Hernias Ultrasound

REVIEW ARTICLE
Dynamic Ultrasound of Hernias of the Groin and

Anterior Abdominal Wall
A. Thomas Stavros, MD, FACR, FSRU and Cindy Rapp, BS, RDMS
Key Words: inguinal hernia, spigelian hernia, femoral hernia,

inguinal); and through broad flat tendons called aponeuroses
sports hernia, incarceration, Valsalva, preperitoneal
(direct inguinal). Hernias do not occur through the belly of ab-
dominal wall muscles unless they have been surgically incised.
(Ultrasound Quarterly 2010;26:135Y169)
TECHNICAL REQUIREMENTS
G roin hernias are common occurrences and usually present

with a lump, bulge, and/or pain. Hernias that present with
an obvious lump or bulge are often diagnosed clinically and
A high-frequency (Q12 MHz) 50-mm-long transducer
should be used in most patients. Only in very obese patients is
a lower-frequency transducer necessary, usually a 7- to 9-MHz
infrequently require imaging (except to look at the contra- curved array. Using a 50-mm-long transducer is important
lateral side preoperatively). On the other hand, hernias that because its larger field of view allows us to identify landmarks
present with pain without a lump or bulge are more often better, especially in patients who have diastasis of aponeu-
referred for diagnostic imaging. In the distant past, hernio- roses. In departments where the longest transducer available
graphy was the procedure of choice. More recently, computed is 38 mm, using a trapezoidal or virtual convex display can be
tomography (CT) and magnetic resonance imaging (MRI) helpful. In some cases, extended field of view modes can be
have been used to identify and describe hernias (Fig. 1). helpful, particularly in indirect inguinal hernias that extend
However, real-time ultrasound has an insurmountable advan- into the scrotum and long incisional hernias. It is important to
tage over other imaging modalitiesVthe ability to scan the be able to store and review video loops to capture dynamic
patient in both upright and supine positions and to use dynamic events that are so critical to diagnosis.
maneuvers such as Valsalva and compression and the ability
to document motion in real time (Fig. 2). This is important HERNIA CONTENTS
because positioning and dynamic maneuvers affect our ability Most sonographically detected hernias do not contain
to diagnose a hernia, alter its size and contents, and evaluate its bowel. In fact, most hernias contain only fat (Fig. 3). The fat
reducibility. Sonography also enables us to assess tenderness may be intraperitoneal (mesenteric or omental) or preperi-
and clinical significance of a hernia. toneal in origin. Generally, it is not possible sonographically
There are various definitions of the groin. The most to distinguish whether the hernia contains intraperitoneal or
common definition is that the groin is represented by the preperitoneal fat. Only in rare cases of hernias that contain
ilioinguinal crease at the junction of the abdomen and the thigh both intraperitoneal and preperitoneal fat can the distinc-
and the adjacent areas just above and below. In the strictest tion be made (see video, Supplementary Digital Content 1,
sense, the only groin hernias are inguinal. However, Spigelian http://links.lww.com/RUQ/A4). Hernias that contain intraper-
and femoral hernias lie in such close proximity to the inguinal itoneal fat can potentially later contain bowel and are thus po-
area that we will consider them groin hernias as well. tentially of greater risk than those that contain only preperitoneal
Sonographic evaluation of the groin should include fat. Some hernias contain free fluid of intraperitoneal origin
assessment for spigelian, direct and indirect inguinal, and (Fig. 4). Hernias that contain bowel (Fig. 5) (see video, Sup-
femoral hernias. According to Dorland’s Medical Dictionary, plementary Digital Content 2, http://links.lww.com/RUQ/A5)
a hernia is defined as Bthe protrusion of a loop or knuckle are considered higher risk because strangulation may lead to
of an organ or tissue through and abnormal opening.[ Not infarction of bowel. Large hernias that are the most likely to
all hernias contain bowel. In fact, most sonographically diag- contain bowel are easier to detect clinically and less often re-
nosed hernias contain only fat. Hernias occur in areas of natu- quire sonographic imaging for diagnosis. Hernias can contain
ral weaknessVin areas where vessels penetrate the abdominal small bowel, colon, or appendix. Other hernias contents that
wall (femoral and spigelian); where fetal migration of testis, are much less common include ovaries and Bbladder ears.[
spermatic cord, or round ligament have occurred (indirect
DYNAMIC MANEUVERS
Received for publication August 14, 2009; accepted June 29, 2010.
Invision Sally Jobe, Radiology Imaging Associates, Denver, CO. The dynamic maneuvers that are the key to ultrasound’s
Supplemental digital contents are available for this article. Direct URL citations advantage over CT and MR include Valsalva maneuver, com-
appear in the printed text and are provided in the HTML and PDF versions of pression maneuver, and upright positioning. Dynamic maneu-
this article on the journal’s Web site (www.ultrasound-quarterly.com). vers are useful because many hernias spontaneously reduce
Reprints: A. Thomas Stavros, MD, FACR, FSRU, Invision Sally Jobe, Radiology
Imaging Associates, 2530 South Fillmore Street, Denver, CO 80210 when the patient is supine and breathing quietly, making them
(e-mail: tstavros@riaco.com). undetectable. Hernias that contain only fat are nearly isoechoic
Copyright * 2010 by Lippincott Williams & Wilkins with surrounding tissues, and therefore, they are relatively
Ultrasound Quarterly & Volume 26, Number 3, September 2010 www.ultrasound-quarterly.com 135
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Stavros and Rapp Ultrasound Quarterly & Volume 26, Number 3, September 2010
Furthermore, in some patients, the pain is caused by

other etiologies. Upright positioning is essential in all patients
being sonographically evaluated for groin hernia. Many patients
are either symptomatic only in the upright position or are more
symptomatic in the upright position. Hernia contents can change
in the upright position. Fluid can best be demonstrated with
the patient in the upright position, especially in females. It
may take minutes for the free fluid to Bpuddle[ in the inferior
end of the hernia sac once the patient has been placed in the
upright position. Therefore, delayed imaging in the upright
position may be helpful in demonstrating the peritoneal fluid
(Fig. 8). Others contain bowel only in the upright position.
Some hernias either are only present in the upright position or
are much better demonstrated in the upright position (direct
FIGURE 1. Abdominal CT scan demonstrating bilateral

moderate-sized fat-containing indirect inguinal
hernias (arrows).
inconspicuous. Dynamic maneuvers can cause the fat within a

hernia to move, making the hernia contents more conspicuous.
The direction of movement can be helpful because move-
ment of surrounding tissues is almost always in the ante-
roposterior direction, whereas hernia contents often move
horizontally during compression maneuvers (see video, Sup-
plementary Digital Content 3, http://links.lww.com/RUQ/A6).
Hernia contents may change with dynamic maneuvers. Fi-
nally, reducibility and tenderness can be assessed. The Val-
salva maneuver is most useful when the patient is supine.
It forces hernia contents anteriorly and often horizontally in
an inferomedial direction (Fig. 6) (see videos; Supplementary
Digital Contents 4, http://links.lww.com/RUQ/A7 and SDC 5,
http://links.lww.com/RUQ/A8). Some hernias become visible
only during the Valsalva maneuver (see video, Supplementary
Digital Content 6, http://links.lww.com/RUQ/A9).
In other cases, hernia sacs that can be seen in quiet
respiration elongate and widen during the Valsalva maneuver.
Hernia contents can change during the Valsalva maneu-
ver. Hernias that appear to contain only fat during quiet
respiration may be shown to contain bowel during the Val-
salva maneuver (see video, Supplementary Digital Content 7,
http://links.lww.com/RUQ/A10). In some patients, the hernia
becomes tender during the Valsalva maneuver. Compression
is essential to assess reducibility and tenderness in patients
who have sonographically detectable hernias, regardless of
whether the patient is upright or supine. Compression man-
euvers are also useful in supine patients in whom the Valsalva
maneuver is ineffective. Compression helps assess reducibil-
ity of a hernia. Hernias may be completely reducible, partially
reducible, or nonreducible (incarcerated; see videos; Supple-
mentary Digital Contents 8, http://links.lww.com/RUQ/A11;
SDC 9, http://links.lww.com/RUQ/A12; and SDC 10,
http://links.lww.com/RUQ/A13. The shape of hernias corre-
lates with reducibility. A hernia with a broad fundus and narrow FIGURE 2. A, Abdominal CT showing no evidence of femoral
neck is likely to be nonreducible, whereas a hernia with a broad hernias visualized. B, Transverse image of the femoral canal
neck compared with the fundus is more likely to be reducible during quite respiration appearing normal. C, Transverse
(Fig. 7). Assessing tenderness is very important because dy- image of the femoral canal during Valsalva showing bilateral
namic sonography is so sensitive that it detects many asymp- fat containing hernias with the right being larger than the
tomatic and clinically insignificant hernias. left (arrows).
136 www.ultrasound-quarterly.com * 2010 Lippincott Williams & Wilkins
Ultrasound Quarterly & Volume 26, Number 3, September 2010 Dynamic Ultrasound of Hernias of the Groin
FIGURE 3. Long-axis image of an indirect inguinal hernia

(arrows) that contains only fat. IEA indicates inferior
epigastric artery.
inguinal and femoral). The reducibility of a hernia may vary

