vol25.no9.online.

q 8/15/06 1:57 PM Page 1199

Image Presentation

Sonography in Identification
of Abdominal Wall Lesions
Presenting as Palpable Masses

Sudheer Gokhale, MBBS, MD

Objective. Abdominal wall lesions often present as palpable masses. The purpose of this presentation
is to provide an overview of the sonographic appearances of different abdominal wall lesions.
Methods. Patients were scanned with high-frequency (5- to 12-MHz) linear transducers. Extended or
panoramic views were recorded often to show the lesion in perspective to adjacent structures in the
abdominal wall. Results. The different layers of the abdominal wall could be clearly shown on high-
frequency sonography, and the abdominal wall abnormalities were recognized in all the patients.
Conclusions. Hernias are the most common abdominal wall lesions. Herniated bowel loops have vari-
able appearances depending on their air-fluid content and degree of obstruction. Localized fluid col-
lections in the abdominal wall (seromas, liquefying hematomas, and abscesses) can be well visualized.
More infrequently, tumors or vascular lesions can be identified in the abdominal wall. Key words:
abdominal sonography; abdominal wall; hernia.

A
Received April 25, 2006, from Choithram Hospital
and Research Centre, Indore, India. Revision request-
ed May 6, 2006. Revised manuscript accepted for
publication May 15, 2006.
Address correspondence to Sudheer Gokhale,
MD, MBBS, 53 Wasudevnagar, Indore 452 004, India.
E-mail: sudheergokhale@hotmail.com
bdominal wall lesions often mimic intra-abdom-
inal conditions and frequently present as palpa-
ble masses. This is more common with patients
who have a thick abdominal wall with a large
layer of fat. Pathologic processes that may involve the
abdominal wall occasionally raise diagnostic challenges
because of the low specificity of physical findings. The
most common situation when a sonographic examina-
tion of the abdominal wall is needed is when there is a
doubt about a palpable abdominal mass to decide
whether it is in the abdominal wall or inside the abdomi-
nal cavity. Sometimes a clinically suspected intra-abdom-
inal mass proves to be in the wall, and sometimes an
abdominal wall lesion is seen as an incidental finding on
abdominal sonography performed for some other reason.
Often patients with chronic abdominal pain need an
examination of the abdominal wall, especially when a
positive Carnett sign suggests the cause of pain to be in
the abdominal wall.1,2

© 2006 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 2006; 25:1199–1209 • 0278-4297/06/$3.50
vol25.no9.online.q 8/15/06 1:57 PM Page 1200

