R e s i d e n t s ’ S e c t i o n • S t r u c t u r e d R ev i ew

Murphy et al.
Adult Abdominal Hernias

Residents’ Section
Structured Review
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Residents

inRadiology Adult Abdominal Hernias

Kevin P. Murphy 1 Educational Objectives and Key Points
Owen J. O’Connor 1. Given that abdominal hernias are a frequent imaging finding, radiologists not only are
Michael M. Maher required to interpret the appearances of abdominal hernias but also should be comfortable
with identifying associated complications and postrepair findings.
Murphy KP, O’Connor OJ, Maher MM 2. CT is the imaging modality of choice for the assessment of a known adult abdominal
hernia in both elective and acute circumstances because of rapid acquisition, capability of
multiplanar reconstruction, good spatial resolution, and anatomic depiction with excellent
sensitivity for most complications.
3. Ultrasound is useful for adult groin assessment and is the imaging modality of choice for
pediatric abdominal wall hernia assessment, whereas MRI is beneficial when there is reasonable
concern that a patient’s symptoms could be attributable to a hernia or a musculoskeletal source.
4. Fluoroscopic herniography is a sensitive radiologic investigation for patients with groin pain
in whom a hernia is suspected but in whom a hernia cannot be identified at physical examination.
5. The diagnosis of an internal hernia not only is a challenging clinical diagnosis but also
can be difficult to diagnose with imaging: Closed-loop small-bowel obstruction and abnor-
mally located bowel loops relative to normally located small bowel or colon should prompt
assessment for an internal hernia.

A
hernia is defined as “protrusion of
a part or structure through the tis-
sues normally containing it” [1].
The key elements of a hernia are
the sac, neck, and contents. The contents of an
abdominal hernia most commonly consist of
fat and bowel, but almost any solid or hollow
abdominopelvic viscus can be partly or com-
Keywords: abdominal hernia, bowel obstruction, bowel pletely contained within a hernial sac. Ab-
strangulation, hernia
dominal hernias, associated complications,
DOI:10.2214/AJR.13.12071 and postrepair imaging findings are extremely
commonly encountered in radiology practice.
Received October 14, 2013; accepted after revision Abdominal hernias can be classified into ab-
December 30, 2013.
dominal wall and internal varieties.
1  nal hernias, however, continue to have a high
All authors: Department of Radiology, Cork University
Hospital and University College Cork, Cork, Ireland. Disease Epidemiology
Address correspondence to M. M. Maher The estimated lifetime risk of a spontane-
(M.Maher@ucc.ie). ous abdominal hernia is 5%. Secondary her-
nias generally occur as a result of previous
WEB
This is a web exclusive article. surgery or trauma. Hernia repair is the sec-
ond most common abdominopelvic operation
AJR 2014; 202:W506–W511 in the United States, after cesarean delivery.
More than 1 million repairs are performed
0361–803X/14/2026–W506
annually [2, 3]. Inguinal hernias are far more
© American Roentgen Ray Society common in males than in females and are bi-
lateral in as many as 10% of cases. Inguinal
hernias account for more than 70% of abdom-
inal wall hernias; femoral (10–15%), umbili-
cal, epigastric, and incisional hernias account
for most of the other types [4]. Femoral her-
nias are far more common in females, but
nevertheless, inguinal hernias are twice as
common as femoral hernias among females.
Incisional and parastomal hernias occur after
9.9% of laparotomies and 0.7% of laparosco-
pies [5]. Complications related to hernia re-
pair, such as recurrence, infection, and post-
operative collections, occur in as many as
20% of cases [3] (Fig. 1). Complicated inter-
mortality (> 50% in some series), particularly
in the presence of strangulation [6, 7].
Pathophysiologic Basis
Most pediatric abdominal hernias originate
from developmental anomalies, but this is not
the case in adults. Any cause of increased in-
traabdominal pressure represents a predis-
position to the development of an adult ab-
dominal hernia. These causes include chronic

