Ultrasound of Groin & Abdominal Hernias

Samir Haffar
Gastroenterologist – Sonographer
Ultrasound of groin and anterior
abdominal wall hernias

Ultrasound of groin & anterior abdominal wall hernias
① Generality on groin & anterior abdominal wall hernias
② Inguinal hernias
③ Femoral hernias
④ Spigelian hernias
⑤ Hernias of anterior abdominal wall
⑥ Incisional hernias
⑦ Ultrasound features of strangulated hernia
⑧ Differential diagnosis of groin & abdominal wall hernias
⑨ Normal post-operative ultrasound features
⑩ Complications of hernia repair

① Generality on groin and anterior

Types of groin and anterior abdominal wall hernias
• Groin hernias: Indirect inguinal hernia
Direct inguinal hernia
Femoral hernia
Spigelian hernia
• Abdominal wall hernias: Epigastric hernia (above umbilicus)
Umbilical hernia
Hypogastric hernia (below umbilicus)
Divarication of rectus abdominis
• Incisional hernias
Jamadar DA et al. AJR 2007;188:1356–1364.

Groin hernias
Inferior epigastric artery
& inguinal ligament
Indirect inguinal hernia
Femoral hernia
Spigelian hernia

Anterior abdominal wall hernias
Epigastric hernia
Periumbilical hernia
Umbilical hernia
Infraumbilical
divarication

Incisional hernias
Midline vertical
incision
Lower abdominal
Pfannenstiel incision
(bikini cut)
Subcostal incision

• Lower Pfannenstiel incision (A): bikini cut
Potential sites for incisional hernia: black rectangle
• Subcostal skin incision (B)
Potential sites for incisional hernia: ovals
• Midline vertical incision (C)
Potential sites for incisional hernia: curved arrow
Incisional hernia
Three surgical incisions

Contents of hernias
• Fat: Most hernias contain only fat
Intraperitoneal or preperitoneal fat
Not possible to distinguish them sonographically
Hernia with intraperitoneal fat could contain bowel
• Fluid: Free fluid of intraperitoneal origin
• Bowel: Small bowel, colon, or appendix
Higher risk of strangulation and bowel infarction
• Less common: Ovary and bladder
Stavros AT et al. Ultrasound Quarterly 2010;26:135–169.

Complications of groin & anterior
• Irreducible hernia:
Contents cannot be reduced in absence of other complications
• Obstructed hernia:
Loop of viable bowel within the hernia becomes obstructed
• Strangulated hernia:
There is vascular compromise to the bowel within a hernia

Technical considerations
• Knowledge of surface anatomy of expected location of
groin and anterior abdominal wall hernias is important
• Using a high-frequency linear transducer (at least 7–10 MHz)
because abnormality confined to anterior abdominal wall
• Patient initially scanned in supine position
• Dynamic ultrasound: Valsalva maneuver
advantage over CT & MR Coughing
Compression
Upright position

Transducers
• High-frequency (7–10 MHz) linear transducer:
Standard examination
• Low-frequency (3–5 MHz) curved transducers:
Examination of larger patients
Additional depth required for complete evaluation
Revzin MV et al. RadioGraphics 2016;36:2028–2048.

Dynamic ultrasound of hernias
Advantage of US over CT and MRI
• Valsalva: Some hernias visible only during Valsalva
• Coughing: Some hernias visible only during coughing
• Compression: Essential to assess reducibility & tenderness
• Upright position: Some hernias present only in upright position
Fluid best demonstrated in upright position
Fluid may take few minute to reach hernia
Standard examination in supine position

Shape of hernias and reducibility
• Hernia with narrow neck and broad fundus:
Likely to be nonreducible
• Hernia with broad neck compared with fundus:
More likely to be reducible

Typical shape
of direct inguinal hernia
Shape of hernias and reducibility
Wide neck compared to fundus
Correlates with complete
reducibility
Typical shape
of linea alba hernia
Narrow neck compared to fundus
More likely to be non-reducible,
become obstructed & strangulate

Incarcerated or non-reducible hernia?
• It is preferable not to use the term incarcerated at all
Some confuse incarceration w obstruction or strangulation
They believe incarceration to be surgical emergency when it is not
• Presence of bowel loops in strangulated hernias makes them emergent
• We use the term non-reducible instead of incarcerated because
referring clinicians are less likely to confuse it with strangulation

Normal ultrasound anatomy of
inguinal region

Based primarily on localization of deep inguinal ring,
which is just lateral and slightly cephalic to origins of
inferior epigastric vessels (IEVs)
Ultrasound identification of inguinal canal

• Transverse scan of between umbilicus & pubic symphysis
• Transducer moved caudally until IEVs (2 veins and 1 artery)
seen lying deep to lateral border of rectus abdominis
• Vessels tracked infero-laterally to their origin at external iliac vessels
• Once deep inguinal ring located on short axis
Transducer angled along expected course of the IC
Parallel to medial half of the inguinal ligament

IEVs: inferior epigastric vessels
Image 1:
Transverse scan between umbilicus
& pubic symphysis
Image 2:
Transverse scan several cm inferiorly
Image 3:
Transverse scan at edge of rectus
abdominis muscle
Image 4:
Transducer parallel & perpendicular
to inguinal canal at origin of IEVs
Long-axis & short-axis views