Abdominal Wall Lesions Presenting as Palpable Masses

Materials and Methods Tuberculous abscesses from caries of the ribs

can present as palpable lumps per se. They are
Patients were scanned with a Voluson 730 Expert localized collections of fluid, typically seen
system (GE Healthcare, Milwaukee, WI), an AU4 around the lower ribs and at or a little inferior to
Idea system (Esaote SpA, Genoa, Italy), and an the costal margin (Figure 3A). They may reveal
HDI 5000 system (Philips Medical Systems, internal echoes, depending on the debris inside.
Bothell, WA) with high-frequency (5- to 12-MHz) Destruction of the corresponding rib may be seen
linear transducers. Extended or panoramic views on the sonographic examination (Figure 3B).4,5
were recorded often to show the lesion in perspec-
tive to adjacent structures in the abdominal wall. Hernias
There was no need for any abdominal prepara-
tion. Any abdominal wounds were cleaned and, if Hernias are the most common abdominal wall
possible, covered with a thin, sterile, plastic adhe- lesions seen in sonographic practice. Depending
sive membrane, or, more simply, the probe was on their location and cause, they are divided into
covered with a sterile cover or glove. Patient’s ages different categories. With a high-frequency trans-
ranged from neonate to 68 years. ducer, the fascial defect can be visualized under-
lying the hernia. Herniated bowel loops have a
Anatomy variable appearance depending on their air-fluid
content and degree of obstruction. During the
The abdominal wall is a laminated structure. The real-time examination, induction and reduction
different layers are skin, superficial fascia, subcu- of a hernia can be observed. The patient is asked
taneous fat, muscle layer, the transversalis fascia,
and a layer of extraperitoneal fat (Figure 1). The Figure 1. A, Anterior abdominal wall on a transverse scan. RA
anterior muscle layer is composed of paired indicates rectus abdominis; EO, external oblique; IO, internal
midline rectus muscles and anterolaterally situ- oblique; and TA, transverse abdominis. The arrow points to the
aponeurosis of lateral muscles. B, Layers of the rectus sheath on
ated internal and external oblique and transverse
a transverse scan of the abdominal wall. Arrows point to the
abdominis muscles. The rectus abdominis mus- anterior rectus sheath, peritoneum, and fascia transversalis.
cles are attached superiorly to the anterior arcs of
5 to 7 ribs and inferiorly to the pubic crest. They A
are enclosed within the anterior and posterior
layers of the rectus sheath, which is a continua-
tion of the aponeurosis of the internal oblique,
external oblique, and transverse abdominis mus-
cles. The posterior rectus sheath ends at the arcu-
ate line, midway between the umbilicus and
symphysis pubis. In midline, the anterior and
posterior layers of the rectus sheath fuse to sepa-
rate the 2 recti and form the linea alba.
The skin is echogenic. The subcutaneous
fat layer is variable in thickness and is usually
hypoechoic.3 The muscles reveal medium-level
B
echoes. A typical lamellar pattern of the muscle
fibers usually can be recognized.

Fluid Collections

Localized fluid collections in the abdominal wall

are seromas, abscesses, or liquefying hematomas.
Noninfected seromas after surgery are usually
anechoic collections. Fluid collections complicat-
ed by infection or hemorrhage appear more com-
plex, with variable degrees of internal echoes,
layering, and septa (Figure 2).3

1200 J Ultrasound Med 2006; 25:1199–1209

vol25.no9.online.q 8/15/06 1:57 PM Page 1201

Gokhale

Figure 4. Ventral hernia with omental fat protruding through

Figure 2. Abdominal wall seroma after surgery. the defect in the rectus sheath. Arrows point to the defect in the
rectus sheath.

to cough or perform a Valsalva maneuver while

scanning over the suspected site is performed,
and with an increase in abdominal pressure,
suddenly the hernia will precipitate, and any
doubts will be resolved. Figure 5. A, Periumbilical hernia containing fat. H indicates her-
nial sac. Arrows point to the defect in the rectus sheath. B, Three-
Ventral Hernias dimensional rendering of a periumbilical hernia containing fat.
A ventral hernia occurs typically where there is A
no muscle support along the linea alba in the
midline in the epigastrium (Figure 4) or perium-
bilical region (Figure 5). The hernia very often
contains only fatty tissue but may be large and
contain bowel loops also.6,7

Figure 3. A, Tuberculous abscess inferior to the costal margin.

B, Tuberculous abscess surrounding rib caries. Note rib destruc-
tion. A indicates abscess.

J Ultrasound Med 2006; 25:1199–1209 1201

vol25.no9.online.q 8/15/06 1:57 PM Page 1202

Abdominal Wall Lesions Presenting as Palpable Masses

Spigelian Hernia Inguinal Hernia

A spigelian hernia occurs because of a defect in
the aponeurosis of the transverse abdominis
muscle and the rectus sheath. The most com-
mon site is the point where the linea semilunaris
crosses the arcuate line.8,9 The hernia may some-
times extend laterally and present as a flank
lump (Figure 6).
An indirect inguinal hernia occurs as a result of
protrusion of the peritoneal sac and contents
through the internal inguinal ring into the
inguinal canal and sometimes into the scrotum.12
The internal inguinal ring is a defect in the
transversalis fascia anterior to the femoral ves-
sels, lateral to the inferior epigastric artery, and

Incisional Hernia Figure 7. A, Large incisional hernia containing bowel loops.

