically classified into two major
groups: hemangiomas and vascular malformations [77].
In 1996, in Rome, the International Society for the Study
of Vascular Anomalies (ISSVA) also classifies vascular
anomalies into tumors and malformations (Table 2).
Vascular tumors are hemangiomas, hemangioendothelio-
mas, and angiosarcomas, while vascular malformations are
classified based on blood flow rate as slow-flow (capillary,
venous, and lymphatic) and fast-flow (arterial and arterio-
venous) anomalies [78].
This classification was broadened and detailed during the
2014 ISSCA workshop in Melbourne, which further catego-
rized vascular tumors and malformations into subdivisions
of these two groups. Tumors are classified according to their
clinical behavior, and malformations are classified according
to their flow characteristics, histopathologic features, and
associations with other anomalies [79].
The classification system was recently updated during the
May 2018 ISSCA meeting in Amsterdam [80].
Vascular malformations are commonly seen in the head,
neck, and extremities and rarely affect the trunk [81]. There
are only a few case reports regarding AVM and vascular
tumors of the anterior abdominal wall [82–84]. Ultrasound
and MRI, along with magnetic resonance angiography
13

(MRA), are the most used imaging modalities for the evalu-
ation of vascular anomalies of the abdominal wall [85].
Whereas ultrasound can assess the vascularity of the
anomaly (Fig. 14), the type of vessels feeding the lesion,
and the presence of a high-flow component, MRI and MRA
are excellent methods for depicting the anatomical extent,
multicompartmental involvement, and vascular angioarchi-
tecture. Ultrasound is great for follow-up and helps guide
interventional therapies. CT is rarely used due to radiation
concerns. Digital subtraction angiography (DSA) is usually
performed for therapeutic intervention [86].
Abdominal wall tumors
All the soft tissue tumors can be found in the abdominal
wall, but the most frequent ones are lipomas (Fig. 15), myx-
oid tumors (Fig. 16), and neurofibromas (Fig. 17).
The most common benign tumor of the abdominal wall is
a lipoma [87]. Lipomas are mesenchymal tumors made up
of mature adipose tissue [88].
They can affect any region of the body and can occur at
any age, but they are more common in the fifth decade and
are multiple in 5% of patients. Often associated with a period
Fig. 14  Vascular malformation of the abdominal wall. Ultrasound
shows dilated vessels in the subcutaneous tissues (a, b panoramic
view). Color Doppler ultrasound confirms the vascular nature of
the lesions. RA rectus abdominis, EO external oblique, IO internal
oblique, TA transversus abdominis, LA linea alba, LS semilunar line
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Journal of Ultrasound
of weight gain, lipomas are painless and can vary in size,
from very small to giant.
Lipomas can be located in superficial tissues (subcutane-
ous) or less frequently in deep tissues (subfascial tissues)
[89]. The superficial lipomas generally can be clinically
detected and appear as compressible, palpable soft tissue
masses that do not adhere to the surrounding tissue.
Lipomas may be located in subcutaneous tissues (ante-
rior to the muscle fascia), above muscles (supramuscular),
between muscles (intermuscular), within muscles (intramus-
cular), or below muscles (submuscular) [90].
The deep-seated lipomas are hard to detect clinically, and
not infrequently, the clinical presentation of such a lipoma
is similar to that of a sarcoma [91].
Ultrasound is generally performed to confirm the clinical
diagnosis. Lipomas may have a variable echotexture (hypo-
echoic, isoecogenic, or hyperechoic) relative to adjacent fat
or muscular tissues, can be homogeneous or inhomogene-
ous, and can be encapsulated or nonencapsulated, and some-
times their differentiation from other masses is difficult [92].
Usually, they present as an oval ipoechoic compressible
mass (Fig. 15a) with its greatest diameter parallel to the skin,
containing short linear reflective striations that run parallel
to the skin. Lipomas are usually not hypervascularized at
color (Fig. 15b) or power Doppler imaging [92].
Desmoid tumors (also known as aggressive fibromatosis)
are rare benign tumors derived from mesenchymal progeni-
tor cells with a locally aggressive tendency for recurrence
but not with metastatic potential [93].
They make up 0.03% of all neoplasms and less than 3% of
all soft tissue tumors [94]. Typically, they occur in women,
Fig. 15  Lipoma. Ultrasound shows an oval, isoechoic mass (a) with
its greatest diameter parallel to the skin; it is not hypervascularized
(b) on color Doppler imaging
Journal of Ultrasound

Fig. 16  Desmoid tumor. Ultrasound shows an oval, poorly defined, solid, nonencapsulated mass (a) with internal vascularity (b, c)

Fig. 17  Neurofibroma. Ultrasound shows an oval, hypoechoic mass with well-defined margins (a) and internal vascularity (b)

particularly in young women (25–40 years of age), and are
usually associated with previous surgical scars, trauma,
estrogen therapy, pregnancy, familial adenomatosis poly-
posis, and Gardner syndrome [93].
Desmoid tumors can develop in any part of the body,
such as musculoaponeurotic structures and connective tis-
sues, but especially in the abdominal wall (the rectus and
internal oblique muscles and their fascias) [95].
The course of desmoid tumor development is unpre-
dictable, as spontaneous regression, a long-lasting stable
state, and disease progression can occur, and reliable and
validated predictive factors are lacking.
Desmoid tumors comprise at least two different clin-
icopathological entities: sporadic desmoid tumors and
desmoid tumors associated with germline mutations of
APC [96].

13

On ultrasound, desmoids frequently appear as oval,
poorly or well-defined solid soft tissue masses with variable
echogenicity (Fig. 16a) that are nonencapsulated and can
infiltrate the surrounding tissue, generally abdominal wall
muscles. They may present internal vascularity (Fig. 16b, c)
and, characteristically, do not cross the midline [97].
Peripheral nerve tumors are mostly benign and include
two histotypes: schwannomas and neurofibromas [98].
Neurofibromas infiltrate nerve trunks, and many neurofi-
bromas require nerve resection and graft for removal.
Neurofibromas are round, oval or fusiform, and hypo-
echoic with well-defined margins, and internal cystic
changes may be observed (Fig. 17). The most important
criterion for the ultrasound diagnosis is the relation of the
mass to a nerve [99].
10. Bucknall TE, Cox PJ, Ellis H (1982) Burst abdomen and incisional
Conclusions
A variety of disorders affecting the abdominal wall is com-
monly encountered in daily clinical practice. Knowledge of
the medical history, as well as the symptoms and signs, is
basic for a correct diagnostic approach. However, the clinical
presentations are often similar, and imaging is required to
narrow down the list of different diagnoses. Sonography is
effective in assessing abdominal wall disorders, thus repre-
senting a valuable tool for ensuring appropriate management
and limiting functional impairment.
Compliance with ethical standards  tional imaging of abdominal wall hernias. Am J Roentgenol
Conflict of interest  The authors declare that they have no conflict of
interest.
Ethical approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
This article does not contain any studies with human participants or
animals performed by any of the authors.
Informed consent  Informed consent was obtained from all individual
participants included in the study.
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