US landmarks of inferior epigastric vessels (IEVs)
Image 1
Transverse US between umbilicus & pubic symphysis
IEVs at mid-lateral posterior surface of rectus
abdominis
Image 2
Transverse US several cm inferiorly
IEVs lie more laterally
Image 3
Transverse US at edge of rectus abdominis
Level where most spigelian hernias occur
Image 4
Transducer parallel & perpendicular to inguinal canal
at origin of IEVs (long-axis & short-axis views)

Inferior epigastric vessels
Fonseca EKUN et al. Radiol Bras 2018;51(3):193–199.
Rectus abdominis muscle, oblique abdominal muscles, inferior
epigastric vessels (arrow), & peritoneal fat interface (dotted line)
Transverse color Doppler US of left anterior abdominal wall

Right inguinal ligament
Extended field-of-view oblique longitudinal image
Inguinal ligament (arrows) extending from pubic tubercle
to anterior superior iliac spine (ASIS)
Normal inguinal ligament comprises parallel strands
of echogenic fibers and is approximately 5-mm thick
Lee RKL et al. Can Assoc Radiol J 2013;64:295–305.

Contents of inguinal canal
Male individuals
Inguinal canal
Female individuals
Nuck canal
Wittenberg AF et al. Curr Probl Diagn Radiol 2006;35:12–21.
Vas deferens
Testicular/cremasteric/deferential arteries
Pampiniform plexus
Genital branch of genitofemoral nerve,
Round ligament
Ilio-inguinal nerve
Lymphatic vessels

Normal inguinal anatomy
Spermatic cord (C), external iliac artery (A), external iliac vein (V),
inferior epigastric artery (E) and superior pubic ramus (curved arrow)
40-year-old healthy man
Long-axis US parallel & cranial to right inguinal ligament

Normal inguinal canal
Deep inguinal ring
Oblique longitudinal sonogram along inguinal canal
Spermatic cord (arrowheads) passes
through deep inguinal ring (arrow),
lateral to inferior epigastric vessels
Superficial inguinal ring
Spermatic cord (arrowheads) in
inguinal canal extending through
superficial inguinal ring (arrow)

US of normal inguinal canal & spermatic cord
Vas deferens as hypoechoic tubular structure (white arrowheads)
Testicular vessels adjacent to vas deferens (black arrows)
Spermatic cord slightly more hypoechoic than rest of IC contents
Inguinal canal outlined by white arrows
Long-axis Doppler US of left inguinal canal

R: rectus abdominis muscle – H: Hesselbach’s triangle
1- Spigelian hernia
4- Femoral hernia
3- Direct inguinal
hernia
2- Indirect
inguinal hernia
Transducer position to evaluate groin hernias

Hesselbach’s triangle
Medial border: lateral edge of rectus abdominis muscle
Lateral border: inferior epigastric vessels
Inferior border: spermatic cord

Inguinal hernias
• Two types of inguinal hernias: indirect and direct
• The terms direct and indirect refer to how hernias present during
open surgical repairs
• From a US point of view, the terms direct & indirect are confusing
It would be less confusing to characterize them as internal inguinal
ring (indirect) and non-ring (direct) hernias

Long axis view through right inguinal canal
Normal anatomy
IEVs (three circles) lie medially
to deep inguinal ring (black oval)
Indirect inguinal hernias
Pass through deep ring laterally
and over IEVs
Direct inguinal hernias
Originate medially to IEVs
Yoong P et al. Indian J Radiol Imaging 2013; 23(4):391–396.

Most common type of groin hernia – Congenital
• Gender: More common in males – can occur in females
• Neck of hernia: Within internal inguinal ring
Superior and lateral to origin of IEA
• Fundus of hernia: Within inguinal canal
Anterolateral to spermatic cord/round ligament
• Sliding type Wide neck, reducible, intraperitoneal contents
• Non-sliding type Narrow neck, nonreducible, preperitoneal fat
More difficult to diagnose by US
IEA: inferior epigastric artery

Anatomical landmarks of indirect inguinal hernia
RA: rectus abdominis
EIA: external iliac artery – EIV: external iliac vein
CFA: common femoral artery – CFV: common femoral vein
GSV: greater saphenous vein
IL: inguinal ligament – IIR: internal inguinal ring
SC: spermatic cord – RL: round ligament
IIH: indirect inguinal hernia
Neck of hernia
Arises in internal inguinal ring
Sac of hernia:
Extends anteriorly then inferomedially
Lies anterior to spermatic cord in males
or round ligament in females

Indirect inguinal hernias always pass superficial to IEA
Long-axis US of inguinal canal
Neck of hernia:
Lies in internal inguinal ring (IIR)
that is superior & lateral to proximal inferior epigastric artery (IEA)
Sac of hernia:
Courses horizontally in inferomedial direction in inguinal canal (IC)
Diagram

Long-axis view of inguinal canal
Hernia contents forced distally in
horizontal direction in inguinal
canal (arrows & dotted arrows)
Valsalva maneuver
Fat-containing
indirect inguinal hernia
Quiet respiration

Upright position in indirect inguinal hernia
Moderate indirect
inguinal hernia
containing only fat
Long-axis view
Upright position
Long-axis view
Supine & Valsalva
Hernia contains fluid
proving it contains
intraperitoneal contents
Hernia slightly larger
Still contains only fat
Long-axis view
Delayed upright position

Relationship of inguinal hernias to spermatic cord
Indirect inguinal hernias (ind) usually lie anterior to spermatic cord
Direct inguinal hernias (dir) lie posterior to the spermatic cord
Short-axis view