An incisional hernia develops as a late complica- B, Incisional hernia, extended view. C, Incisional hernia at the site
tion of abdominal surgery. It also has been seen of laparoscopy.
after laparoscopic procedures. Most incisional A
hernias will present within the first year; however,
some go unnoticed by the patient and are inci-
dentally detected on sonography or computed
tomography. Sonography is very useful in ruling
out a hernia at surgical sites and in monitoring
the integrity of wire mesh implants (Figure 7).10–12

Figure 6. A, Spigelian hernia containing bowel loops. B, Spigelian

hernia containing obstructed bowel loops.

A
B

1202 J Ultrasound Med 2006; 25:1199–1209

vol25.no9.online.q 8/15/06 1:57 PM Page 1203

Gokhale

above the inguinal ligament. The superficial Figure 8. A, Inguinal hernia with sac containing only fluid. B,
inguinal ring is a defect in the external oblique Inguinal hernia containing bowel loops. C, Inguinal hernia,
extended view (continued).
aponeurosis. Direct inguinal hernias protrude
through a weakened inguinal canal floor, medial A
to the inferior epigastric artery. Depending on the
content, namely, fluid, air-containing bowel, or
fluid-containing bowel, inguinal hernias will have
different appearances on sonography (Figure 8,
A–C). Distended, adynamic bowel indicates
obstructed loops (Figure 8D). The inferior epigas-
tric artery can be visualized on color Doppler
sonography, and then differentiation of a direct or
an indirect inguinal hernia is possible (Figure 8,
E–G).13,14 In female neonates and infants, ovaries
may prolapse into the hernia and can be identi-
fied by their typical appearance (Figure 9).
B
Femoral Hernia
A femoral hernia protrudes through the femoral
canal (Figure 10A). Sonographic differentiation
depends on demonstration of the hernia medial
to the femoral vein (Figure 10B).15 Most patients
are elderly and obese and have abdominal or
groin pain with or without a palpable mass.

Miscellaneous Lesions

Urachal Cyst
A urachal cyst may be seen in between the
umbilicus and the bladder. It is usually situated
in the lower third of the urachus but can be seen
just inferior to the umbilicus. These cysts may
appear totally anechoic or may reveal low-level
internal echoes (Figure 11).16,17

Endometriosis
Endometriosis of the abdominal wall may occur
as a long-term complication of uterine surgery. It
has no specific appearance but is seen as a focal C
mass at the scar of previous surgery with attacks
of cyclic pain and swelling (Figure 12).18–20

Abdominal Wall Hematoma

A rectus sheath hematoma may develop after
paroxysms of coughing or sneezing or after
seizures. The underlying cause is usually either
anticoagulant therapy or some bleeding disor-
der. Because these hematomas are limited with-
in the rectus sheath, they are not very big. Their
shape depends on their location. Above the arcu-
ate line, they are usually ovoid in shape with the
long axis superoinferior and are seen on one side

J Ultrasound Med 2006; 25:1199–1209 1203

vol25.no9.online.q 8/15/06 1:57 PM Page 1204

Abdominal Wall Lesions Presenting as Palpable Masses

D E

F G

Figure 8. (continued) D, Inguinal hernia containing obstructed bowel loop. E, Inguinal hernia, longitudinal section. Arrows outline
the small hernial sac. F, Direct right inguinal hernia medial to the inferior epigastric artery. G, Indirect right inguinal hernia lateral to
the inferior epigastric artery.