W506 AJR:202, June 2014

 Adult Abdominal Hernias
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Fig. 1—51-year-old man who underwent left inguinal hernia repair, had severe Fig. 2—57-year-old man in emergency department with painful, irreducible left
pain 5 days afterward, and underwent abdominopelvic CT. CT image shows large groin swelling and vomiting. CT image shows incarcerated fat-containing left
pelvic hematoma (curved arrow), recurrent fat-containing left inguinal hernia inguinal hernia (arrow) and surrounding inflammatory fat stranding (arrowheads),
(arrowhead), and mesh (straight arrow) used for repair. which raise concern for strangulation.

cough, obesity, bladder outlet obstruction, and
ascites. In addition, conditions that precipitate
localized or generalized weakening of the ab-
dominal boundaries can contribute to hernia
formation. These conditions include previous
surgery, trauma, and aging. Specifically in re-
lation to incisional hernias, impaired wound
healing, deficient collagen, and extracellular
matrix formation all contribute to defect de-
velopment [8]. Clinical evaluation is sufficient
for diagnosing an uncomplicated abdominal
wall hernia in most cases. Patients typically
describe a lump that appears or increases in
size with coughing, standing, or straining and
that reduces spontaneously on relaxation or
with manual pressure.
Imaging Approach
Ultrasound is the first-line imaging investi-
gation for hernia detection in children [9, 10]
and for nonacute adult groin hernia detection,
particularly in patients with a palpable swell-
ing or cough impulse [11]. Ultrasound has an
excellent positive predictive value for hernia
detection in adults [11], and a major advantage
is the capability of dynamic assessment with
and without a Valsalva maneuver. CT is op-
timal for assessing most hernias in the acute
phase [3, 10], whereas MRI findings are more
informative if there is reasonable likelihood of
a musculoskeletal cause of the symptoms. MRI
should also be considered as the first-line in-
vestigation of young patients with groin symp-
toms or those with normal ultrasound findings
in the nonacute phase. Like ultrasound, MRI
has the benefit of imaging with and without a

Fig. 3—68-year-old man in urology clinic with small
weight loss and left scrotal swelling that decreases
with micturition. CT image shows part of bladder
(arrow) is contained within direct left inguinal
hernia medial to inferior epigastric neurovascular
bundle (arrowhead). This hernia is also known as
sliding hernia.
Fig. 4—53-year-old man with incidental finding
of indirect right inguinal hernia during CT for
investigation of weight loss. CT image shows indirect
right inguinal hernia that contains appendix (arrow).
No significant stranding is present around appendix,
but hernia was not clinically reducible, suggesting
incarceration, hence it is known as Amyand hernia.
Inferior epigastric vessels medial to hernial neck
(arrowhead) are visible.
Fig. 5—64-year-old woman with abdominal pain,
vomiting, distention, and palpable right groin
swelling. CT image shows right-sided femoral hernia
medial to femoral vessels (curved arrow). Hernia has
narrow neck (straight arrow) that constricts contents
of sac, which contains small bowel. Resulting
dilatation of proximal small bowel loops (arrowheads)
is evident.

AJR:202, June 2014 W507

 Murphy et al.

Fig. 6—74-year-old
man with incidental
finding of fat-containing
direct left inguinal
hernia during pelvic
MRI for prostate
cancer staging. Axial
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T1-weighted MR image
depicts direct left
inguinal hernia (arrow),
which passes medially
to inferior epigastric
artery and vein
(arrowhead).