Relationship of indirect inguinal hernia to spermatic cord
Short-axis view
Hernia displacing & compressing the hyperechoic
spermatic cord posteriorly

Anatomical landmarks of direct inguinal hernia
Neck of hernia:
Inferior & medial to proximal IEA
Sac of hernia:
Posterior & medial to spermatic cord in men
or round ligament in females
RA: rectus abdominis muscle
DIH: direct inguinal hernia

• Arise in 2 ways:
Passing through a defect in conjoined tendon
Markedly stretching the tendon into inguinal canal
• Conjoined tendon and neck of direct inguinal hernia:
Arises inferior and medial to inferior epigastric vessels
Neck typically wider than fundus: makes strangulation rare
• Frequently bilateral, although often asymmetric
Second most common type of groin hernia – Acquired

Large fat- and bowel-containing hernial sac sac (H)
Located medial to IEVs (arrows) in Hesselbach triangle
EIA = external iliac artery, EIV = external iliac vein
52-year-old man with right groin pain

Relationship of direct inguinal hernia to spermatic cord
Short-axis view
Hernia displacing and compressing the hyperechoic spermatic
cord anteriorly and laterally

Conjoined tendon of inguinal region
Not really a well-defined structure
• Consists of aponeuroses of internal oblique and transverse
abdominis muscles and underlying transversalis fascia
• Conjoined tendon insufficiency:
Thinning and anterior bulging of conjoined tendon
Precursor to development of direct inguinal hernias
• Causes of conjoined tendon insufficiency
Increased intra-abdominal pressure:
Obesity, pregnancy, ascites, coughing, straining

Direct inguinal hernia and conjoined tendon
Starvos AT et al. Ultrasound Quarterly 2010;26:135–169.
Conjoined tendon (between 3 vertical arrows and arrowhead)
Underlying transversalis fascia (oblique arrow) and peritoneum (asterisk)
Long-axis view of right inguinal canal/ upright position

Bilateral direct inguinal hernia
Short-axis views of bilateral fat-containing direct inguinal hernias
Bilateral direct inguinal hernias occur commonly
Right side Left side

Relationship of conjoined tendon to spermatic cord
Quiet respiration & supine
Layers separated by loose
connective tissues or fat
Valsalva or upright position
1: internal oblique aponeurosis – 2: transverse abdominis muscle –
3: transversalis fascia – 4: peritoneum
Layers tend to be pushed together
& more difficult to distinguish
from each other

Relationship of conjoined tendon to spermatic cord
Quiet respiration/Supine position
Conjoined tendon posterior
to spermatic cord
Anterior bulging of conjoined tendon
which protrudes anterior to spermatic
cord & pushes/rotates the cord laterally
Short-axis left inguinal canal
Valsalva maneuver

Posterior inguinal wall insufficiency
and direct inguinal hernia
• In short axis:
Posterior inguinal wall insufficiency appears
indistinguishable from direct inguinal hernia
• In long axis
Posterior inguinal wall insufficiency is semicircular
Direct inguinal hernia protrudes inferiorly
within inguinal canal in a finger-like projection

Posterior inguinal wall insufficiency
Precursor to development of direct inguinal hernia
Posterior inguinal wall insufficiency appears semicircular
Long-axis US of left inguinal canal in upright position

Extend distally within inguinal canal in finger-like projection
posterior to spermatic cord
Long-axis US of left inguinal canal in upright position
Inferior epigastric
artery

Femoral hernia
• Rare and difficult to diagnose clinically unless strangulated
Hernia detected by US much more common than suggested
• More common in women than in men
Increased intra-pelvic pressure in third trimester of pregnancy
• Saphenous-femoral junction is key landmark for its identification
• Narrow neck in comparison to fundus width: risk of strangulation
• Contents: fat mostly – bowel non-reducible & frequently strangulated
• Best demonstrated during Valsalva maneuver or upright position
• Frequently bilateral

Anatomical landmarks of femoral hernia
Femoral hernia arise within femoral canal
Median to common femoral vein (CFV)
Just superior to sapheno-femoral junction
Inferior to inguinal ligament (IL)
Small femoral hernia remain medial to CFV
Larger hernias wrap around anterior to CFV
FH: femoral hernia

Normal right sapheno-femoral junction
Transverse US of right saphenofemoral junction
FA: femoral artery – FV: femoral vein – GSV: great saphenous vein
Yoong P et al. Indian J Radiol Imaging 2013; 23(4):391–396.
Femoral vein distends if intra-abdominal pressure increased
This is the inferior margin of femoral canal
Quiet respiration During Valsalva maneuver

Normal US of right femoral canal
Femoral canal (F)
Femoral artery (A) & vein (V)
Pectineus muscle (P)
Iliopsoas muscle (I)
Superior pubic ramus (arrows)
Transverse US
Quiet respiration
Longitudinal US
Valsalva
Transverse US
Valsalva
Contour of normal
peritoneal cavity (arrows)
Subcutaneous tissues (S)
Inguinal ligament (L)
Expected dilatation
of femoral vein
Brandel DW et al. J Ultrasound Med 2016;35:121–128.

Left femoral hernia
Femoral artery (A)
Femoral vein (V)
Femoral canal (F)
Transverse US
Quiet respiration
Longitudinal US
Valsalva
Transverse US
Valsalva
Hernia (blue arrowheads)
through normal rounded
contour of peritoneal
cavity (yellow arrows)
Subcutaneous tissues (S)
Inguinal ligament (L)
Hernia (blue arrows)
deforming rounded
medial contour of
femoral vein (V)
Brandel DW et al. J Ultrasound Med 2016; 35:121–128.