Figure 9. A, Inguinal hernia in an infant girl containing a prolapsed ovary. B, Inguinal hernia in an infant girl with an ovary reduced
in the peritoneal cavity. H indicates hernial sac; and OV, ovary.
A B

1204 J Ultrasound Med 2006; 25:1199–1209

vol25.no9.online.q 8/15/06 1:57 PM Page 1205

Gokhale

(Figure 13A). Below the arcuate line, because of

the absence of the linea alba, they can extend
across the midline. Then the hematoma may be
seen as a padlike lesion with its maximum length
along the transverse axis.21–23 In one neonate, an
abdominal wall hematoma was seen to spread
transversely in the supraumbilical region
(Figure 13, B and C). In patients with postsurgi-
cal disseminated intravascular coagulation,
large hematomas are seen in the abdominal wall
in the vicinity of the surgical scar (Figure 13D).
A
Everted Xiphisternum
This may present as a palpable mass in the epi-
gastrium, which is not painful and is firm to hard
on palpation (Figure 14).

Neoplasms

Lipomas are occasionally seen in the abdominal

wall. They appear as well-defined ovoid or pad-
like masses (Figure 15A). Most lipomas in the
abdominal wall are isoechoic to slightly hypere-
choic compared with the muscles (Figure 15B). A
thin echogenic capsule can usually be seen.3,24

Figure 10. A, Femoral hernia. H indicates hernial sac. B, Color

Doppler scan of a femoral hernia at 2 different levels showing
the mass medial to the femoral vessels.
B
A Figure 11. A, Urachal cyst. The cyst is infected and contains
faintly echogenic fluid. B, Urachal cyst. The anterior wall of the
tense cyst produces reverberation artifacts.

Figure 12. Endometriosis in a cesarean delivery scar.

J Ultrasound Med 2006; 25:1199–1209 1205

vol25.no9.online.q 8/15/06 1:57 PM Page 1206

Abdominal Wall Lesions Presenting as Palpable Masses

Figure 13. A, Rectus sheath hematoma in an elderly woman after

severe cough. Arrows point to the fascia transversalis. B, Abdominal
D
wall hematoma in a neonate. C, Abdominal wall hematoma over-
lying umbilical vein insertion in a neonate. UV indicates umbilical
vein. D, Abdominal wall hematoma in a cesarean delivery scar in a
patient with disseminated intravascular coagulation.

Figure 14. A, Prominently everted xiphisternum (Xi phi-Str) pre-

A
senting as a lump in the epigastrium. Arrows point to the xiphis-
ternum. B, Prominently everted xiphisternum presenting as a
lump in the epigastrium, extended view. Liv indicates liver; P, pan-
creas; Rcts, rectus sheath; St, stomach; and XS, xiphisternum.
B

1206 J Ultrasound Med 2006; 25:1199–1209

vol25.no9.online.q 8/15/06 1:57 PM Page 1207

Gokhale

The other tumor that occurs in the abdominal

wall is the desmoid tumor, which arises from the
fascia or aponeurosis of muscles. They often
occur at site of previous laparotomy scars. They
occur more commonly in female patients than in
male patients (Figure 16).25,26
The most frequent malignant nodules are
metastatic melanomas. Metastases from lym-
phoma and lung, breast, ovary, and colon cancer
are less common (Figure 17).

Inguinal Masses A

Apart from hernias, other lesions may present as

small, palpable masses in the inguinal area.

Undescended Testis
Testicular descent can get arrested at any point
from the renal hilum to the external inguinal ring.
Of all the undescended testes, 90% to 95% are low
and in the inguinal canal. Sonography is very use-
ful in detection of undescended testes. The un-
descended testis is usually small. It is ovoid and
B
reveals a homogeneous, hypoechoic structure.
Figure 16. A, Desmoid tumor in a previous scar. B, Color
The presence of an echogenic hilum distinguish- Doppler scan of a Desmoid tumor in a previous scar revealing
es a lymph node from a testis (Figure 18).27,28,29 some vascularity in the lesion.

Figure 15. A, Lipoma. B, Multiple lipomas. Figure 17. Metastatic nodular deposits in a patient with ovari-
an cancer.
A

Figure 18. Undescended testis.