between supine and upright position, so it is important to FIGURE 5. Short-axis view of the inguinal canal in the
assess reducibility in both positions (see videos; Supple- upright position showing an indirect inguinal hernia that
mentary Digital Contents 11, http://links.lww.com/RUQ/A14, contains bowel.
and SDC 12, http://links.lww.com/RUQ/A15). In most patients,
groin hernias are more reducible in the supine than in the up- femoral hernias. The key landmark in distinguishing between
right position, whereas in others, the opposite is true. Finally, the first 3 types is the inferior epigastric artery. This artery
tenderness may vary between the supine and upright positions. arises from the external iliac artery and then courses super-
omedially, crossing the spigelian fascia and the semilunar line,
KEY SONOGRAPHIC LANDMARKS IN eventually coursing along the midposterior aspect of the rectus
IDENTIFYING THE TYPE OF GROIN HERNIAS abdominis muscle. The inferior epigastric artery can be iden-
THAT LIE ABOVE THE INGUINAL LIGAMENT tified sonographically in all patients along the midposterior
Four types of hernias occur with the broader definition surface of the rectus abdominis muscle at a level about half
of the groin: indirect inguinal, direct inguinal, spigelian, and way between the umbilicus and pubic symphysis while scan-
ning in a transverse plane (Fig. 9). The artery lies anterior the
peritoneum and is thus never obscured by bowel gas. Once
the artery is identified in the transverse plane, it can be traced
inferiorly and laterally to its origin from the external iliac artery.
The internal inguinal ring lies in the crotch between the external
iliac artery and the proximal inferior epigastric artery. Direct
inguinal hernias arise through the Bconjoined tendon[ inferior
and medial to the origin of the inferior epigastric artery. Spi-
gelian hernias occur through the spigelian fascia just lateral to
where it is penetrated by the inferior epigastric artery. Femoral
hernias lie within the femoral canal inferior to the inguinal
ligament (Fig. 10). Once the origin of the inferior epigastric
artery is identified, the transducer should be rotated into an
axis that is parallel to the inguinal ligament, which courses
obliquely from superolaterally to inferomedially. The patient
should be scanned in long axis parallel to the inguinal ligament
and short axis perpendicular to the inguinal ligament rather
than scanning transversely and longitudinally (Fig. 9).
Inguinal Hernias
Inguinal hernias can be classified as direct or indirect.
FIGURE 4. Long-axis image of a fluid-containing femoral The terms direct and indirect refer to how hernias present
hernia that presented with pain and swelling. during open surgical repairs. Direct inguinal hernias protrude
* 2010 Lippincott Williams & Wilkins www.ultrasound-quarterly.com 137
FIGURE 6. Split-screen long-axis views of a fat-containing indirect inguinal hernia during quiet respiration and Valsalva maneuvers.
The left image shows the hernia during quiet respiration (arrows). The right image, obtained during a Valsalva maneuver,
shows the hernia contents being forced distally in a horizontal direction within the inguinal canal (arrows and dotted arrows).
into the surgically opened inguinal canal Bdirectly[ from pos- lateral direction after passing through the internal inguinal
teriorly. Indirect inguinal hernias, on the other hand, enter the ring (deep inguinal ring). From a sonographic point of view,
surgically opened inguinal canal Bindirectly[ from a supero- the terms Bdirect[ and Bindirect[ are confusing. It would be
FIGURE 7. Left image and diagram showing a typical shape for direct inguinal hernia, a wide neck in comparison to the fundus. This
hernia shape correlates with complete reducibility. Right image and diagram show a typical shape for a an linea alba hernia, a
very narrow neck in comparison to the fundal width. This hernia shape correlates with nonreducibility and with an increased
risk of strangulation.
FIGURE 8. A, Long-axis view of a moderate-sized indirect inguinal hernia obtained in the supine position during a Valsalva
maneuver and showing it to contain only fat. B, Long-axis view of the same hernia obtained immediately after the patient was
placed in the upright position. The hernia appears slightly larger than it was in the previous image but still contains only fat.
C, Delayed imaging in the upright position now showing that the hernia also contains fluid. This proves that the hernia contains
intraperitoneal contents not just preperitoneal contents.
less confusing to characterize them as internal inguinal ring However, delayed or incomplete closure of the canal of Nuck
(indirect) and nonring (direct) hernias. can also occur in females. The neck of an indirect inguinal
hernia is the segment that lies within the internal inguinal ring
Indirect Inguinal Hernias and the fundus lies within the inguinal canal (Fig. 11). The
Indirect inguinal hernias are the most common type neck (internal inguinal ring) lies just superior and lateral to the
of groin hernia. They are congenital and represent a persis- origin of the inferior epigastric artery and tends to be oriented
tence of a patent process vaginalis. In males, the testis de- in an anteroposterior direction, whereas the fundus (inguinal
scends from the abdominal cavity into the scrotum, which can canal) is oriented horizontally and courses inferiorly and
result in delayed or incomplete closure of the inguinal canal. medially, passing superficial to the origin of the inferior epi-
Thus, indirect inguinal hernias are more common in males. gastric artery. The fundus of an indirect inguinal hernia lies
FIGURE 9. Diagram and images of the main landmark for evaluating the inguinal area, the inferior epigastric vessels (EIVs). Image 1
is obtained in a transverse plane about half-way between the umbilicus and the pubic symphysis. The inferior epigastric artery
and its paired veins lie along the midlateral posterior surface of the rectus abdominis muscle. Image 2 is obtained several centimeters
inferiorly, and the EIVs lie more laterally. Image 3 is obtained at a level where the IEVs (arrow) lie at the edge of the rectus
muscle. (This is the level at which most spigelian hernias occur.) Image 4 shows that once the origin of the inferior epigastric
artery, the transducer should be rotated into planes that are parallel and perpendicular to the inguinal canalVlong-axis and
short-axis views.
In some cases, it can be difficult to demonstrate the

relationship of the hernia neck to the inferior epigastric vessels.
In such cases, it is helpful to assess the relationship of the
hernia sac to the spermatic cord. Indirect inguinal hernias tend
to lie along the anterior and lateral aspect of the spermatic
cord, whereas direct inguinal hernia sacs tend to lie medial
and posterior to the cord (Fig. 14; see videos; Supplementary
Digital Contents 13, http://links.lww.com/RUQ/A16 and SDC
14, http://links.lww.com/RUQ/A17). In females, indirect in-
guinal hernias lie anterior to the round ligament (Figs. 15A, B).
Large indirect direct inguinal hernias can flatten and splay
the spermatic cord (Figs. 16 and 17; see video, Supplementary
Digital Content 15, http://links.lww.com/RUQ/A18), causing
pain that radiates into the scrotum. Indirect inguinal hernias are
far more likely than are direct inguinal hernias to extend into the
scrotum or labium majus (Fig. 18; see video, Supplementary
FIGURE 10. Abdominal and pelvic CT image, reformatted in
Digital Content 16, http://links.lww.com/RUQ/A19).
the coronal plane, illustrating the locations of the 4 types of Direct Inguinal Hernias
‘‘groin’’ hernias. Indirect inguinal hernias arise within the internal
or deep inguinal ring, which lies in the crotch between the Direct inguinal hernias are the second most common
external iliac artery and the proximal inferior epigastric artery. type of groin hernia and are acquired. They arise in 2 ways:
Direct inguinal hernias arise through the ‘‘conjoined tendon,’’ either a passing through a defect in the conjoined tendon
which lies inferior and medial to the origin of the inferior (Fig. 19) or by markedly stretching the tendon into the ingui-
epigastric artery. Spigelian hernias arise through the spigelian nal canal (Fig. 20). During open hernia repair, direct inguinal
fascia just lateral to the inferior epigastric artery where it reaches
the lateral margin of the rectus muscle. Femoral hernias lie
within the femoral canal, inferior to the inguinal canal and
inguinal ligament.
anterior and lateral to the spermatic cord in males and to the

round ligament in females (Fig. 12). In the short axis, the
internal inguinal ring and the neck of the indirect inguinal
hernia lies between the external iliac artery along its medial
side and the inferior epigastric artery along its lateral side. In
the long axis, indirect inguinal hernias can have 2 different
appearancesVsliding and nonsliding types. The sliding type
has a relatively wide neck in comparison to the fundus and
loss of the angle between the neck and fundus. It is usually
reducible, at least in the supine position, and is more likely to
contain bowel and other intraperitoneal contents. The non-
sliding type has a relatively narrower neck (in comparison to
the fundus) and maintains the nearly 90-degree angle between
the neck and fundus (Fig. 13). Such hernias usually contain
only properitoneal fat, are nonreducible, and have frequently
been misclassified as spermatic cord or inguinal canal lipomas
at surgery. Nonsliding-type indirect inguinal hernias are more
difficult to diagnose sonographically than are sliding types for
several reasons: (1) they tend to be smaller, (2) they contain
only fat that is nearly isoechoic with the surrounding tissues,
and (3) their nonreducibility minimizes motion of contents
during dynamic maneuvers. Because the properitoneal fat in FIGURE 11. This diagram shows the relationship of indirect
nonsliding hernias is nonreducible, it can be mistaken for a inguinal hernias (IIH) to the inferior epigastric artery (IEA) origin
Bspermatic cord lipoma[ or inguinal canal lipoma. True sper- from the external iliac artery (EIA). The neck of the hernia arises in
the internal inguinal ring (IIR), extends anteriorly, then extends
matic cord hernias can occur, but these are rare (Fig. 77). In
inferomedially superficial to the proximal to the IEA and lies
the short axis, the sliding type of direct inguinal hernia can be anterior to the spermatic cord (SC) in males or round
diagnosed either at the level of the internal inguinal ring or ligament (RL) in females. Other landmarks: CFA indicates
at the level of the inguinal canal. However, the nonsliding type common femoral artery; CFV, common femoral vein; EIA, external
can be diagnosed only at the level of the inguinal canal, where iliac artery; EIV, external iliac vein; GSV, greater saphenous vein;
it is widest. IC, inguinal canal; IL, inguinal ligament; RA, rectus abdominis.
of direct inguinal hernias is typically wider than the fundus.

This makes incarceration and strangulation of direct hernias
rare. As is the case for indirect inguinal hernias, contents vary.
Most small-to-medium direct inguinal hernias are completely
reducible, but large direct inguinal hernias may be incompletely
reducible, especially in the upright position. Most direct inguinal
hernias spontaneously reduce completely in the supine position
during quiet respiration and are therefore visible only during
Valsalva maneuvers or in the upright position. The conjoined
tendon consists of the aponeuroses of the internal oblique and
transverse abdominis muscles and the underlying transversalis
fascia. It occurs inferior to the lower edge of the external oblique
aponeurosis. In most patients, the aponeuroses of the internal
oblique and transverse abdominis muscles are not closely ad-
herent to each other, the aponeurosis of the transverse abdom-
inis muscle is separated from the underlying transversalis
fascia and peritoneum by a variable layer of preperitoneal fat,
and the conjoined tendon is not really a well-defined structure
(Fig. 22). Thinning and anterior bulging of the conjoined ten-
don (Bconjoined tendon insufficiency[) is a precursor to the
development of direct inguinal hernias. In males, the anterior
FIGURE 12. This diagram and image show a long-axis view of bulging displaces and rotates the spermatic cord laterally. The
an indirect inguinal hernia. The neck of the hernia lies in the thinning and bulging of the conjoined tendon pushes the apo-
internal inguinal ring (IIR) that lies superior and lateral to the neuroses of the internal oblique and transverse abdominis
proximal inferior epigastric artery (IEA). The sac of the hernia muscles closer together, making the conjoined tendon appear to
then courses horizontally in an inferomedial direction within be a more discrete structure than it appears to be when the
the inguinal canal (IC). Indirect inguinal hernias always pass patient is in the supine position and in quiet respiration (Figs. 23
superficial to the IEA. and 24). As the thinning and bulging progresses, a tear can form
within the tendon, leading to the formation of a direct inguinal
hernias protrude directly into the opened inguinal canal from hernia. Smaller direct inguinal hernias extend anteriorly into the
posteriorly, accounting for their name. Indirect inguinal hernias, floor of the inguinal canal, but larger hernias turn inferiorly and
on the other hand, extend into the opened inguinal canal in- medially extending distally within the canal. Factors that can
directly from superiorly and laterally. The conjoined tendon cause conjoined tendon insufficiency to progress to frank direct
area, and thus the neck of a direct inguinal hernia, arises inferior inguinal hernia over time include any cause of increased intra-
and medial to the inferior epigastric vessels (Fig. 21). The neck abdominal pressure (obesity, pregnancy, ascites, coughing, and
FIGURE 13. Image and diagram of 2 different types of indirect inguinal hernias. A, Sliding-type hernia. The neck (arrows) is as wide
as or is wider than the fundus (arrowheads), and loss of the angle between the internal inguinal ring and inguinal canal. Sliding
hernias usually contain intraperitoneal contents and are reducible. B, Nonsliding-type hernia. The neck (arrows) is narrow in
comparison to the fundus (arrowheads), and the nearly 90-degree angle between the internal inguinal ring and the inguinal canal
is preserved. These hernias usually contain only properitoneal fat and are nonreducible. They have often been misclassified as
lipomas of the inguinal canal or spermatic cord. Dotted circles indicate inferior epigastric artery.
FIGURE 14. This patient has bilateral inguinal hernias, direct on the right and indirect on the left, and illustrates differences in
the position of hernia sacs relative to the spermatic cord. Left illustration: indirect inguinal hernias (ind) usually lie anterior to the
spermatic cord (SC), while direct (dir) inguinal hernias lie posterior to the cord (SC). The middle split screen images in short
axis show the right direct hernia sac (h) lying posterior to the cord (SC) and the left indirect hernia sac (H) lying anterior to the
cord (SC). B, The right split screen images in long axis show the right direct hernia sac lying posterior to the cord (SC) and
the left indirect hernia sac lying anterior to the cord (SC).
straining) and generalized connective tissue weakness. Because inguinal hernias. However, sonographically detected femoral
these underlying causes affect both sides, direct inguinal hernias hernias are far more common than the literature would suggest.
are frequently bilateral, although often asymmetric (Fig. 25). Unlike inguinal hernias, femoral hernias are more common
It is difficult to explain why bilaterally symmetrical direct in- in women than in men. It is thought that the increased intra-
guinal hernias can vary so much clinically. It is not unusual to pelvic pressure that occurs during the third trimester of preg-
find one direct inguinal hernia symptomatic and exquisitely nancy together with the hormone-induced softening of tissues
tender, whereas the contralateral hernia is asymptomatic and predisposes to the development of femoral hernias. Femoral
nontender. hernias arise within the femoral canal inferior to the inguinal
Direct inguinal hernias, and their precursors, posterior canal and ilioinguinal crease. The femoral canal lies just me-
inguinal wall insufficiency, are common problems for athletes, dial to the common femoral vein (CFV) and just superior to
but we will discuss this later in the section on sports hernias. the saphenofemoral junction (Fig. 26). The saphenofemoral
junction, similar to the origin of the inferior epigastric artery
Femoral Hernias for inguinal hernias, is the key landmark for identifying the
The literature reports that femoral hernias are rare femoral canal (see video, Supplementary Digital Content 17,
because they are difficult to diagnose clinically unless they http://links.lww.com/RUQ/A20). The most common location
become strangulated. They are, in fact, much less common than for femoral hernias is medial to the CFV, but a few lie anterior
FIGURE 15. A, Long-axis view of a fat-containing indirect inguinal hernia (oblique arrows) showing the sac anterior to the
round ligament (vertical arrow) in a female patient. B, Short-axis view of a fat-containing indirect inguinal hernia (arrow) seen anterior
to the round ligament.
FIGURE 16. Short-axis view of an indirect inguinal hernia FIGURE 18. Extended field-of-view image showing a long-axis
showing it displacing and compressing the hyperechoic view of a very large indirect inguinal hernia extending down
spermatic cord posteriorly. the entire length of the inguinal canal into the scrotum.
H indicates hernia; T, testis.
to the common femoral vessels (Figs. 27 and 28). Most of the
femoral hernias that lie anterior to the CFV arise medially and the Valsalva maneuver or in the upright position during com-
then extend anteriorly (see video, Supplementary Digital Con- pression maneuvers. Femoral hernias, like direct inguinal her-
tent 18, http://links.lww.com/RUQ/A21). It is rare for a femoral nias, are often bilateral (Fig. 2C; see videos; Supplementary
hernia to actually arise anteriorly (Teale hernia; Fig. 29). Digital Contents 19, http://links.lww.com/RUQ/A22 and SDC
Although it has been reported that femoral hernias can lie 20, http://links.lww.com/RUQ/A23).
posterior or lateral to the CFV, we have never seen one in either
of these locations. A femoral hernia tends to have a narrow neck Spigelian Hernias
in comparison to the width of its fundus, a shape that predis- Spigelian hernias that present clinically, like femoral
poses it to strangulation. In fact, femoral hernias are the most hernias, are rare, and like femoral hernias, sonographically
likely type of groin hernia to strangulate (Fig. 30). Femoral
hernia contents vary, as in all other groin hernias. In addition, as
is the case for all other groin hernias, most contain only fat.
Femoral hernias that contain bowel are almost always non-
reducible and frequently strangulated as well. The femoral canal
lies deeper than the inguinal canal and may be more difficult
to assess with a high-frequency linear array transducer. As is
the case for direct inguinal hernias, small and even moderate-
sized femoral hernias frequently reduce completely in the
supine position during quiet respiration and are most read-
ily demonstrated with the patient in the supine position during
FIGURE 19. Long-axis view of a fat-containing direct inguinal