Relationship of femoral hernia to femoral vessels
Most hernias arise medial to CFV
Can extend anterior to CFA
Few small femoral hernias (Teale hernia)
arise anterior to CFV (black arrow)
FH: most common femoral hernia location
IP: iliopsoas muscle
a: common femoral artery
v: common femoral vein

Teale-type femoral hernia
Small Teale-type femoral hernia
Lying anterior to common
femoral vein (FV)
Transverse US of right femoral canal
No femoral hernia
on the left

Large femoral hernia
Large nonreducible femoral hernia
Arises within femoral canal (asterisk) medial to CFV
Neck extends anteriorly (arrows)
Fundus filled with peritoneal fluid (arrowheads)
High risk for strangulation: narrow neck & large fundus
Short-axis view of femoral canal

Bilateral femoral hernias
Bilateral fat containing hernias
Right larger than left (arrows)
Short-axis view of femoral canal
Quite respiration During Valsalva
No femoral hernia
Right side Right sideLeft side Left side

Incarcerated femoral hernia
Hernia (H) medial to
femoral canal (F)
No effacement of FV
Right short-axis view
Quiet respiration
Right long-axis view
During Valsalva
Right short-axis view
During Valsalva
Hernia (blue arrowheads)
through normal rounded
contour of peritoneal
cavity (yellow arrows)
Fluid in hernia sac (Fl)
suggesting incarceration
Mild bulging of
hernia (blue arrows)
No effacement of
femoral vein (V)
Brandel DW et al. J Ultrasound Med 2016; 35:121–128.

Muscles of anterior abdominal wall

Normal US anatomy of anterior abdominal wall
Extended field-of-view transverse image
Lateral abdominal wall
Hypoechoic rectus muscle
(arrowheads) w strands of internal
echogenicity (arrows) representing
tendinous intersections
Medial abdominal wall
1. Skin and subcutaneous layer
2. External oblique muscle
3. Internal oblique muscle
4. Transversus abdominis muscle
5. Peritoneal cavity

Anatomical landmarks of spigelian hernia
SH: spigelian hernia
Occurs along linea semilunaris (lateral border
of rectus abdominis) just superior to inferior
epigastric artery where this artery passes under
the lateral border of rectus abdominis muscle

Spigelian hernia
Groin or anterior abdominal well hernia?
• Spigelian hernia usually considered as anterior abdominal wall
rather than groin hernias
• Neck of spigelian hernias often lies within 2 cm of internal
inguinal ring (IIR), where indirect inguinal hernias arise
• Pain caused by spigelian hernias can be difficult to distinguish
from that caused by indirect inguinal hernias
• We discuss spigelian hernias with groin hernias in this presentation

Spigelian hernia
• External oblique tendon always intact
Hernia sac extend medially over anterior aspect of rectus abdominis
and/or extends laterally over external oblique muscles
Forcing it into shape of an anvil or mushroom
• Narrow neck & broad fundus, like femoral hernia:
Partially non-reducible with high risk of strangulation
• Hernia pass through multiple layers of tendons
Projections extend between multiple layers of lateral muscles
• Spigelian fascia like linea alba can become diastatic and widen

Small spigelian hernia
Internal oblique & transverse abdominis aponeuroses are torn
External oblique aponeurosis usually not torn
Hernia sac extend medially over anterior surface of right rectus muscle
& laterally over anterior aspect of right external oblique muscle
Giving a mushroom/anvil shape: non-reducibility, risk of strangulation
Transverse extended field-of-view image
Non-reducible fat-containing right-sided spigelian hernia

Spigelian hernia
Transverse sonogram along linea semilunaris
41-year-old woman with left spigelian hernia
Later border of rectus abdominis (R) and flank muscles (F)
and between them bowel (B) and extraperitoneal fat (EF) of hernia

Large bowel-containing nonreducible left spigelian hernia
Narrow neck and broad fundus: typical shape for spigelian hernias
Large spigelian hernia
Transverse sonogram of left spigelian hernia in upright position

Strangulated spigelian henia
Large bowel- and fat-containing left-sided spigelian hernia (arrows)
Hyperechoic texture of edematous strangulated contents

Report of ultrasound for groin hernia
It is important to use correct verbiage in reporting
results of a dynamic groin ultrasound exam

Example of normal ultrasound report of groin
Indication: Right groin pain
Examination: Dynamic groin ultrasound with 12-MHz transducer
Procedure: Right groin evaluated both in supine & upright
positions with and without compression & Valsalva
maneuvers
Findings: No evidence of direct or indirect inguinal, femoral,
or spigelian hernias
Impression: No evidence of a right groin hernia

Example of ultrasound report on groin hernia
Indication: Right groin pain
Examination: Bilateral dynamic groin ultrasound with 12-MHz transducer
Procedure: Right and left groin evaluated in supine & upright positions
with and without compression & Valsalva maneuvers
Findings:
Type
Side
Size
Contents
Reducibility
Tenderness
Ipsilateral hernias
Contralateral hernias
Right
Small
Fat-containing
Completely reducible
Moderately tender
No direct inguinal, femoral, or spigelian hernia on the right
No contralateral left-sided groin hernias
Impression: 1. Small, fat-containing, reducible, moderately tender, right
indirect inguinal hernia that is the cause of patient’s pain
2. No other ipsilateral groin hernias
3. No contralateral groin hernias