Valsalva maneuver. CT and MRI are both ex-
cellent modalities for the assessment of palpa-
ble abdominal masses in the nonacute phase
[12]. CT assessment is usually performed with
oral and IV contrast media; Valsalva maneu-
vers can also be used. Fluoroscopic herniog-
raphy is sensitive and has a high negative pre-
dictive value in the assessment of groin pain
in patients who have no clinical finding of a
palpable hernia in the nonacute phase [13].
It should be considered, when available, as a
first-line alternative to MRI and ultrasound in
the care of adult patients when hernia is the di-
agnosis of exclusion. Fluoroscopy allows ex-
amination of the patient with real-time imag-
ing during straining or a Valsalva maneuver.
Barium swallow and meal are useful for imag-
ing a suspected hiatal hernia.
Imaging Appearance
Groin Hernias
At CT, a fascial defect in which the con-
tents are continuous with intraabdominal
structures is observed in inguinal and femoral
hernias. Bowel and fat (Fig. 2) are the most
common hernial contents, but all or part of
Fig. 8—40-year-old man
who underwent scrotal
and groin ultrasound
for palpable scrotal
swelling. Ultrasound
image depicts direct left
inguinal hernia medial
to left inferior epigastric
vessels (arrowhead),
which contains loop of
small bowel (arrow).
many viscera can be contained within the her-
nial sac (Fig. 3). Hernias with certain contents
have eponymous names: Amyand hernia con-
tains an incarcerated appendix (Fig. 4), and
Littre hernia contains a Meckel diverticulum.
A sliding inguinal hernia (or sliding hernia),
however, has all or part of an extraperitoneal
viscus (e.g., bladder [Fig. 3]) as part of the sac
wall. A direct inguinal hernia (defect in the
posterior wall of the inguinal canal) is medial
to the inferior epigastric vessels. An indirect
hernia (contents pass through the deep ring
into the canal) is lateral to this neurovascular
bundle. The sac of a femoral hernia, however,
passes into the short (≈ 13 mm) femoral canal
medial to the femoral vein (Fig. 5).
MRI is often helpful in assessing groin
pain when the main differential diagnosis
is a musculoskeletal abnormality. It should
also be used in the evaluation of younger pa-
tients with nonacute signs and symptoms. In
these patients, MRI can depict muscle inju-
ries, including strains, interstitial and com-
plete tears, tendon avulsion injuries, bursitis,
and bone edema, which may not be as well
appreciated at CT. Because of their ubiqui-
Fig. 7—71-year-old man with readily palpable
right inguinal hernia undergoing herniography for
investigation of left groin pain without palpable
left groin hernia. Herniographic image depicts
large indirect right inguinal hernia (arrows). Neck
(arrowhead) is lateral in region of deep ring.
tous nature, hernias are often incidentally di-
agnosed at imaging (Fig. 6).
Fluoroscopic herniography (peritoneog-
raphy) in the assessment of groin pain with-
out a palpable hernia involves percutaneous
sterile introduction of iodinated contrast me-
dium into the peritoneal cavity via an infra-
umbilical midline anterior abdominal wall
approach. The hernial orifices are then flu-
oroscopically examined with the patient in
the prone oblique and erect positions at rest,
during straining, and during Valsalva ma-
neuvers. The typical finding is pooling of
contrast medium within an abnormal blind-
ending groin protrusion. Direct inguinal her-
nias can be delineated from indirect herni-
as according to the morphologic features of
the contrast-filled hernial sac and location of
the neck relative to the pubic tubercle. An in-
direct inguinal hernia has a more elongated
sac that passes along the inguinal canal with
a neck that lies more superolaterally rela-
tive to the tubercle than does a direct hernia
(Fig. 7). The neck and sac of femoral herni-
as lie below and lateral to the pubic tubercle,
whereas an inguinal hernia is above and me-
dial to the tubercle.
Sonography is frequently the first-line
imaging modality for assessment of groin
hernias in adults, particularly when non-
acute palpable swelling is found. Because of
the low cost, portability, and availability of
sonography, the contents of a small abdomi-
nal wall hernia can be quickly ascertained.
Sonography has the major benefit of dynam-
ic assessment, such as with and without a

W508 AJR:202, June 2014

 Adult Abdominal Hernias

Fig. 9—58-year-old Valsalva maneuver (Fig. 8) and before and

man with history
of colon cancer
after coughing. If the patient has an irreduc-
and laparotomy for ible palpable lump, then the contents, most
investigation of commonly bowel or fat, can be defined.
recurrent abdominal
pain. CT image shows
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ventral incisional Nongroin Abdominal Wall Hernias