FIGURE 17. Short-axis view of a direct inguinal hernia showing hernia passing through an acute tear (asterisk) in the conjoined
it displacing and compressing the hyperechoic spermatic tendon (arrows) and extending down the inguinal canal
cord anteriorly and laterally. (arrowheads).
between the multiple layers of lateral muscles (either between

the transverse abdominis and internal oblique or between the
internal and external oblique muscles). In some cases, the spi-
gelian fascia, like the linea alba, can become diastatic and
widen. Extended field of view modes may be helpful in dem-
onstrating the anatomy in such cases (Figs. 32 and 33).
Sports Hernia
Sports hernia is a common cause of groin and/or pubic
pain among elite and professional athletes. Sports hernia is a
complex, confusing, and controversial subject. Neither is there
a universally accepted definition of sports hernia nor is there
uniform agreement on the best treatment. Sports hernia has
also been called the Bsportsman’s hernia,[ Bathletic pubalgia,[
and many other names. It is complex (1) because it occurs in
an area where many tendons come together and are hard to
separate from each other and where weakness in one may lead
to failure of another or to instability of the pubic symphysis,
(2) because there are often multiple different abnormalities
FIGURE 20. Long-axis view of this large direct inguinal hernia that together contribute to pain, and (3) because surgery may
showing the thinned and stretched conjoined tendon and help some of the underlying causes but not others. Sports
underlying transversalis fascia and peritoneum (arrows) hernias most commonly occur in elite athletes who kick, bend
forming the hernia sac. Dotted circle indicates inferior over at the waist, and make sudden changes in direction.
epigastric artery.
detected spigelian hernias are more common than the literature

would suggest. Spigelian hernias are usually considered
anterior abdominal wall hernias rather than groin hernias.
They can occur anywhere along the course of the spigelian
fascia, the complex aponeurotic tendon that lies between the
oblique muscles laterally and the rectus muscles medially.
However, almost all spigelian hernias occur at the inferior
end of the semilunar line, inferior to the arcuate line, where the
posterior rectus sheath is absent and where the spigelian fascia
is penetrated and weakened by the inferior epigastric vessels
(Fig. 31). In many patients, this location is within a couple
of centimeters of the internal inguinal ring. Furthermore, when
symptomatic, the pain caused by spigelian hernias can be
difficult to distinguish from that caused by indirect inguinal
hernias. Therefore, we are including spigelian hernias in our
discussion of groin hernias. The spigelian fascia is composed
of several different layers of loosely apposed aponeurotic ten-
dons. From external to internal lie the aponeuroses of the ex-
ternal oblique, the internal oblique, and the transverse abdominis
muscles. Internal to the aponeuroses lie the transversalis fascia
and peritoneum. In spigelian hernias, the transverse abdominis
tendon is always torn. In most cases, the internal oblique apo-
neurosis is also torn (Fig. 32). The external oblique tendon is
always intact and usually forces the hernia sac to extend either
medially over the anterior aspect of the rectus abdominis mus- FIGURE 21. Diagram showing the relationship of a direct
cle and/or laterally over the external oblique muscles, forc- inguinal hernia (DIH) to the surrounding anatomy. The neck
ing it into the shape of an anvil or mushroom (Figs. 33 and of the hernia arises in the area of the conjoined tendon and
34). Like femoral hernias, spigelian hernias have narrow lies inferior and medial to the proximal inferior epigastric artery
(IEA). The hernia sac does not pass superficial to the IEA and
necks and broad fundi (see videos; Supplementary Digital
lies posterior and medial to the spermatic cord (SC) or round
Contents 21, http://links.lww.com/RUQ/A24 and SDC 22, ligament (RL). CFA indicates common femoral artery; CFV,
http://links.lww.com/RUQ/A25), making them at least partially common femoral vein; EIA, external iliac artery; EIV, external
nonreducible and predisposing them to strangulation (Fig. 35). iliac vein; GSV, greater saphenous vein; IIR, internal inguinal
Because spigelian hernias pass through multiple layers of ten- ring; IL, inguinal ligament; RA, rectus abdominis muscle; SC/RL,
dons, projections of the hernia may also extend intraparietally spermatic cord/round ligament.
FIGURE 22. A, Short-axis view of a direct inguinal hernia showing a thinned and bulging conjoined tendon composed of the
internal oblique aponeurosis (superficial arrows) and the transverse abdominis aponeurosis (arrowhead) and the underlying
transversalis fascia (horizontal arrow) and peritoneum (asterisk). B, Long-axis view of a direct inguinal hernia showing the conjoined
tendon (between the 3 vertical arrows and the arrowhead), the underlying transversalis fascia (oblique arrow), and peritoneum
(asterisk).
Soccer players, hockey players, and American- and Australian-

rules football players are most commonly affected. Sports
pubalgia can be especially debilitating for elite and professional
athletes, causing long periods of disability, and can be career-
threatening. Sports hernias are far more common in men than
in women because of differences in the insertion of the rectus
muscles into the pubis, but the incidence is increasing in women.
The type of hernia most often associated with groin
pain in athletes is the direct inguinal hernia or its precursor,
Bposterior inguinal wall deficiency[ (conjoined tendon insuf-
ficiency). However, in many athletes with groin pain, hernia is
not the only cause of pain or even the main cause of pain.
Dynamic ultrasound is the best modality for demonstrating
groin hernias associated with sports pubalgia, but MRI is
generally better for demonstrating causes of pain other than
hernia. The underlying pathological diagnosis is usually ten-
dinosis of either the adductor longus origin and/or the rectus
abdominis insertion. The tendons of these 2 muscles inter-
digitate, making them inseparable from each other as they
insert onto the pubis. Tendinosis of one usually leads to ten-
dinosis of the other and, eventually, to instability of the pubic
symphysis and osteitis pubis. Tendinosis of the rectus abdo-
minis muscle can also lead to microtears where the apo-
neuroses of the internal oblique and transverse abdominis
muscles (components of the conjoined tendon) insert onto the FIGURE 23. Diagram showing the relationship of the
rectus sheath, causing them to bulge anteriorly into the ingu- conjoined tendon to the spermatic cord in quiet respiration
inal canalVposterior inguinal wall insufficiency or conjoined in the supine position (upper illustration) and bulging of the
tendon insufficiencyVand leading to dilatation of the external conjoined tendon during Valsalva maneuver or in the upright
(superficial) inguinal ring. The thinned and bulged conjoined position (lower illustration). 1 indicates internal oblique
tendon pushes the spermatic cord laterally, rotates it, and aponeurosis; 2, transverse abdominis muscle; 3, transversalis
fascia; 4, peritoneum. In the supine position, the layers are
compresses it. Because of the effects on the spermatic cord, the separated by loose connective tissues or fat. During the Valsalva
resulting pain often radiates into the scrotum. Posterior ingu- maneuver or in the upright position, the layers tend to be
inal wall insufficiency is usually bilateral, although symptoms pushed together and are more difficult to distinguish from each
may only be unilateral. It the short axis, posterior inguinal wall other. When the aponeuroses of the internal oblique and
insufficiency appears indistinguishable from direct inguinal transverse abdominis muscles are pushed together, the
hernia (Figs. 23 and 24). However, in the long axis, posterior conjoined tendon appears to be a more discrete structure.
FIGURE 24. Split-screen images: The left image shows the relationship of the conjoined tendon to the spermatic cord in quiet
respiration in the supine position. The conjoined tendon lies posterior to the spermatic cord. The right image shows anterior bulging
of the conjoined tendon during Valsalva maneuver, which now protrudes anterior to the spermatic cord and pushes and rotates
the cord laterally.
inguinal wall insufficiency and direct inguinal hernia have The direct inguinal hernia sac will be seen posterior to the
different shapes. The posterior wall insufficiency is semicir- spermatic cord (Figs. 14A, B; see videos; Supplementary Dig-
cular, whereas the direct inguinal hernia protrudes inferiorly ital Contents 13, http://links.lww.com/RUQ/A22 and SDC 14,
within the inguinal canal in a finger-like projection (Fig. 36). http://links.lww.com/RUQ/A7), whereas in the posterior in-
At the level of the proximal inguinal, canal insufficiency and guinal wall insufficiency, the inguinal canal will appear normal.
direct inguinal hernia can only be distinguished from each Posterior inguinal wall insufficiency can progress to
other in the long axis because they appear identical to each direct inguinal hernia in 2 ways: (1) the conjoined tendon can
other in the short axis. However, more distally within the tear completely or (2) the tendon can become so thinned and
inguinal canal, the distinction can be made in the short axis. stretched that it is pushed inferomedially into the distal inguinal
FIGURE 25. Split-screen images showing short-axis views of bilateral fat-containing direct inguinal hernias. Bilateral direct
inguinal hernias occur commonly.
canal. Both arise inferior and medial to the origin of the inferior
epigastric vessels, but in patients with acute tendon tears, the
neck is small and the hernia sac appears thin (transversalis
fascia and peritoneum; Fig. 37), whereas in severe stretching of
the conjoined tendon, the neck is wide and the hernia sac
appears thicker (aponeuroses of internal oblique and transverse
abdominis muscles as well as transversalis fascia and perito-
neum; Figs. 20 and 36). Because there is usually some degree of
tendinosis and/or osteitis pubis, even when a direct inguinal
hernia or posterior inguinal wall insufficiency is present, simply
assessing sonographically for hernia is often insufficient for the
workup of these patients. Ultrasound can show tendinosis in the
rectus and adductor tendons in some cases (Fig. 38), but it is not
as reliable in doing so as in MRI. In addition, MRI can
demonstrate osteitis pubis and findings such as the secondary
cleft, whereas sonography cannot. Only repairing an inguinal
hernia or posterior wall deficiency in a patient who has other
pathological diagnosis may not cure the patient’s groin pain.
Thus, optimal imaging workup of athletes with groin pain
usually requires both dynamic ultrasound of the groin and MRI.
In patients who have inguinal hernias or inguinal wall insuffi-
ciency, both surgical repair of the hernia and either surgical FIGURE 27. Illustration showing a short-axis view of the
relationship of femoral hernias to the femoral vessels. Most
femoral hernias arise medial to the common femoral vein and
can extend anterior to the CFV as they enlarge. A few small
femoral hernias (Teale hernia) may arise anterior to the CFV
(arrows). a, indicates common femoral artery; FH and arrow,
most common femoral hernia locations; IP, iliopsoas muscle;
V, common femoral vein.
FIGURE 26. Illustration showing the relationship of a femoral