⑤ Hernias of anterior abdominal wall

Linea alba
• Fusion of fibers of ant/post sheaths of right & left rectus muscles
Most patients: 3 layers of fibers – Minority: single layer of fibers
• Thick markedly hyperechoic structure easily seen on ultrasound
• First step is diastasis recti:
Linea alba thinner and wider than normal
Anterior bulging not evident in supine & quiet respiration
Anterior bulging visible during Valsalva or upright position
• Second step is linea alba hernia
Defect usually near midline – May occur eccentrically

Spectrum of appearances of linea alba
Typical small linea alba hernia
Neck near midline of linea alba
Normal thick linea alba
Thinner but wider linea alba
Fewer decussations of rectus sheath fibers
Diastasis recti: supine & quiet respiration
Marked thinning & bulging of linea alba
Diastasis recti: Valsalva/upright position
Small linea alba hernia
Eccentric neck near right edge of linea alba
Transverse view

Diastasis recti
Marked widening, thinning, and bulging of linea alba
Diastasis recti
Extended field-of-view transverse image of linea alba
Upright position

Linea alba hernias typically have narrow necks
and broad fundi in transverse view
Shape correlates with non-reducibility
and increased risk of strangulation

Epigastric hernia
Defect in linea alba (arrows) through which extraperitoneal fat herniates
Hernia (H) shows no movement during Valsalva maneuver
which is not unusual for these hernias when small
Longitudinal sonogram along linea alba

Multiple epigastric hernias
Longitudinal view of linea alba
Two separate epigastric hernias:
1. small fat-containing non-reducible epigastric hernia inferiorly
2. tiny tear a couple of centimeters superiorly
Investigate entire length of linea alba in case of epigastric hernia

Paraumbilical hernia
FJamadar DA et al. AJR 2007;188:1356–1364.
Defect in linea alba through which extraperitoneal fat herniates (arrows)
Rectus abdominis muscles (R) can be seen on either side of defect
69-year-old man with supraumbilical fullness
Transverse midline sonogram

Umbilical hernia
4-month-old boy with umbilical hernia
Transverse sonogram at umbilicus
Medial margins of both rectus abdominis muscles (R)
between which is umbilical hernia (H)

Hypogastric hernia
Fat-containing hypogastric linea alba hernia (asterisk)
Lies immediately inferior to umbilicus (U)
Neck of hernia is very narrow (arrows)
Strangulated hyperechoic fatcompared to surrounding subcutaneous fat
Longitudinal sonogram of hypogastric hernia

Infraumbilical divarication of rectus abdominis
Transverse sonogram
Pre-Valsalva maneuver
Separation of rectus abdominis
muscles (R)
Arrowheads show medial extent
of rectus abdominis muscles
Transverse sonogram
Post-Valsalva maneuver
Rectus abdominus muscles (R)
closely approximated to midline
Arrowheads show medial extent
of rectus abdominis muscles

• Lower Pfannenstiel incision (bikini cut)
Curvilinear cutaneous/subcutaneous incision (A)
Vertical component between rectus abdominis
Potential for incisional hernia: black rectangle
• Subcostal skin incision (B)
Shorter than deeper incision
Extension along incision medially & laterally
Potential for hernia: ovals
• Midline vertical incision (C)
Suture perforations (circles) on either side
Site for incisional hernias: curved arrow
Incisional hernia
Three surgical incisions

Incisional hernia of right upper quadrant
Fat-containing incisional hernia in RUQ of cholecystectomy scar
Narrow neck (arrows) and broad fundus and is non-reducible
Ultrasound of right upper quadrant

Transverse sonogram upper abdominal wall
Sac of incisional hernia (arrowheads) contains small bowel
with gas extending through a defect in abdominal wall (arrows)
at site of previous surgery
Incisional hernia

⑦ Ultrasound features of strangulated hernia

US features of strangulated hernias
• Fluid within the hernia sac
• Isoechoic thickening of normally thin & echogenic hernia sac
• Presence of hyperechoic fat
• Thickening of bowel wall in bowel-containing hernia
In strangulated hernias, more than one of these findings
are present, even when Doppler demonstrates
normal flow within hernia contents

Strangulated indirect inguinal hernia
Short-axis view of inguinal canal Long-axis view of inguinal canal
IIR: internal inguinal ring
Rafailidis V et al. J Ultrasound Med 2016;35:e15–e28
Irreducible indirect inguinal hernia Bowel through IIR (arrow)
Blood flow only in hernia’s neck
Thickened bowel & fluid in hernia sac
Surgery confirmed strangulation

Strangulated femoral hernia
Short-axis view of right femoral hernia
1. Transudative or exudative fluid
2. Isoechoic thickening of hernia sac wall
Sac normally appears thin and echogenic
Two US features of strangulation

Strangulated umbilical hernia
Normal flow within hernia
on spectral Doppler
despite it being strangulated
Longitudinal US of umbilicus Color & spectral Doppler US
Abnormal hyperechogenicity
of fat within umbilical hernia
Indicating that it is strangulated

Doppler is not the most sensitive modality
for demonstrating strangulation
Grayscale sonography is

⑧ Differential diagnosis of groin and
anterior abdominal wall hernias
The list is long