B

J Ultrasound Med 2006; 25:1199–1209 1207

vol25.no9.online.q 8/15/06 1:57 PM Page 1208

Abdominal Wall Lesions Presenting as Palpable Masses

Lipoma of the Spermatic Cord and

Inguinal Canal
Lipoma is the most common tumor in the
inguinal canal and spermatic cord. It appears as
a spindle-shaped, echogenic mass along the
inguinal canal or in the upper part of the scro-
tum. Lipoma of the cord is a poorly recognized
entity that can be present with groin symptoms
and clinical findings indistinguishable from
those of an inguinal hernia (Figure 19).30,31

Lymph Nodes
Sonography is helpful for categorizing a palpa-
ble inguinal mass. Most lymph nodes are ovoid.
They typically have an echogenic central area
and a hypoechoic peripheral zone (Figure 20).25

Pseudoaneurysm A
With the widespread increase in transfemoral
vascular interventions and vascular reconstruc-
tion procedures, pseudoaneurysms in the groin
are not uncommon. The pseudoaneurysm is
seen as a localized fluid-filled structure, which
may reveal pulsations. Swirling of echogenic
blood may be seen on real-time examination
within the cystic fluid-filled cavity. On Color
Doppler examination, it reveals a typical yin-
yang flow (Figure 21).32,33

B
Figure 20. A, Enlarged inguinal lymph node. Note the
echogenic hilum. B, Color Doppler scan reveals the vascular
hilum of the lymph node.

Figure 19. Lipoma of the inguinal canal. Figure 21. Pseudoaneurysm of the common femoral artery.