hernia (FH) to the surrounding anatomy. Femoral hernias arise
within the femoral canal, which lies medial to the common
femoral vein just superior to the saphenofemoral junction
and inferior to the inguinal ligament. Small femoral hernias
remain medial to the CFV, but larger hernias usually wrap
around anterior to the CFV. CFA indicates common femoral
artery; CFV, common femoral vein; EIA, external iliac artery; FIGURE 28. Split-screen images showing no evidence of a
EIV, external iliac vein; GSV, greater saphenous vein; IEA, femoral hernia during quiet respiration in the left image. The
inferior epigastric artery; IIR, internal inguinal ring; IL, inguinal right image, taken during a Valsalva maneuver, shows a
ligament; RA, rectus abdominis muscle; SC/RL, spermatic fat-containing femoral hernia (arrows) medial to the common
cord or round ligament. femoral vein (CFV).
FIGURE 29. Split-screen image showing a small Teale-type

femoral hernia lying anterior to the common femoral vein (FV)
on the right but no femoral hernia on the left.
FIGURE 31. Illustration showing the relationship of a spigelian

hernia (SH) to the surrounding anatomy. Almost all spigelian
hernias arise from the inferior end of the spigelian fascia just
lateral to where it is penetrated by the inferior epigastric vessels
just lateral to the lateral edge of the rectus abdominis muscle.
Although these are usually considered anterior abdominal wall
rather than groin hernias, the neck of spigelian hernias often lies
within 2 cm of the internal inguinal ring (IIR), where indirect
inguinal hernias arise. CFA indicates common femoral artery;
CFV, common femoral vein; EIA, external iliac artery; EIV,
external iliac vein; GSV, greater saphenous vein; IEA, inferior
epigastric artery; IL, inguinal ligament; RA, rectus abdominis
muscle; SC/RL, spermatic cord or round ligament.
or medical treatment of the associated tendinosis and pubic

symphysis instability may be necessary.
Report for Dynamic Ultrasound of Groin Hernias
It is important to use correct verbiage in reporting the
results of a dynamic groin ultrasound exam. In addition to the
indication, the report should contain the following elements:
(1) the examination name, (2) the specific dynamic compo-
nents of the examination, (3) the side, (4) the presence or ab-
sence of a hernia and, if present, include (5) the hernia size, (6)
the hernia contents, (7) its reducibility, and (8) whether it is
tender. Surgeons who treat these patients expect to see all of
these elements in the report. If all of these findings were
not reported, the surgeon will either demand that the exami-
nation be reviewed or repeated or worse lose confidence in
skill with which the examination was performed. We gener-
FIGURE 30. Short-axis view showing a large nonreducible
femoral hernia that arises within the femoral canal (asterisk)
ally do not measure hernias. We usually subjectively report size
medial to the common femoral vein (CFV). The neck (arrows) as small, medium, or large. A hernia may be completely redu-
extends directly anteriorly, and the fundus (arrowheads) is cible, partially reducible, or nonreducible. Nonreducibility may
filled with peritoneal fluid. Because of the long narrow neck vary between supine and upright positions. Most hernias are
and large fundus, this hernia is at extremely high risk for more reducible in the supine than in the upright position, but
strangulation. in some, the opposite is true. We report hernias as being either
FIGURE 32. Collage of images and illustrations showing a small spigelian hernia in which the aponeuroses of both the transverse
abdominis (TA) and the internal oblique (IO) muscles are torn, but in which the external oblique (EO) aponeurosis, as usual, is
intact. This is the most common pattern of aponeurosis defects in spigelian hernias. Drawing adapted from Skandalakis.
FIGURE 33. Transverse extended field-of-view image showing

a small, nonreducible, fat-containing right-sided spigelian
hernia. Because the external oblique aponeurosis is not torn,
it forces the hernia sac to extend medially over the anterior
surface of the right rectus muscle and laterally over the anterior
aspect of the right external oblique muscle. This results in a FIGURE 34. Large bowel-containing nonreducible left
mushroom or anvil shape, a shape that correlates with spigelian hernia showing a narrow neck and broad fundus,
nonreducibility and an increased risk of strangulation. the typical shape for spigelian hernias.
may necessitate using a larger piece of mesh. And of course, the

presence of a contralateral hernia may lead to bilateral rather
than unilateral repair. If the contralateral side is not mentioned
in the report, the surgeon may request that a second examina-
tion be performed at no cost to the patient to assess that side.
Three example reports follow: (1) a negative report, (2)
a positive unilateral report, and (3) a positive bilateral report.
Report 1
Examination: Dynamic ultrasound of the right groin
Indication: Right groin pain
Procedure: The right groin was evaluated in both supine
and upright positions with and without compression and
FIGURE 35. Transverse extended field-of-view image of a
large bowel- and fat-containing strangulated left-sided Valsalva maneuvers using a 12-MHz transducer.
spigelian hernia (arrows). Note the hyperechoic texture of Findings: There is no evidence of direct or indirect inguinal,
the edematous strangulated contents. femoral, or spigelian hernias.
Impression: There is no evidence of a right groin hernia.
nontender or mildly, moderately, or severely tender when Report 2

compressed by the transducer. Tenderness is important in Examination: Bilateral dynamic groin ultrasound
determining whether a hernia is more likely to be incidental or Indication: Right groin pain
clinically significant. When a hernia is present and has been Procedure: The right and left groin areas were evaluated in
described in the report, we also report about our search for both supine and upright positions with and without
additional types of ipsilateral or contralateral groin hernias. A compression and Valsalva maneuvers using a 12-MHz
surgeon who is considering a laparoscopic hernia repair will transducer.
definitely want to know about the presence of additional ipsi- Findings: There is a
lateral and contralateral hernias. In a patient with an inguinal Size: small
hernia, the presence an ipsilateral femoral or spigelian hernia Contents: fat-containing
FIGURE 36. Collage of images and illustrations showing the differences in the appearances of posterior inguinal wall insufficiency
(upper) and direct inguinal hernia (lower) on long-axis views. Insufficiency of the posterior inguinal wall appears semicircular,
whereas a frank direct inguinal hernia will extend distally within the inguinal canal in a finger-like projection posterior to the
spermatic cord. At the level of the proximal inguinal canal, the distinction is possible only on long-axis views because insufficiency
and frank hernia appear identical to each other on short-axis views obtained proximally.
Report 3
Examination: Bilateral dynamic groin ultrasound
Indication: Right groin pain
Procedure: The right and left groin areas were evaluated in
both supine and upright positions with and without
compression and Valsalva maneuvers using a 12-MHz
transducer.
Findings: There is a
Size: moderate-sized
Contents: fat- and bowel-containing
Reducibility: reducible in the supine position but nonreducible
in the upright position
Tenderness: exquisitely tender
Side: right
Type: indirect inguinal hernia.
Other ipsilateral hernias: There is no direct inguinal, femoral,
or spigelian hernia on the right.
Contralateral hernias: There is a small, fat-containing, com-
FIGURE 37. Long-axis view of an acute tear of the conjoined
tendon (arrows). Note that the neck is small in comparison to
pletely reducible, nontender, left indirect inguinal hernia.
the fundus. This is an unusual configuration for a direct Impression:
inguinal hernia. (1) There is a moderate-sized, fat-containing, exquisitely
tender right indirect inguinal hernia that is completely
reducible with transducer pressure when the patient is
Reducibility: completely reducible supine, but is nonreducible in the upright position. This is
Tenderness: moderately tender the cause of the patients right groin pain.
Side: right (2) There are no other ipsilateral groin hernias.
Type: indirect inguinal hernia. (3) There is also an incidental small fat containing, com-
Other ipsilateral hernias: There is no direct inguinal, femoral, pletely reducible, nontender left indirect inguinal hernia.
or spigelian hernia on the right.
Contralateral hernias: There are no contralateral left-sided
groin hernias.
Impression:
(1) There is a small, fat-containing, completely reducible,
but moderately tender, right indirect inguinal hernia that
is the cause of the patient’s pain.
(2) There are no other ipsilateral groin hernias.
(3) There are no contralateral groin hernias.
FIGURE 39. Illustration showing a spectrum of appearances

of the linea alba in the transverse views. A, Normal thick linea
alba. B, Thinner, but wider, linea alba. This could be due to
fewer decussations of rectus sheath fibers or could represent
diastasis recti when the patient is in the supine position in quiet
respiration. C, Marked thinning and bulging of the linea alba
that occurs in diastasis recti during a Valsalva maneuver or in
the upright position. D, Transverse view of a typical small
epigastric linea alba hernia with its neck near the midline of the
FIGURE 38. Split-screen images showing bilateral tendinosis linea alba. E, Small linea alba hernia whose neck has occurred
of the adductor longus tendons. Note that the edema and eccentrically near the right edge of the linea alba. Note that
thickening of the tendon (arrows) is greater on the symptomatic linea alba hernias typically have narrow necks and broad
right side than on the contralateral left side. The tendinosis in fundi in the transverse view, a shape that correlates with
patients with athletic pubalgia is usually bilateral but asymmetric. nonreducibility and increased risk of strangulation.
Linea Alba Hernias