Hydrocele: Communicating hydrocele
Non-communicating hydrocele: encysted – funicular
Varicocele: Males/Females
Cryptorchidism: Undescended testes – Ectopic testes
Testicular dislocation
Disease of spermatic cord: Corditis – Thrombosis of pampiniform plexus
Endometriosis
Urachal anomalies: Urachal cyst – Infected patent sinus
Vascular lesions: Varix of greater saphenous vein
Femoral pseudo-aneurysm
Femoral arterio-venous fistula
Musculoskeletal lesions: Muscle tear – Muscle hematoma – Tendinosis
Neoplasms Benign – Malignant
Enlarged lymph nodes: Reactive – Metastatic
Differential diagnosis of groin & abdominal wall hernias

Normal anatomy of inguinal canal and scrotum
Obliteration of the superior portion of processus vaginalis

Classification of congenital hydroceles
Communicating hydrocele Encysted hydrocele Funicular hydrocele

Inguinal canal hydrocele
Failure of processes vaginalis to obliterate
• 6% of male infants at delivery – most resolve by 18 months
• Typically located anterior and medial to spermatic cord
• Present with bulge in region of inguinal canal
• Two types:
Communicating Coexist commonly w indirect inguinal hernia
Noncommunicating Encysted: fluid trapped in remnant of PV
Funicular: communicates w peritoneal cavity
• Ultrasound Fluid collection +/- low-level echoes (debris)
Debris may result from: infection, bleeding,
trauma or cholesterol crystals

Communicating hydrocele
Passage of ascites from peritoneal cavity (P)
through inguinal canal (arrow) into scrotum
Processus vaginalis reopen & allow passage of ascites into scrotum
and cause an acquired communicating hydrocele
59-year-old man – right scrotal hydrocele – ascites due to cirrhosis
Sagittal gray-scale montage US image

Noncommunicating encysted hydrocele
Anechogenic fluid collection (*) along spermatic cord (arrows)
Fluid separate from and above the testis (T)
No communication with peritoneal cavity (P) is seen
10-month-old boy with palpable right inguinal mass

Noncommunicating encysted hydrocele
Ovoid cystic lesion in right spermatic cord (arrow)
T indicates testis
Longitudinal ultrasound of right spermatic cord
Yang DM et al. J Ultrasound Med 2007;26:605–614.

Cyst of Nuck canal
Cyst (arrows) along inguinal ligament of a female patient
This is along the course of round ligament
and suggestive of cyst of Nuck canal
Long-axis sonogram of Nuck canal

Noncommunicating funicular hydrocele
Anechoic fluid collection (*) in inguinal canal
communicating (arrow) with peritoneal cavity (P)
Fluid does not extend into scrotum
3-month-old boy with palpable right inguinal mass
Sagittal color Doppler montage US image

Varicocele in male individuals
• Primary varicocele: Incompetent valves of pampiniform plexus
More common on left – bilateral 30%
Isolated right-sided varicoceles 6%
• Secondary varicocele: Abdominal/retroperitoneal neoplasms
Complication of prior vasectomy (30%)
• Clinic: Soft groin mass, pain, and/or infertility
• Ultrasound: Serpiginous anechoic tubular structures
“bag of worms” appearance in inguinal canal
Diameter >2 mm ( with Valsalva & upright)
Partial or complete thrombosis is common
Noncompressible & partial fill at Doppler

ALARA principle
Total US exposure
as low as reasonably achievable
American Institute of Ultrasound in Medicine (AIUM)
American Institute of Ultrasound in Medicine. J Ultrasound Med 2011;30:151–155.

If isolated right-sided varicoceles are detected,
the retroperitoneum and abdomen should
be evaluated for any pathologic process
(most commonly a neoplasm)
I Revzin MV et al. RadioGraphics 2016;36:2028–2048.

Clinical assessment of varicocele
Dubin L, Amelar RD. Fertil Steril 1970;21:606–609
Lorenc T et al. J Ultrason 2016;16:359–370.
Dubin and Amelar classification
Most widely used system to assess severity of varicocele
Subclinical Not visible or palpable on physical exam; noted on US
Grade I Palpable varicocele only during Valsalva maneuver
Grade II Palpable varicocele at rest
Grade III Visible and palpable varicocele at rest

Ultrasound assessment of varicocele
Avoid excessive compression of scrotum by transducer
• Testicular volume:
0.52 × length ×width × height in cm
• Supine position:
Vein diameters of pampiniform plexus at rest & during Valsalva
Assessment of reflux during Valsalva in supine & upright
Reflux time: ˃ 2 sec for diagnosis
Peak reflux velocity
Varicocele extension: inguinal canal, supra/peritesticular regions
• Upright position:
Same as for supine position

Measurement of vein diameter
Varicocele if diameter of veins in pampiniform plexus ˃ 2 mm
3.4 mm

Venous reflux in color Doppler
Reflux during Valsalva maneuver
Color Doppler during ValsalvaColor Doppler at rest
No color flow at rest

Venous reflux in spectral Doppler
Significant venous reflux of > 2 sec durationValsalva

Ultrasound classifications of varicocele
No universal & recognized system to classify varicocele
• Classifications:
Sarteschi (1993)1 – Chiou (1997)2 – Ios and Lazzarini (2013)3
Not widely used
• Criticisms to these classifications4:
1. Poor correlation with clinical status of patients qualified
for varicocele surgical treatment
2. Low predictive value for impaired spermatogenesis,
which is the primary indication for surgical treatment
1 Sarteschi LM. G Ital Ultrasonologia 1993;4: 43–49.
2 Chiou RK et al. Urology 1997;50:953–956.
3 Iosa G, Lazzarini D. J Ultrasound 2013;16: 57–63.
4 Lorenc T et al. J Ultrason 2016;16:359–370.