hernia containing Abdominal wall hernias are found less of-
small bowel (arrows). ten in the ventral and lumbar regions than in
the inguinal territory. Umbilical and incisional
hernias are the most common nongroin ante-
rior abdominal wall hernias (Figs. 9 and 10).
Umbilical hernias tend to be small and occur
in females, whereas parumbilical hernias tend
to be large owing to separation and diastasis of
the rectus abdominis muscle. Hernias through
the linea alba above the umbilicus are termed
epigastric hernias and below the umbilicus,
hypogastric hernias. Lumbar hernias protrude
through the superior and inferior lumbar tri-
Fig. 10—38-year-old angles between the 12th rib and the iliac crest,
woman with clinically frequently as a result of surgery or trauma. As
large left lumbar hernia
in superior location and
with groin hernias, a fascial defect is seen on
background history of most occasions, and the contents are readily
spina bifida undergoing discernible at CT (Fig. 10). MRI is useful for
planning CT before assessing the size of a defect in nonacute her-
surgical repair. CT
image shows wide- nias. Ultrasound assessment of nongroin ante-
necked hernia (arrows) rior abdominal hernias with a high-frequency
that contains bowel linear-array probe shows a defect in the fascia
and part of left kidney.
Twelfth rib (arrowhead) of the anterior abdominal wall and allows de-
is also highlighted. tection of bowel or adipose tissue in a sac.

Internal and Pelvic Hernias

An internal hernia is among the most chal-
lenging abdominal hernia diagnoses on CT. The
key in assessment is the orientation and location
of the bowel relative to the duodenum and co-
lon. Paraduodenal hernia is the most common
type of internal hernia (left greater than right).
In a left paraduodenal hernia, the key finding is a
cluster of dilated small-bowel loops lateral to the
fourth part of the duodenum between the stom-
ach and pancreas (Fig. 11). With the increasing
frequency of bariatric surgery, hernias through
the transverse mesocolon (Petersen hernias)
are fast becoming the most frequently encoun-
tered internal hernias. Closed-loop obstruction
Fig. 11—34-year-
old man admitted is an important associated finding in all types
with abdominal of internal hernia, in which transition points are
pain, vomiting, and seen at either end of a dilated bowel loop (Fig.
distention who
underwent CT
12). This may be the only finding; its presence
that showed left should raise concern for an internal hernia.
paraduodenal hernia. In the case of pelvic hernias, a hernial
CT image shows sac is found most commonly adjacent to the
abnormally located
small-bowel loops anus, labia majora, or gluteal muscles in the
(straight arrows) perineum or less commonly the obturator or
between stomach sciatic foramina. Pelvic hernias tend to occur
(arrowheads) and
left renal vein
in elderly multiparous women because of ac-
(curved arrow). quired laxity of the pelvic floor.