Linea alba hernias are anterior abdominal wall hernias
that protrude through the linea alba. Those that occur superior
to the umbilicus are called epigastric hernias and those that
occur inferior to the umbilicus are called hypogastric hernias.
Hypogastric hernias are much less common than epigastric
hernias because the linea alba is much narrower and shorter
inferior to the umbilicus than it is superior to the umbilicus.
The linea alba is a thick layer of aponeurosis that
separates the rectus abdominis muscles. It is formed by fusion
and interlacing of fibers of the anterior and posterior sheaths
of the right and left rectus muscles. Unlike the conjoined
FIGURE 41. Extended field-of-view image of the linea alba that
tendon and semilunar line, in which there are multiple thin was obtained in the transverse plain with the patient in the
layers of thin, loosely associated aponeurosis that do not form upright position showing marked widening and thinning of the
a discrete well-defined structure, the linea alba is single- linea alba and a large, fat-containing, nonreducible epigastric
thick, well-defined, markedly hyperechoic, and easily seen on linea alba hernia (arrowheads). Note that the neck, the defect in
ultrasound in most patients (Fig. 39A). However, the degree the line alba (arrows) is narrow in comparison to the fundus
of decussation of fibers from the right and left sides (arrowheads). Note also that the fat within the hernia appears
varies from individual to individual. In most patients, there to be all preperitoneal, as the transversalis fascia deep to the
are 3 layers of interlaced fibers, but in a minority of patients, neck is intact (asterisks). Linea alba hernias are more common
there may be as little as a single layer of interlaced fibers. In in patients who have preexisting diastasis recti.
the latter group, the linea alba is weaker and more predis-
posed to stretching (diastasis recti) and tearing (epigastric In patients with diastasis recti, the anterior bulging extends
linea alba hernia). Any cause of prolonged increased intra- along the entire craniocaudal length of the epigastric segment
abdominal pressure can predispose toward weakening of the of the linea alba. In patients with epigastric hernia, any bulg-
linea albaVpregnancy, morbid obesity, and ascites. The first ing will be more localized along the craniocaudal axis. Dias-
step is often Bdiastasis recti,[ thinning and stretching of the tasis recti do not usually cause tenderness, whereas epigastric
linea alba, that is most apparent during straining or in the hernias often do. Epigastric linea alba hernias are easier to
upright position. The stretching of the linea alba results in diagnose than are groin hernias as long as they are scanned with
pulling of the decussated fibers apart, decreasing their inter- the proper transducer and the sonographer or sonologist is ac-
lacing, weakening the tendon, and predisposing to epigastric tually visually inspecting the linea alba. Epigastric hernias are
herniation. In patients with diastasis recti, the linea alba is usually superficial enough in location that they are best shown
thinner and wider than normal. When the patient is supine with 10- to 12-MHz linear array transducers. With these trans-
and in quiet respiration, the associated anterior bulging of the ducers, the defect through the linea alba is usually quite con-
tendon is not evident (Fig. 39B). However, having the patient spicuous because it is either isoechoic or hypoechoic compared
perform a Valsalva maneuver or raise the head off the pillow with the markedly hyperechoic linea alba. The defect is usually
while lying supine or having the patient stand will make the very near the midline, but this may occur eccentrically toward
anterior bulging visible (Figs. 39C and 40; see video, Supple- the right or left side of the linea alba (Figs. 39D, E, 41, and 42).
mentary Digital Content 23, http://links.lww.com/RUQ/A26).
FIGURE 40. Extended field-of-view image of the linea alba that FIGURE 42. Transverse view of the linea alba showing a
was obtained in the transverse plane with the patient in the small, fat-containing, nonreducible epigastric linea alba hernia
upright position showing marked widening, thinning, and arising from tear that is eccentrically located near the right
bulging of the linea albaVdiastasis recti. edge of the linea alba (arrows).
The most frequent reason for missing an epigastric linea alba

hernia is that the examination for abdominal pain was per-
formed with the standard 3-MHz curved linear array transducer
that is focused too deep in the elevation axis to identify anything
but very large hernias in very obese patients. One must have an
index of suspicion to use the appropriate transducer.
Although clinically detected epigastric hernias tend to
be fairly large and often contain bowel and other intraperito-
neal contents, sonographically detected epigastric hernias are
usually small to moderate-sized and contain only preperito-
neal fat (Fig. 43). In hernias that contain only preperitoneal fat,
the underlying peritoneal membrane and transversalis fascia
are intact, and the hernia cannot be seen or repaired laparo-
scopically. Epigastric hernias always have a very narrow neck
in comparison to the size of the fundus and are thus usually
not reducible (see video, Supplementary Digital Content 24,
http://links.lww.com/RUQ/A27) and are at increased risk for
strangulation, even when small. Some epigastric hernias that
contain only preperitoneal fat are so small that it is hard to be-
lieve that herniation is the cause of pain (Fig. 44). They typically
present with pain and are not palpable. It is more likely that
the pain is the result of the tear and/or tendinosis of the linea
alba rather than herniation of a tiny amount of properitoneal fat.
Simply identifying diastasis in a patient who complains FIGURE 44. Image of the tiny tear of the linea alba (arrows)
of epigastric midline pain is not enough. The linea alba in the that caused pain, but was not palpable. Such tears are relatively
area of pain and along its entire epigastric segment must be common in patients with preexisting diastasis recti.
examined for hernias because patients with diastasis are at
increased risk for multiple epigastric hernias. It is important small a piece of mesh to repair all of the hernias. It is our ex-
to assess the entire length of the linea alba in any patient in perience that so-called recurrent epigastric hernias are more
whom one epigastric linea alba hernia is found. Because most likely to be second hernias that were not recognized and re-
contain only properitoneal fat, they cannot be seen laparo- paired rather than true recurrences (Fig. 45; see video, Supple-
scopically and must be repaired externally. If the surgeon does mentary Digital Content 25, http://links.lww.com/RUQ/A28).
not know that multiple hernias are present, he/she may use too
FIGURE 45. Longitudinal view of the linea alba showing 2

FIGURE 43. Transverse view of a small, mushroom-shaped, separate epigastric hernias: (1) a small fat-containing,
fat-containing, nonreducible epigastric linea alba hernia nonreducible, epigastric linea alba inferiorly and (2) a tiny tear
(arrowheads). There is a small tear of the linea alba. The fat a couple of centimeters superiorly. This patient had 3 other
within the hernia is preperitoneal fat. The underlying small hernias further superiorly. Multiple epigastric linea alba
transversalis fascia (arrow with black outline) and peritoneal hernias are common enough that the entire length of the
membrane (white hollow arrow) are intact and in the linea alba should be investigated in a patient in whom an
normal position. epigastric hernia is found.
Umbilical Hernias
Umbilical hernias occur through a widened umbilical
ring. In newborns, they result from delayed return to the
abdomen of bowel loops that lie in the base of the umbilical
cord in the first trimester. In many cases, umbilical hernias in
newborns will regress spontaneously by 3 or 4 years. Those that
do not regress by the age of 4 are usually repaired. Umbil-
ical hernias can, however, develop at any time during life. Any
cause of chronic increased intra-abdominal pressure or con-
nective tissue weakness can lead to dilatation of the umbili-
cal ring and formation of umbilical hernia. Umbilical hernias
contain intraperitoneal contents, but smaller umbilical hernias
usually contain only intraperitoneal fat (Fig. 47). We are
asked to sonographically evaluate umbilical hernias much less
frequently than we are asked to evaluate patients for groin pain
because the diagnosis is usually obvious clinically. The role of
FIGURE 46. Longitudinal view of a moderate-sized, ultrasound is usually limited to the evaluation of umbilical pain
periumbilical, fat-containing hypogastric linea alba hernia in patients who are so morbidly obese that an umbilical hernia
(asterisk). It lies immediately inferior to the umbilicus (U). Note cannot be detected clinically or to the assessment for strangu-
that the neck of the hernia (arrows) is very narrow and that lation. In obese patients, the umbilicus courses obliquely from
the edematous strangulated fat is hyperechoic in comparison deep superiorly to superficial inferiorly (Fig. 48). Thus, the
to the surrounding subcutaneous fat. umbilical ring may be much more superiorly located that is
suspected from the location of the umbilicus in obese patients.
The much less common hypogastric linea alba hernia usually Untreated umbilical hernias have a tendency to increase in size
lies within a few centimeters of the umbilicus because the linea over time. They are usually reducible, but they may become
alba is present only in that area. Inferior to that, the rectus nonreducible and can also become strangulated. Clinically, it
muscles are more closely apposed or even fused. Like epi- may be difficult to distinguish between acute omphalitis and
gastric hernias, hypogastric linea alba hernias have narrow
necks, usually are small to moderate-sized, contain only pre-
peritoneal fat, are usually not reducible, and are prone to
strangulation (Fig. 46).
FIGURE 48. Longitudinal view showing a moderate-sized

fat-containing umbilical hernia (arrows) in a morbidly obese
patient who presented with umbilical pain. The hernia was not
clinically apparent. In such obese patients, the umbilicus lies
FIGURE 47. Longitudinal view showing a moderate-sized several centimeters inferior to the umbilical ring. Thus, one
fat- and bowel-containing umbilical hernia (H). Umbilical must investigate superior to the umbilicus to identify small to
hernias pass through dilated umbilical rings (U). moderate hernias.
FIGURE 49. Transverse view showing a small nonreducible, FIGURE 51. Longitudinal view of a small periumbilical hernia
strangulated umbilical hernia. Note that the edematous in a patient who presented with periumbilical pain during the
strangulated fat within the hernias is hyperechoic compared third trimester of pregnancy. It is a fat-containing, nonreducible
with the surrounding subcutaneous fat. epigastric linea alba hernia. The increased intra-abdominal
pressure together with the softening of ligaments that occurs
in the late third trimester predisposes to all sorts of hernias.
a strangulated small umbilical hernia. Both can present with Asterisk indicates hernia; M, myometrium of gravid uterus;
pain and redness in the umbilical area. Sonography, however, U, umbilicus.
can readily make the distinction (Figs. 49 and 50). The sono-
graphic evaluation of umbilical hernias is similar to that for
any other hernia. Dynamic maneuvers, identification of type, Incisional Hernias
size, contents, reducibility, and tenderness are noted. Incisional hernias occur through surgical scars. Her-
niation can occur through any type of surgical scar, including
Paraumbilical or Periumbilical Hernias laparoscopy ports and stomal sites. They can occur anywhere
A paraumbilical hernia is not really a distinct type on the anterior abdominal wall that an incision is made.
of hernia. It is usually either an epigastric or hypogastric The herniation can occur as the result of thinning and
linea alba hernia that lies very close to the umbilicus (Figs. 51 stretching of the scar or as the result of a tear in a segment of
and 52). Periumbilical linea alba hernias, whether epigastric the scar. Whether the scar is stretched or torn affects that
or hypogastric, are particularly likely to become strangulated shape of the hernia, its reducibility, and its risk of strangula-
(Fig. 46). tion. Incisional hernias resulting from thinning and stretching
FIGURE 50. Scans of a patient who presented with umbilical pain and discoloration has an infected urachal sinus. A, Transverse
view showing an edematous umbilicus. B, Longitudinal view showing a patent urachal sinus tract (arrows) passing through the
edematous tissues in the inferior umbilicus. C, Longitudinal view with color Doppler showing intense inflammatory hyperemia
with the inflamed tissues that surround the infected patent urachal sinus tract (arrow).
FIGURE 54. Split-screen image performed without

compression on the left and with compression on the right
showing a narrow-necked fat-containing ventral incisional
hernia that is incompletely reducible.
of the scar have wide necks and are reducible, whereas those
FIGURE 52. Longitudinal view showing a small fat-containing, resulting from tears in the scar are more likely to have narrow
nonreducible periumbilical hypogastric linea alba hernia. necks and be nonreducible (Figs. 53 and 54). Incisional her-
Note that the defect is through the linea alba and lies inferior nias can occur where natural hernias cannot, through the
to the umbilicus and umbilical ring (US). bellies of muscles that have been incised (Fig. 55). Incisional
hernias can occur through very small scars, such as laparo-
scopy ports (see video, Supplementary Digital Content 26,
http://links.lww.com/RUQ/A29). Patients who have undergone
TRAM flap breast reconstruction surgery are particularly
likely to have one or more incisional hernias (see video, Sup-
plementary Digital Content 27, http://links.lww.com/RUQ/A30).
FIGURE 55. Longitudinal view showing a moderate-sized,