1208 J Ultrasound Med 2006; 25:1199–1209

vol25.no9.online.q 8/15/06 1:57 PM Page 1209
References
1. Thomson WH, Dowes RF, Carter SS. Abdominal wall ten-
derness: a useful sign in chronic abdominal pain. Br J Surg
1991; 78:223–225.
2. Suleiman S, Johnston DE. The abdominal wall: an over-
looked source of pain. Am Fam Physician 2001; 64:431–
438.
3. Truong S, Pfingsten FP, Dreuw B, Schumpelick V. Value of
sonography in diagnosis of uncertain lesions of the
abdominal wall and inguinal region [in German]. Chirurg
1993; 64:468–475.
4. Dhar AM, Bhargav SK, Bankata S. Isolated abdominal pari-
etal cold abscess diagnosed on ultrasound. Indian J Radiol
Imaging 1999; 9:165.
5. Taylor RH, McNicol MW. Ultrasound in the diagnosis of
two unusual tuberculous abscesses. Br J Surg 1980;
67:556.
6. Thomas JL, Cunningham JJ. Ultrasonic evaluation of ven-
tral hernias disguised as intra-abdominal neoplasms. Arch
Surg 1978; 113:589–590.
7. Spangen L. Ultrasound as a diagnostic aid in ventral
abdominal hernia. J Clin Ultrasound 1975; 3:211–213.
8. Spangen L. Spigelian hernia. Acta Chir Scand Suppl 1976;
462:1–47.
9. Deitch EA, Engel JM. Spigelian hernia: an ultrasonic diag-
nosis. Arch Surg 1980; 115:93.
10. Fischer JD, Turner FW. Abdominal incisional hernia: a ten-
year review. Can J Surg 1974; 17:202–204.
11. Ellis H, Gajraj H, George CD. Incisional hernias: when do
they occur? Br J Surg 1983; 70:290–291.
12. Engel JM, Dietrich EE. Sonography of the anterior abdom-
inal wall. AJR Am J Roentgenol 1981; 137:73–77.
13. Korenkov M, Paul A, Troidl H. Color Duplex Sonography:
diagnostic tool in the differentiation of inguinal hernias. J
Ultrasound Med 1999; 18:565–568.
14. Zhang GQ, Sugiyama M, Hagi H, Urata T, Shimamori N,
Atomi Y. Groin hernias in adults: value of color Doppler
sonography in their classification. J Clin Ultrasound 2001;
29:429–434.
15. Riehl J, Schneider B, Sieberth HG. Femoral hernia: diagno-
sis with B-image, duplex and color-coded Doppler ultra-
sound [in German]. Ultraschall Med 1995; 16:145–147.
16. Cappele O, Sibert L, Descargues J, Delmas V, Grise P. A
study of the anatomic features of the duct of the urachus.
Surg Radiol Anat. 2001; 23:229–235.
17. Yu JS, Kim KW, Lee HJ, Lee YJ, Yoon CS, Kim MJ. Urachal
remnant diseases: spectrum of CT and US findings.
Radiographics. 2001; 21:451–461.
18. Patterson GK, Winburn GB. Abdominal wall endometrio-
sis: a report of eight cases. Am Surg 1999; 65:36–39.
J Ultrasound Med 2006; 25:1199–1209
Gokhale
19. Francica G, Giardiello C, Angelone G, Cristiano S, Finelli R,
Tramontano G. Abdominal wall endometriomas near
cesarean delivery scars: sonographic and color Doppler
findings in a series of 12 patients. J Ultrasound Med 2003;
22:1041–1047.
20. Hensen JH, Van Breda Vriesman AC, Puylaert JB.
Abdominal wall endometriosis: clinical presentation and
imaging features with emphasis on sonography. AJR Am J
Roentgenol 2006; 186:616–620.
21. Lee TM, Greenberger PA, Nahrwold DL, Patterson R.
Rectus sheath hematoma complicating an exacerbation of
asthma. J Allergy Clin Immunol 1986; 78:290–292.
22. Cavagna E, Carubia G, Schiavon F. Anatomo-radiologic
correlations in spontaneous hematoma of the rectus abdo-
minis muscles. Radiol Med (Torino) 2000; 99:432–437.
23. Humphrey R, Carlan SJ, Greenbaum L. Rectus sheath
hematoma in pregnancy. J Clin Ultrasound 2001; 29:306–
311.
24. Nguyen K, Sauerbrei EE, Nolan RL, Lewandowski BJ. The
abdominal wall. In: Rumack CM, Wilson SR, Charboneau
JW (eds). Diagnostic Ultrasound. Vol 1. St Louis, MO:
Mosby-Year Book; 1998: 487–499.
25. Overhaus M, Decker P, Fischer HP, Textor HJ, Hirner A.
Desmoid tumors of the abdominal wall: a case report.
World J Surg Oncol 2003; 1:11.
26. Casillas J, Sais GJ, Greve JL, Iparraguirre MC, Morillo G.
Imaging of intra- and extraabdominal desmoid tumors.
Radiographics 1991; 11:959–968.
27. Weiss RM, Carter AR, Rosenfield AT. High-resolution real-
time ultrasonography in the location of the undescended
testis. J Urol 1986; 135:936–938.
28. Pekkafali MZ, Sahin C, Ilbey YO, Albayrak S, Yildirim S,
Basekim CC. Comparison of ultrasonographic and laparo-
scopic findings in adult nonpalpable testes cases. Eur Urol
2003; 44:124–127.
29. Kanemoto K, Hayashi Y, Kojima Y, Maruyama T, Ito M,
Kohri K. Accuracy of ultrasonography and magnetic reso-
nance imaging in the diagnosis of non-palpable testis. Int J
Urol 2005; 12:668–672.
30. Nasr AO, Tormey S, Walsh TN. Lipoma of the cord and
round ligament: an overlooked diagnosis? Hernia 2005;
9:245–247.
31. Heller CA, Marucci DD, Dunn T, Barr EM, Houang M, Dos
Remedios C. Inguinal canal “lipoma.” Clin Anat 2002;
15:280–285.
32. Rapoport S, Sniderman KW, Morse SS, Proto MH, Ross GR.
Pseudoaneurysm: complication of faulty technique in
femoral arterial puncture. Radiology 1985; 154:529–530.
33. Mitchell DG, Needleman L, Bezzi M, et al. Femoral artery
pseudoaneurysm: diagnosis with conventional duplex and
color Doppler US. Radiology 1987; 164:687–690.
1209