Sarteschi classification
Not widely used
Grade I Reflux at level of groin only during Valsalva
Without scrotal deformation or testicular hypotrophy
Grade II Reflux at prox segment of pampiniform plexus during Valsalva
Grade III Reflux in distal vessels at lower scrotum only during Valsalva
Grade IV Spontaneous reverse flow increasing during Valsalva
With scrotal deformation and possible testicular hypotrophy
Grade V Resting reflux in dilated pampiniform plexus
Possibly increasing during Valsalva maneuver
Always accompanied by testicular hypotrophy
Sarteschi LM. G Ital Ultrasonologia 1993; 4:43–49.

Sarteschi’s classification grade 2
Longitudinal US of supra-testicular region during Valsalva
Varicocele grade 2 according to Sarteschi classification
Valentino M et al. J Ultrasound 2014;17:185–193.

Pauroso S et al. J Ultrasound 2011;14:199–204.
Relaxing condition
Venous reflux evident at rest
Venus diameter increases
during Valsalva
Valsalva’s maneuver

Venous diameter does not
increases during Valsalva
Valsalva’s maneuverRelaxing condition
Venous reflux evident in
basal condition
Pauroso S et al. J Ultrasound 2011;14:199–204.

Recent proposed classification of varicocele
• Kozakowski et al1
Peak retrograde velocity during Valsalva
Difference of venous diameters between rest & Valsalva
Surgery: peak reflux velocity >38 cm/s & diameter difference >20%
• Goren et al2
Reflux duration during Valsalva
Improved semen parameters after varicocelectomy if reflux >4.5sec
Correlates with clinical severity according to Dubin and Amela
1 Kozakowski KA et al. J Urol 2009;181:2717–2723.
2 Goren MR et al. Urology 2016;88:81–86.

Peak retrograde velocity during Valsalva
Kozakowski KA et al. J Urol 2009;181:2717–2723.
Surgery: peak reflux velocity >38 cm/s

Factors to surgical consideration of varicocele
• Pain
• Infertility
• Persistently abnormal semen quality
• Altered sperm function tests
• Failure of testicular development
• Testicular volume differentials > 15–20%
• Peak reflux velocity > 38 cm/s
• Reflux duration > 4.5 sec
• 20/38 harbinger can be extended to 15% asymmetry as well
Macey MR et al. Ther Adv Urol 2018;10(9):273–282

Partially thrombosed varicocele
Variococele in a 21-year-old man after spermatic cord ligation
Sagittal color Doppler US image of right inguinal canal
Dilated partially thrombosed varicocele (arrow)
that contains internal echoes
Very little detectable blood flow

Round ligament varices in female individuals
• Incidence: Rare and most commonly seen during pregnancy
• Clinic: Acute swelling/pain in groin, similar to inguinal hernia
• Ultrasound: Same as those of varicoceles in males
• Evolution: Most resolve spontaneously after delivery
• Thrombosis: Rare – Intense painful swelling of groin
Noncompressible veins & no flow signal in color US
Visible clot may be seen in lumen
• Surgery: Surgery if uncontrollable pain, thrombosis and rupture
Decompression of groin may alleviate symptoms

Round ligament varices
Pregnant woman at 8 month with right groin swelling
Log-axis color Doppler US of right groin
Multiple vessels in
inguinal canal (arrows)
Quiet respiration After Valsalva maneuver
Vessels more prominent with
Valsalva maneuvering

Partially thrombosed left round ligament varices
Decreasing uterine flow occurring in postpartum period can lead
to thrombosis of round ligament varices
Partially thrombosed round ligament varices
Female patient with left groin pain 4 weeks postpartum
Long-axis US of inguinal canal (Nuck canal)

Undescended testes (cryptorchidism)
• Incidence: 30% premature – 3-6% full-term – 1.2-1.8% at 1 year
Spontaneous descent after first year uncommon
Unilateral 90% - bilateral 10%
• Location: Abdominal, retroperitoneal, pelvic, inguinal
80% have testes in inguinal canal
• Ectopic testes: Not to confuse undescended testes w ectopic testes
Testes located outside of their normal descent path
Base of penis, perineal, femoral, anterior abd wall
• Associations: Patent procesus vaginalis 90%, inguinal hernia 50%
• Complication: Higher risk of torsion due to higher testicular cancer

Most frequent locations of undescended
and ectopic testes
Nepal P et al. S Afr J Rad 2018;22(1):a1374.