FIGURE 53. Image showing a fat-containing incisional hernia peritoneal fluid-containing incisional hernia through the belly
in the right upper quadrant of a cholecystectomy scar. It has a of the rectus muscle, a site in which natural hernias do not
narrow neck (arrows) and a broad fundus and is nonreducible. occur.
Multiple Hernias
Patients who have one type of hernia are more likely to
have additional hernias. They are more likely to have con-
tralateral hernias of the same type, and they are more likely
to have either ipsilateral or contralateral hernias of different
types. There are several reasons for this. First, bilateralism
may be due to timing of closure of fetal canals, and delayed
closure for any reason is likely to affect both sides simulta-
neously. Second, the underlying factors leading to the forma-
tion of hernias can affect all sites simultaneously. Factors that
increase the risk of hernias include any cause of chronically
increased intra-abdominal pressure and repetitive stress. Preg-
nancies, morbid obesity, and ascites can all increase intra-
abdominal pressures long enough to lead to the development
of hernias. Certain professions lead to repetitive stress inju-
ries. Sedentary lifestyle, nutritional deficiencies, and hereditary
factors can all result in weak connective tissues. There is evi-
dence that patients who have hernias have increased levels of
circulating metalloproteinases that can weaken soft tissues.
In a patient with unilateral groin pain, but no demonstrable
hernia on that side during dynamic ultrasound, the examination
can be stopped after examining the symptomatic side. However,
in any patient in whom one type of groin hernia is found during
the dynamic ultrasound examination, we must look for the other FIGURE 57. Long-axis view of the right inguinal area showing
3 types of ipsilateral groin hernias. Femoral and indirect inguinal both direct (dir) and indirect (ind) inguinal hernias with the
hernias can occur together (Fig. 56; see video, Supplementary inferior epigastric vessels (asterisk) between them, a so-called
Digital Content 28, http://links.lww.com/RUQ/A31). In addi- ‘‘pantaloon’’ hernia. The necks of the direct and indirect
tion, direct and indirect inguinal hernias can occur on the same inguinal hernias resemble pant legs straddling the inferior
side. On the long-axis views, the necks of the hernias resemble epigastric vessels.
pant legs straddling the inferior epigastric vessels, explaining
why the combination of the 2 hernias has been termed a
Bpantaloon[ hernia (Fig. 57; see videos; Supplementary Dig-
ital Contents 29, http://links.lww.com/RUQ/A32 and SDC 30
http://links.lww.com/RUQ/A33). We should evaluate the con-
tralateral groin as well. This is especially important in patients
who will undergo laparoscopic hernia repairs because surgeons
are more likely to perform bilateral repairs using a laparoscopic
approach than they are when performing external herniorrhaphy.
Direct inguinal hernias and femoral hernias are the most likely
to be bilateral. It is not at all unusual to find as many as 4 or 5
hernias in a single patient (Figs. 58, AYE; see videos; Supple-
mentary Digital Contents 31, http://links.lww.com/RUQ/A34;
SDC 32, http://links.lww.com/RUQ/A35; SDC 33,
http://links.lww.com/RUQ/A36; SDC 34, http://links.lww.com/RUQ/A37;
and SDC 35, http://links.lww.com/RUQ/A38). Multiple linea alba
and incisional hernias are also relatively common (see videos; Sup-
plementary Digital Contents 25, http://links.lww.com/RUQ/A28;
and SDC 27, http://links.lww.com/RUQ/A30).
Recurrent Groin Hernias
Hernia repair can be performed by direct anterior inci-
sion of the inguinal canal or by laparoscopy. Old hernia repairs
that were performed decades ago were done without mesh.
Originally, fascia was pulled up to reinforce the inguinal area,
but this tended to widen the femoral canal and led to Brecur-
recurrent[ femoral hernias. BTension-free[ external repairs
using proline mesh were developed to prevent this. Recent data
FIGURE 56. Longitudinal image showing femoral and indirect suggest that laparoscopic repairs have results equal to those of
inguinal hernias on the left side. external repairs. Laparoscopic repairs have the advantage of
FIGURE 58. Images of a patient with 5 different hernias. A, Split-screen image showing a small fat-containing left femoral hernia
lying anterior to the CFV during quiet respiration (left) and during a Valsalva maneuver (right). B, Split-screen image showing a
moderate-sized fat-containing left femoral hernia lying medial and anterior to the CFV in quiet respiration (left) and during a
Valsalva maneuver (right). C, Split-screen image showing a small fat-containing right indirect inguinal hernia during quiet
respiration (left) and during a Valsalva maneuver (right). D, Split-screen image showing a small fat-containing right indirect
inguinal hernia during quiet respiration (left) and during a Valsalva maneuver (right). E, Image showing a small fat-containing
nonreducible hypogastric linea alba hernia, the fifth hernia in this patient.
allowing bilateral repair but require general anesthesia. External free and use mesh. Mesh can be used with both external and
repairs are generally limited to one side, but these can be done laparoscopic repairs. Several different types of mesh are used.
with regional anesthesia. Most hernia repairs today are tension Unfortunately, recurrent or residual groin pain after hernior-
rhaphy is relatively common. Recurrent hernia is not the only
cause of residual or recurrent groin pain after herniorrhaphy. A
variety of causes of acute and chronic postherniorrhaphy pain
exist, and dynamic sonography is an integral part of the eva-
luation patients with such pain.
In the short-term phase, residual pain, unchanged from
before surgery, is rare and is usually the result of an unsuc-
cessful hernia repair. The original hernia persists and can be
demonstrated sonographically. More commonly, immediate
pain is caused by entities other than recurrent hernia. Other
cause for acute or subacute pain include incisional pain, pain
caused by acute hematomas (Fig. 59) or seromas (Fig. 60),
and/or sometimes pain radiating into the scrotum as the result
of spermatic cord compression by seroma or hematoma, the
mesh, a repair that makes the internal inguinal ring too tight.
In such cases, it is important to assess the ipsilateral scrotum
and testis with grayscale imaging and Doppler because cord
compression of any cause can lead to testicular infarction
FIGURE 59. Image of a patient who presented with severe (Fig. 61A). Doppler evidence of testicular ischemia may indicate
pain, swelling, and ecchymosis 2 weeks after a left-sided inguinal the need for emergency decompression either by evacuating an
herniorrhaphy. Sonography showed a huge hematoma filling inguinal canal hematoma/seroma or by loosening the repaired
the entire inguinal canal from the groin to the upper pole internal inguinal ring (Fig. 61B). Inguinal canal hematomas
of the testis. or seromas that do not compress the spermatic cord or cause
FIGURE 62. Image of a patient who developed pain and

redness in the left groin weeks after an otherwise successful
herniorrhaphy. Sonography showed a stitch (s) within the
center of a hyperemic complex fluid collection, a subacute
stitch abscess.
FIGURE 60. Image of a patient who presented with severe fibrosis and scarring of the ilioinguinal nerve. Once again,
right groin pain and swelling a few days after herniorrhaphy dynamic sonography is essential in evaluating such patients,
and had developed a very large seroma around the mesh (m). but this is more difficult than in patients whose hernias have
not been previously repaired. In patients who had herniorrhaphy
testicular ischemia, on the other hand, can usually be managed without mesh, the recurrent hernia is usually of the same type
conservatively. Postherniorrhaphy hematomas or seromas can as the original. However, it is not unusual, even after tension-
become secondarily infected and evolve into abscesses. Stitch free repairs, to find a Brecurrent[ femoral hernia. In such cases,
granulomas or abscesses can cause pain (Fig. 62). especially after external repair, it is quite possible that the
Late recurring pain also has a variety of causes, but femoral hernia was present before repair but was subclinical
recurrent hernia becomes a greater concern, particularly when and unrecognized. This is one of the reasons why it is impor-
the pain is similar in type that was present before surgery. Late tant to look for all types of groin hernias during dynamic
pain causes include recurrent hernia, seroma, hematoma, ab- sonography. In our experience, recurrent femoral hernias are
scess, traction on the edges of the mesh, immune reaction to less common after tension-free repairs that use mesh because
the mesh, spiral clips, compression of the spermatic cord, and they usually use a piece of mesh large enough to cover the
FIGURE 61. Image of a patient who developed a large acute hematoma within the left inguinal canal after herniorrhaphy and
complained of pain radiating into the scrotum. A, Split-screen images of the testes showing the left to be swollen and edematous.
B, A pulsed Doppler spectral analysis of the left testis showing decreased velocities and increased impedance due to compression
of the spermatic cord by the hematoma. Doppler evidence of decreased flow to the ipsilateral testis in patients with postherniorrhaphy
hematomas indicates the need to evacuate the hematoma.
FIGURE 63. Image in which the mesh used in the hernia repair
is thick and echogenic, and individual fibers within the mesh
are visible. It casts a strong acoustic shadow. The mesh can FIGURE 65. Patient in whom the mesh is thin and poorly
be this well seen in only a small percentage of cases. defined and casts only a weak acoustic shadow. Such mesh can
only be identified with high-frequency transducers, optimal
technique, and careful search.
conjoined tendon, internal inguinal ring, femoral canal, and
spigelian area. In patients whose hernias were repaired with possible to determine that it is a recurrent inguinal hernia. The
mesh, it is not possible to determine sonographically whether key to finding recurrent hernias in patients who have mesh in
a recurrent inguinal hernia is direct or indirect. It is only place is to identify the mesh and then assess for herniations
along the edges of the mesh with dynamic maneuvers. In
patients who are being evaluated for recurrent hernia, the most
useful dynamic maneuver is usually the compression maneu-
ver while the patient is in the upright position.
Because there are many types of mesh, the appearance
varies greatly. In ideal cases, we can actually see the texture
of the mesh (Fig. 63). However, in most cases, we only see the
mesh as either an echogenic line of variable thickness with
variable shadowing or merely an area of variable shadowing
(Figs. 64 and 65). Some newer types of mesh are thin and much
more difficult to identify sonographically. Normal mesh can have
folds and can be rolled at the edges, and it can normally bulge
mildly outwardly in the upright position and during Valsalva
maneuvers (Fig. 66). History from the patient is rarely helpful
because patients are unaware of the type of mesh used. However,
every effort should be made to identify the mesh because recur-
rent hernias do not occur through the center of mesh but through
the edges of the mesh. Most recurrent hernias occur along the
inferomedial edge of the mesh (Fig. 67; see videos; Supple-
mentary Digital Contents 36, http://links.lww.com/RUQ/A39
and SDC 37, http://links.lww.com/RUQ/A40), but it is im-
portant to identify the mesh and then assess the entire periph-
ery of the mesh because hernias can occur along any edge
of the mesh (see video, Supplementary Digital Content 38,
FIGURE 64. Image showing a more common appearance for http://links.lww.com/RUQ/A41). It is likely that herniation from
herniorrhaphy mesh. It appears thick and echogenic and casts the edge of the mesh occurs because the affected edge has
a strong acoustic shadow, but individual fibers within the Bpulled loose[ (Fig. 68). The edges of the mesh can be anchored
mesh are not visible sonographically. to the surrounding connective tissues with sutures, surgical clips,
FIGURE 66. Images of some patients wherein the mesh can bulge during the Valsalva maneuver or when the patient is scanned
in the upright position. This can be normal. These split-screen images show wrinkled mesh in the supine position in quiet
respiration (left) and bulging with straightening of some of the wrinkles in the upright position (right).
or special spiral clips. The sutures and clips hold the mesh and resumes activities that put the repair at risk within the first
in place for about the first 6 weeks after surgery. After this, 6 weeks. There are times when the patient complains of a tear-
fibrosis forms and generally holds the mesh in place. It is ing sensation during some movement and then the onset of re-
during the first 6 weeks after surgery before the mesh has had current inguinal pain, but in most, the onset is more insidious.
time to become fibrosed to the anterior abdominal wall that A chronic hematoma/seroma can cause chronic pain and
the mesh is most likely to pull loose from its anchors. In our its evacuation can relieve the pain, so searching for a hema-
experience, this is most likely to occur after laparoscopic toma or seroma is a standard part of the postherniorrhaphy
repairs, not because the repair has been defective or because sonogram. Some patients can develop an allergic or hypersen-
laparoscopic repair is less effective, but because the patient sitivity reaction to the mesh. In such cases, there may be a thin
feels Btoo well, too soon[ after the minimally invasive repair seroma localized to the surface of the mesh.
In cases where there is no sonographically demon-
strable hernia, hematoma, or seroma, it is important to assess
the mesh for tenderness. In many cases without sonographi-
cally demonstrable pathological finding, the mesh is tender.
FIGURE 68. Transverse extended field-of-view image showing