AJR:202, June 2014 W509


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Fig. 12—54-year-old man with history of bowel
surgery arriving in emergency department with
abdominal pain and vomiting. CT image shows
internal hernia through defect in transverse
mesocolon (straight arrow) with associated closed-
loop small-bowel obstruction (arrowheads). Distal
transverse colon (curved arrow) is also visible.
Adult diaphragmatic hernias are most
commonly posttraumatic and left sided (Fig.
13). A small but important number of con-
genital hernias, particularly the Morgagni
type, are first diagnosed in adulthood. Coro-
nal and sagittal CT reformats are invaluable
for assessing the integrity of the diaphragm
and differentiating eventration (paralysis)
from a true hernia, a defect being visible in
Fig. 14—67-year-old woman with dyspepsia.
Radiograph obtained during barium swallow and meal
with patient in right anterior oblique position shows
large sliding hiatal hernia (arrowhead) and neck
of hernia (arrows) where part of stomach passes
through enlarged esophageal hiatus.
W510 AJR:202, June 2014
Murphy et al.
the latter. A collar sign, a waistlike visceral
constriction at the neck of a diaphragmatic
hernia, is often seen when a right-sided de-
fect leads to partial protrusion of the liver.
This is best appreciated on coronal images.
Left-sided hernias can contain bowel, stom-
ach, colon, spleen, or left kidney. MRI has a
role in assessing the diaphragm for a defect
in the nonacute situation. Fluoroscopic bar-
ium swallow and meal assessment remains
an excellent investigation in the care of pa-
tients with suspected hiatal hernia. The right
anterior oblique and left lateral positions are
most useful for identifying a sliding or, less
common, paraesophageal hernia (Fig. 14).
Fig. 15—61-year-old woman with history of right
femoral hernia mesh plug repair, small palpable
swelling in right groin, and associated groin asymmetry
at clinical examination, raising concern for recurrence.
CT image shows normal appearance of mesh plug
(arrows) that caused clinical findings.
Fig. 13—28-year-
old woman with
long-standing likely
posttraumatic large left
diaphragmatic hernia
undergoing planning CT
before surgical repair.
CT image shows hernia
that contains fat, small
bowel (arrows), and
splenic flexure of
colon (arrowhead).
Hernia Repair and Complications
Because of the high prevalence of hernias
and the frequency with which they are treat-
ed surgically, patients who have undergone
previous hernia repairs frequently need im-
aging to assess for suspected complications.
Bowel obstruction, incarceration, and stran-
gulation are the main complications of her-
nias. The imaging appearances are appli-
cable to both internal and external hernias.
Hernias are the second most common cause
of small-bowel obstruction, which occurs
more often in femoral than inguinal hernias,
although complicated inguinal hernias are
still the most common cause. If bowel is con-
tained within the hernial sac, symptoms of
midgut or hindgut pain with vomiting occur
as the result of acute or recurrent bowel ob-
struction. At imaging, transition from dilated
afferent to collapsed efferent bowel typically
is found at the hernial neck (Fig. 6).
Obstruction is more likely when incar-
ceration occurs. Localized pain or tender-
ness is more commonly present if the hernia
is irreducible (incarcerated). This clinical
finding may be suggested on images if the
neck of the hernia is narrow. Exquisite lo-
cal tenderness and pain should raise concern
for ischemia due to strangulated blood sup-
ply of the hernial contents at the level of the
hernia neck. The risk of strangulation is in-
versely proportional to neck size and is sug-
gested at imaging if there is fluid in the sac,
bowel-wall thickening, or luminal dilatation.
Obstruction of both ends of a bowel loop
increases the risk of strangulation. Thin-
walled veins initially become engorged,
causing mucosal hyperenhancement, pro-
gression to arterial compromise, ischemia

with mucosal hypoenhancement, and final-
ly, infarction, which causes pneumatosis and
free perforation.
Previous hernia repair is often recognized
when scarring, mesh, or sometimes a plug is
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found. Polypropylene mesh is not radiopaque,
but polytetrafluoroethylene is visible on CT
images. MRI better depicts mesh, so MRI is
increasingly being used for postoperative as-
sessment of the integrity of a hernia repair.
It is important to consider previous repair
as a potential cause of abnormalities at sites
of hernia occurrence to avoid medical mis-
adventure (Fig. 15) and to assess for hernia
recurrence, fluid collections, infection, and
visceral complications due to hernia repair.
Ultrasound can also be helpful in this setting
and is the modality of choice for imaging-
guided drainage of these collections. Testic-
ular artery ligation and subsequent testicular
ischemia are among the most feared compli-
cation of groin hernia repair in males, but is
rare, occurring in approximately 0.7% of cas-
es [3]. It is best assessed with ultrasound.
Conclusion
Adult abdominal hernias are common and
frequently encountered by general and gastro-
intestinal radiologists. CT is the key modality
for assessing both abdominal wall and inter-
AJR:202, June 2014 W511
Adult Abdominal Hernias
nal hernias in the acute phase. Inguinal her-
nias are by far the most common ventral ab-
dominal wall hernias, but femoral, umbilical,
and incisional hernias are also frequently en-
countered. The diagnosis of internal hernias
can be difficult, but the presence of closed-
loop bowel obstruction and abnormal place-
ment of small-bowel loops relative to the co-
lon or other viscera should raise suspicion.
Complications of hernias, such as incarcera-
tion, obstruction, and strangulation, can also
be readily assessed with CT. The likelihood of
these complications is inversely proportional
to the size of the neck of the hernia and is in-
fluenced by the type of hernia involved.
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