FIGURE 67. Short-axis view showing a small fat-containing, that a large piece of mesh that was used to repair a large ventral
reducible recurrent inguinal hernia (dotted line) arising from hernia has become detached along its right edge (arrowhead)
the inferomedial edge of the mesh (m), where recurrent allowing a recurrent hernia to protrude from under the detached
inguinal hernias most commonly arise. edge (arrows).
FIGURE 71. Long-axis extended field-of-view image showing

a strangulated hypogastric linea alba hernia. The hallmark of
strangulation is the hyperechogenicity of the fat with the
hernia.
FIGURE 69. Anteroposterior plain radiograph of the pelvis diagnosis of exclusion, confirmed by injecting the nerve, and
showing spiral clips in both inguinal areas from bilateral then surgically dissecting it free of the fibrosis. The normal
inguinal herniorrhaphies. ilioinguinal nerve can be identified sonographically superior
to the inguinal canal, and ultrasound can be used to guide
This can occur for a variety of reasons. First, the mesh may block of the nerve, but we are unaware of sonography being
compress the spermatic cord. In such cases, compressing the able to play a role in diagnosing its entrapment in patients
mesh will cause pain that radiates into the scrotum. Second, who have undergone herniorrhaphy.
the mesh may be placing traction on the fibrosis that holds The spiral clips used to anchor the mesh require special
its edges in place. This is especially common in patients mention. These clips can become tender and can become a
who have had significant weight gain since their surgeries.
The mesh usually bulges anteriorly in such cases. In other
cases, the fibrosis that holds the mesh in place has entrapped
nerves, particularly the ilioinguinal nerve. This has been a
FIGURE 72. Short-axis view of a strangulated left femoral

FIGURE 70. Characteristic sonographic appearance of a spiral hernia showing 2 additional grayscale findings of
clip (arrows) that was used to anchor the edges of mesh used strangulationVtransudative or exudative fluid and isoechoic
to repair and inguinal hernias that was causing pain and thickening of the hernia sac wall. The sac normally appears
tenderness. thin and echogenic.
tenderness and will generally not adversely affect the sound-

ness of the repair because the edge of the mesh will be held
firmly in place by fibrosis, even after the clip is removed.
Hernia Complications
Hernia complications include incarceration, obstruction,
and strangulation. Incarcerated hernias are simply hernias
that are nonreducible. Obstructed hernias contain incarcerated
bowel loops that have become mechanically obstructed. Stran-
gulated hernias contain incarcerated contents whose vascularity
has become compromised. Not all strangulated hernias contain
bowel loops. Even preperitoneal fat can become strangulated.
Most incarcerated hernias are neither obstructed nor strangu-
lated, but all obstructed and strangulated hernias are also in-
carcerated. We prefer not to use the term Bincarcerated[ at all
because many referring clinicians confuse incarceration with
obstruction and/or strangulation. They tooVoften believe in-
carceration to be a surgical emergency when it is not. Only
incarcerated hernias that are also obstructed or strangulated are
surgical emergencies. Even strangulated hernias that contain
only preperitoneal fat may not be emergencies. It is the presence
of bowel loops within strangulated hernias that makes them
emergent. Instead of using the term incarcerated, we use the
FIGURE 73. Longitudinal view showing a strangulated term nonreducible because the referring clinician is less likely
periumbilical epigastric linea alba hernia. The fat is hyperechoic, to confuse it with strangulation.
the sac wall is isoechoic and thickened, and a small bowel The shape of hernias affects their reducibility and their
loop (b) has a thickened wall and is aperistaltic. likelihood of becoming obstructed or strangulated in the
future. The hernia type affects its shape. Hernias that have
relatively broad necks in comparison to their fundi are usually
cause of postherniorrhaphy pain, so have fallen into disfavor completely reducible and rarely become obstructed or stran-
and are seldom used today. However, they were quite popular gulated. Groin hernias that typically have broad necks and
for a time, so there are numerous patients who have them. infrequently strangulate are direct inguinal hernias and some
They have a characteristic radiographic and sonographic ap- indirect inguinal hernias. Hernias that have relatively narrow
pearance (Fig. 69). In some postherniorrhaphy patients who necks in comparison to their fundi are more likely to be non-
have no other sonographically demonstrable pathological reducible, become obstructed, and strangulate. Hernia types
finding, the only finding is focal tenderness directly over the that typically have narrow necks and are at high risk for stran-
offending clip, which has a classic sonographic appearance gulation include femoral (see video, Supplementary Digital
(Fig. 70). Surgical removal of the clip will relieve the pain and Content 39, http://links.lww.com/RUQ/A42), spigelian (Fig. 35),
FIGURE 74. Grayscale imaging findings are more sensitive than Doppler findings for detecting strangulation in a hernia.
A, Abnormal hyperechogenicity of the fat within this umbilical hernia indicates that it is strangulated. B, Color Doppler and pulsed
Doppler spectral analyses show normal flow within the hernia, despite it being strangulated.
linea alba (Fig. 46), umbilical (Fig. 47), and some indirect in-
guinal hernias.
Although vascular compromise is the hallmark of
strangulation, Doppler is not the most sensitive modality for
demonstrating signs of strangulation. Grayscale sonography
is. Doppler shows arterial flow within hernias with some
success but, generally, is not sensitive enough to demonstrate
venous flow and cannot show lymphatic flow at all. Lymphatic
and venous vessel walls are very thin and are easily compressed
within the tissues surrounding the neck of the hernia. Arteries,
on the other hand, are relatively thick-walled and incompress-
ible and are generally not compressed by the tissues surround-
ing the neck of the hernia. Thus, in strangulated hernias, the
lymphatics and veins become obstructed long before arterial
flow decreases. Blood can still get into the strangulated hernia
long after the venous and lymphatic outflow stops. The con-
tinued inflow in the presence of obstructed outflow increases
intravascular pressure, causes increased transudation and exu-
dation of fluid into the extracellular spaces, and changes the
grayscale appearance of the hernia even when Doppler can
still detect arterial inflow. The most sensitive findings of stran-
gulation are the presence of (1) hyperechoic fat (Fig. 71), (2)
isoechoic thickening of the normally thin and echogenic hernia
sac (Fig. 72), (3) fluid within the sac (Fig. 72; see video, Sup-
FIGURE 76. Short-axis view in a female showing a lobulated,
plementary Digital Content 40, http://links.lww.com/RUQ/A43),
thinly septated hydrocele of the canal of Nuck (inguinal canal).
and (4) thickening of the bowel wall in bowel-containing hernias
(Fig. 73). In most strangulated hernias, more than one of these
grayscale findings are present, even when Doppler demon- sac with strangulation because nonstrangulated hernias that
strates normal flow within the hernia contents (Figs. 74A, B). contain intraperitoneal contents can contain peritoneal fluid,
Some care should be taken in equating fluid within the hernia especially in females.
Entities That Simulate Groin Hernias
There is a wide spectrum of space-occupying lesions in
the groin that can simulate hernias of the groin. Lipomas,
process vaginalis cysts or hydroceles (hydroceles of the canal
of Nuck), round ligament cysts, round ligament leiomyomas,
round ligament varices, desmoids, endometriomas, sarcomas,
hematomas, seromas, undescended testes, and metastatic
FIGURE 77. Long-axis view of the right inguinal canal in a

FIGURE 75. Short-axis view of the midright inguinal canal female showing a leiomyoma (L) arising from the round
showing a hydrocele (H) compressing the spermatic cord (SC) ligament (arrows) that presented as a palpable nodule.
posteriorly and to the right. IEA indicates inferior epigastric artery.
FIGURE 78. Image of patient presented with tender swelling in the left labium majus after running. A, Split-screen image showing
the round ligament during quiet respiration in the supine position (left) and in the upright position (right). The round ligament
varices are evident only when the patient is upright. B, Long-axis color Doppler view showing abundant flow within the round
ligament varices when the patient is upright.
peritoneal implants can all occur within the inguinal canal. hydroceles of the inguinal canal can occur in both males and
Inguinal lymphadenopathy, common femoral or external iliac females. In males, these localized fluid collections can occur
artery aneurysms and pseudoaneurysms, iliopsoas bursae, and when the segment of the process vaginalis within the inguinal
sebaceous cysts can all occur within the groin but outside the canal does not fuse while segments proximal and distal to it
inguinal canal. do fuse. This leads to the accumulation of fluid within the
In addition, pain from intra-abdominal inflammatory unfused segment of process vaginalis and results in the for-
processes can simulate groin painVacute appendicitis and mation of a localized process vaginalis hydrocele. In males,
acute diverticulitis can cause pain near the groin. Cysts or these occur within the inguinal canal next to the spermatic
cord and can compress the cord (Fig. 75). In females, the
unfused process vaginalis is called the canal of Nuck, so this
localized cyst or hydrocele is termed a cyst or hydrocele of the
canal of Nuck (Fig. 76). Hydroceles are usually unilocular and
fixed in position within the canal, but these can become
lobulated and/or septated as they enlarge. The round ligament
can give rise to cysts and leiomyomas. Unlike inguinal canal
hydroceles, which are fixed in position, round ligament cysts
can be mobile and can move back and forth between the
abdominal cavity and the inguinal canal (see video, Supple-
mentary Digital Content 38, http://links.lww.com/RUQ/A41).
The round ligament contains smooth muscle fibers from which
leiomyomas can arise (Fig. 77).
FIGURE 79. Long-axis view showing partially thrombosed

left round ligament varices in a patient who presented with
left groin pain 4 weeks postpartum. The decreasing uterine flow
that occurs in the postpartum period can lead to thrombosis FIGURE 80. Long-axis view of the left inguinal canal showing
of round ligament varices that develop as collateral pathways multiloculated complex cyst, an endometrioma. The patient
during pregnancy. complained of intermittent inguinal pain and swelling.
FIGURE 83. Split-screen image showing right and left sides in

a patient who presented with a painless lump in the area of
a previous right lower quadrant surgical incision that was
clinically suspicious for incision hernia. Exuberant scar tissue
causes the palpable abnormality on the right side (left).
Mirror image location on the left side (right) appears
sonographically normal.
swelling months or years after the last pregnancy. They are

relatively inapparent with the patient in the supine position
but become larger and have faster flow in the upright position
FIGURE 81. Short-axis view of the right inguinal canal showing (Figs. 78A, B). Round ligament varices are typically more
a true hyperechoic lipoma of the inguinal canal lying lateral symptomatic and larger when the patient is upright and after
to the spermatic cord (SC). Most so-called lipomas of the exercise, such as running, when they become hyperemic.
inguinal canal are merely nonsliding-type inguinal hernias Occasionally, round ligament varices can thrombose sponta-
that contain only preperitoneal fat. neously, most commonly in the postpartum period when col-
lateral uterine flow through them regresses (Fig. 79).
Round ligament varices develop as collateral pathways Endometriomas can occur along the course of the round
for uterine venous drainage during pregnancy. They are usually ligament within the inguinal canal (Fig. 80). They often have
asymptomatic and incidental, but in some patients, they can a history of cyclical variation in size and tenderness. Most
cause a tender palpable inguinal or labial abnormality. They so-called inguinal canal lipomas are not true lipomas but
usually resolve spontaneously completely after delivery, but in nonsliding-type indirect inguinal hernias that contain only
a few patients, they can persist and cause inguinal pain and
FIGURE 84. Transverse images showing a calcified oil cyst

FIGURE 82. Transverse view of an isoechoic lipoma of the left that presented as a painless palpable lump near a previous
labium majus. The patient complained of painless swelling of hypogastric midline surgical incision that was considered
the left labium. clinically suspicious for an incisional hernia.
FIGURE 85. Long-axis extended field-of-view image showing

and acute right rectus abdominis muscle tear and hematoma
FIGURE 87. Image showing the anterior abdominal wall
that presented with acute pain and swelling in the right groin
desmoid tumor as markedly hypoechoic, irregularly shaped,
and lower anterior abdominal. The referring physician was
and difficult to distinguish from a sarcoma. It presented as a
suspicious of an acute right sports hernia.
painful and tender lump.
properitoneal fat. However, true lipomas can occur anywhere In patients being evaluated for incisional hernias, exu-
along the length of the inguinal canal (Fig. 81) and into the berant scars (Fig. 83) and fat necrosis (Fig. 84) resulting from
scrotum or labium majus (Fig. 82). previous surgeries can clinically simulate an anterior abdom-
Entities That Simulate Anterior Abdominal inal wall incisional hernia.
Hematomas of the rectus abdominis (Fig. 85) or oblique
Wall Hernias muscles (Fig. 86) can cause pain and swelling that simulate
As is the case for patients with groin pain or mass, there anterior abdominal wall hernia. Usually, there is a history of
are a number of entities that clinically simulate anterior ab- significant acute trauma, but not always. In cases where the
dominal wall hernias. Subcutaneous or intramuscular lipomas history is not, classic sonography can be helpful.
have a sonographic appearance identical to those of the inguinal Desmoid tumors (aggressive fibromatosis) are rare, ex-
canal or labium (Figs. 81 and 82). cept in patients with familial adenomatoid fibromatosis, whose
FIGURE 86. Transverse extended field-of-view image

showing an acute tear and hematoma within the internal
oblique muscle (ii). The patient presented with acute pain in FIGURE 88. Image showing the anterior abdominal wall
the left lower quadrant. eo indicates external oblique; desmoid tumor that has a small amount of peripheral
ta, transverse abdominis muscle. blood flow.
FIGURE 89. Although desmoid tumors are considered histologically benign and do not metastasize, they are locally invasive
and will enlarge if they are not excised. A, This desmoid tumor developed as a tender nodule a few months after a pregnancy.
The patient elected not to have it excised. B, Twenty-three months later, the desmoid tumor had enlarged from 1.3 to 2.4 cm.
The patient then elected to have it excised.
tumors are usually intra-abdominal. Anterior abdominal wall maneuvers and scanning in both supine and upright positions.
desmoids are usually sporadic. They arise from the fibrous Dynamic sonography enables us to determine hernia type, size,
elements of the anterior abdominal wall aponeuroses or mus- contents, reducibility, and tenderness. Each of these should
cle sheaths. They are locally invasive and tend to recur if not be determined during the scan and should be specifically men-
excised widely enough, but they do not metastasize distantly. tioned in the final report. We also venture an educated guess
Sonographically, desmoids are solid nodules or masses that are as to the clinical significance of the hernia based on type,
irregularly shaped and have some internal vascularity (Figs. 87 size, contents, and tenderness, and similar to hiatus hernias,
and 88). They are difficult to distinguish from sarcomas, except asymptomatic clinically insignificant groin hernias are fre-
for slightly less blood flow on color or power Doppler. If not quently identified sonographically. Evaluation of groin pain in
excised, they grow progressively (Figs. 89A, B). Benign and elite athletes, so-called sports hernia or athletic pubalgia, is
malignant connective tissue tumors of the anterior abdominal
wall such as fibromas (Fig. 90) and fibrosarcomas (Fig. 91) can
simulate anterior abdominal wall hernias.
SUMMARY
Dynamic ultrasound is the key examination for asses-
sing groin or anterior abdominal wall pain. Dynamic compo-
nents of the examination include Valsalva and compression
FIGURE 90. Long-axis view of a benign fibroma of the anterior FIGURE 91. Transverse view of a fibrosarcoma of the anterior
rectus sheath of the inferior right rectus abdominis muscle sheath of the left rectus abdominis muscle that presented as
that presented as a nontender swelling near the right groin. a painless lump. It is similar in appearance to the fibroma shown
Note that there is minimal internal vascularity. in image Figure 86 but is much more vascular internally.
frequently more complex than in nonathletes because of asso- 3. Rettenbacher T, Hollerweger A, Macheiner P, et al. Abdominal wall
ciated tendinoses and osteitis pubis. Adding MRI to dynamic hernias: cross-sectional imaging of incarceration determined with
sonography. AJR Am J Roentgenol. 2001;177:1061Y1066.
ultrasound is usually necessary to get a complete picture of 4. Aguirre DA, Santosa AC, Casola G, et al. Abdominal wall hernias:
the multifactorial underlying pathologic processes and to help imaging features, complications, and diagnostic pitfalls at multi-detector
decide on the best combination of surgical and nonsurgical row CT. Radiographics. 2005;25:1501Y1520.
treatments. 5. Zarvan NP, Lee FT, Yandow DR, et al. Abdominal hernias: CT findings.
AJR Am J Roentgenol. 1995;164:1391Y1395.
Patients with one hernia frequently have multiple her- 6. Caudill P, Nyland J, Smith C, et al. Sports hernias: a systematic literature
nias; hence, in any patient in whom a hernia is sonographically review. Br J Sports Med. 2008;047373.
demonstrable, the examination should be continued, looking 7. Omar IM, Zoga AC, Kavanagh EC, et al. Athletic pubalgia and sports
for other types of ipsilateral and contralateral groin or ante- hernia: optimal MR imaging technique and findings. Radiographics.
2008;28:1415Y1438.
rior abdominal hernias. Even when no additional hernias are 8. Brittenden J, Robinson P. Imaging of pelvic injuries in athletes. Br J
found, it is important for the surgeon to specifically mention Radiol. 2005;78:457Y468.
in the report that a complete search of both groin areas was 9. Yang DM, Kim HC, Lim JW, et al. Sonographic findings of groin masses.
made and that no additional hernias were found. Strangula- J Ultrasound Med. 2007;26:605Y614.
tion is the most feared complication of groin hernias. Gray- 10. Shadbolt CL, Heinze SB, Dietrich RB. Imaging of groin masses: inguinal
anatomy and pathologic conditions revisited. Radiographics.
scale findings of strangulationVhyperechoic fat, isoechoic 2001;21:S261YS271.
thickening of the hernia sac, fluid within the sac, and thick- 11. Courtney CA, Lee AC, Wilson C, et al. Ventral hernia repair: a study of
ening of the walls of bowel loopsVare all more sensitive for current practice. Hernia. 2003;7:44Y46.
strangulation than is Doppler. Recurrent pain after hernior- 12. Parra JA, Revuelta S, Gallego T, et al. Prosthetic mesh used for inguinal
rhaphy is a relatively common problem. Dynamic sonography and ventral hernia repair: normal appearance and complications in
ultrasound and CT. Br J Radiol. 2004;77:261Y265.
can be helpful in assessing both acute and chronic recurrences 13. Miller PA, Mezwa DG, Feczko PJ, et al. Imaging of abdominal hernias.
of groin pain. Today, most hernia repairs use mesh. The key to Radiographics. 1995;15:333Y347.
sonographic identification of recurrent hernias is to assess the 14. Wechsler RJ, Kurtz AB, Needleman L, et al. Cross-sectional imaging of
edges of the mesh with dynamic maneuvers because recur- abdominal wall hernias. AJR Am J Roentgenol. 1989;153:517Y521.
15. Emby DJ, Aoun G. CT technique for suspected anterior abdominal wall
rent hernias arise from the edges of the mesh. It is important to hernia. AJR Am J Roentgenol. 2003;181:431Y433.
keep in mind that there are causes of groin pain and masses 16. Mufid MM, Abu-Yousef MM, Kakish ME, et al. Spigelian hernia:
other than hernias. There is a multitude of pathologic pro- diagnosis by high-resolution real-time sonography. J Ultrasound Med.
cesses than can simulate hernia. Many of these simulators 1997;16:183Y187.
are both rare and nonspecific, but cysts or hydroceles of 17. Engel JM, Deitch EE. Sonography of the anterior abdominal wall.
AJR Am J Roentgenol. 1981;137:73Y77.
the process vaginalis (or canal of Nuck) and round ligament 18. Kervancioglu R, Bayram MM, Ertaskin I, et al. Ultrasonic evaluation
varices are relatively common and have virtually pathogno- of bilateral groins in children with unilateral inguinal hernia. Acta Radiol.
monic sonographic appearances. 2000;41:653Y657.
19. Bradley M, Morgan D, Pentlow B, et al. The groin hernia: and ultrasound
diagnosis? Ann R Coll Surg Engl. 2003;85:178Y180.
REFERENCES 20. Jaffe Ta, O’Connell MJ, Harris JP, et al. MDCT of abdominal wall
1. Jamadar DA, Jacobson JA, Morag Y, et al. Sonography of inguinal region hernias: is there a role for Valsalva’s maneuver? AJR Am J Roentgenol.
hernias. AJR Am J Roentgenol. 2006;187:185Y190. 2005;184:847Y851.
2. Robinson P, Hensor E, Lansdown MJ, et al. Inguinofemoral hernia: 21. Orchard JW, Read JW, Neophyton J, et al. Groin pain associated with
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Hernias Ultrasound

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REVIEW ARTICLE

Dynamic Ultrasound of Hernias of the Groin and

Key Words: inguinal hernia, spigelian hernia, femoral hernia,

G roin hernias are common occurrences and usually present

Furthermore, in some patients, the pain is caused by

FIGURE 1. Abdominal CT scan demonstrating bilateral

inconspicuous. Dynamic maneuvers can cause the fat within a

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FIGURE 3. Long-axis image of an indirect inguinal hernia

inguinal and femoral). The reducibility of a hernia may vary

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In some cases, it can be difﬁcult to demonstrate the

anterior and lateral to the spermatic cord in males and to the

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of direct inguinal hernias is typically wider than the fundus.

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FIGURE 19. Long-axis view of a fat-containing direct inguinal

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between the multiple layers of lateral muscles (either between

detected spigelian hernias are more common than the literature

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Soccer players, hockey players, and American- and Australian-

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FIGURE 26. Illustration showing the relationship of a femoral

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FIGURE 29. Split-screen image showing a small Teale-type

FIGURE 31. Illustration showing the relationship of a spigelian

or medical treatment of the associated tendinosis and pubic

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FIGURE 33. Transverse extended ﬁeld-of-view image showing

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may necessitate using a larger piece of mesh. And of course, the

nontender or mildly, moderately, or severely tender when Report 2

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FIGURE 39. Illustration showing a spectrum of appearances

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Linea Alba Hernias

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The most frequent reason for missing an epigastric linea alba

FIGURE 45. Longitudinal view of the linea alba showing 2

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FIGURE 48. Longitudinal view showing a moderate-sized

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FIGURE 54. Split-screen image performed without

FIGURE 55. Longitudinal view showing a moderate-sized,

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FIGURE 62. Image of a patient who developed pain and

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FIGURE 68. Transverse extended ﬁeld-of-view image showing

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FIGURE 71. Long-axis extended ﬁeld-of-view image showing

FIGURE 72. Short-axis view of a strangulated left femoral

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tenderness and will generally not adversely affect the sound-

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FIGURE 77. Long-axis view of the right inguinal canal in a