Ultrasound in undescended testes
sensitivity 45% – specificity 78% – accuracy 88%
• US technique: Testes localized by using tracking technique
Identify spermatic cord at deep inguinal ring
Tracking inferiorly on short axis to locate testes
If not found, abdominal location is suspected
Tracking cord proximally may help
• US findings: Most hypoechoic, some hyperechoic
Coarse or eggshell calcifications may be present
Heterogenous parenchyma may be due to cancer
• Size: Small compared to normal positioned testes
Testicular atrophy may be due to previous torsion
• Doppler US: Help to assess testicular viability
Torsion: no venous flow, high resistance art flow

Undescended testis
Ovoid hypoechoic testis (arrow)
Longitudinal sonography of right inguinal canal

Abdominal ectopic testis
Small ectopic testis along rectus sheath (*)
Ectopic testis shows peripheral vascularity indicating viability
2-year-old male child with left cryptorchidism
Sagittal linear color Doppler US of left upper abdomen

Complications of undescended testes
• Infertility
• Trauma: Due to its superficial location
• Malignancy: 10% – 15% of patients
• Torsion: Can be attributed to testicular cancer
• Inguinal hernia

Chronic torsion of undescended testis
5-year-old boy with empty left hemi-scrotum
Sagittal color Doppler US of left inguinal canal
Inguinal canal (white arrows)
Oval hypoechoic, atrophic, undescended testis (*)
No detectable blood flow in testicular parenchyma
Finding most compatible with prenatal testicular torsion

Cancer in undescended testis
30-year-old male patient with left cryptorchidism
US imaging of left inguinal canal
Atrophic and echogenic testis
Postoperative histology: testicular non-seminomatous germ cell tumor
Testicular malignancy: 10–15% of patients with undescended testes

Testicular dislocation
• Direct external pressure to perineum forces testicle out of scrotum
and into surrounding tissue
• Motorcycle accidents are most commonly reported mechanism
• Rare bilateral dislocation: one-third of cases
• US & color US useful for diagnosis & assessing testicular viability
• If US not contributive, CT look for dislocation into abdominal cavity
• Persistent dislocation 1 month associated with diffuse atrophy of
seminiferous tubules & increased risk for neoplastic transformation
Villavicencio CP et al. RadioGraphics 2016;36:2049–2063.

Dislocated testis with spermatic cord injury
Contralateral testis dislocated into IC
Low-resistance waveforms
indicating normal perfusion
44-year-old man after motorcycle collision
Short-axis color Doppler US
Enlarged heterogeneous spermatic
cord (white arrows) w hyperemia
of adjacent structures
Enlarged IC (black arrows)
Long-axis spectral Doppler US

• Retrograde spread of pathogens from urethra, prostate & SV
• Common pathogens: E. coli & Haemophilus influenzae
• Clinic: Painful inguinal mass
• US: Increased size of spermatic cord & inguinal canal
Heterogeneous appearance of vas deferens
Mass-like appearance of echogenic fat
Hyperemia that does not change at Valsalva
Dilated vessels may resemble varicocele
US & color Doppler during Valsalva can help
Mass-like aspect in severe cases w vascular compression
• Treatment: Antibiotics – surgical drainage in severe cases
Corditis
Inflammation of spermatic cord – also known as vasitis

Corditis
44-year-old man with type 1 DM and inguinal pain
Markedly edematous & hyperemic spermatic cord (oval outline)
Increased echogenicity of peri-spermatic fat (F)
which is consistent with inflammation
Short-axis color Doppler US of inguinal canal

• Rare and difficult to diagnose
• Clinical profile similar to other causes of scrotal pain
• Ultrasound findings similar to those of varicocele:
Dilated vessels of pampiniform plexus: > 3 mm
Echoic material characteristic of intraluminal thrombi
Thrombosis of pampiniform plexus

Partial thrombosis of pampiniform plexus
Short-axis US of inguinal canal
Hypoechoic material in
vascular lumen (arrow)
Absence of vascularization
on color Doppler (arrow)
Long-axis US of inguinal canal

Thrombosis of pampiniform plexus veins
Turgut AT et al. Ultrasound Clin 2008;3:93–107.
Thrombus within veins of
pampiniform plexus
Hypoechoic & thickened
vessel walls
34-year-old man presenting with acute scrotum

Inguinal endometriosis
• Location: Round ligament, inguinal lymph nodes, sac of hernia
• Association: 90% with coexisting pelvic endometriosis
• Clinic: Painful groin lump, premenstrual tenderness/swelling
• US: Irregular hypoechoic mass with or without blood flow
Blood flow depends on wether lesion is active or dormant
Cystic changes may be seen in the mass
US findings non-specific, may mimic those of a tumor
• MRI: High signal intensity on T1-weighted images
Low signal intensity on T2-weighted images

Endometrioma of inguinal canal
Long-axis view of left inguinal canal
Female patient with intermittent inguinal pain and swelling
Multiloculated complex cyst, an endometrioma

Endometriosis of inguinal canal
26-year-old woman with cyclic enlargement & pain in right groin
Sagittal color Doppler US
Poorly defined hypoechoic lesion
with vascularity in inguinal canal
Lesion corresponds to area of pain
Axial T1-weighted MR
Intermediate to high signal intensity
in inguinal lesion (arrow)
Associated pelvic endometrioma (E)

Types of urachal anomalies
Vesicourachal
diverticulum
Patent urachus Urachal cyst Umbilical-urachal
sinus

Urachal cyst
Longitudinal sonogram of suprapubic region
Small cystic lesion in anterosuperior anterior aspect of bladder
Suggestive of small urachal cyst (arrow)

Infected urachal cyst
Mixed hypo & anechoic mass in suprapubic region (arrows)
Low-level echoes inside lesion suggestive of pus formation
Urinary bladder wall thickening also noted (arrowheads)
Longitudinal sonogram of suprapubic region

Infected patent urachus sinus
Longitudinal view
below umbilicus
Patent urachal sinus (arrows)
passing through edematous
tissues in inferior umbilicus
Longitudinal view
with color Doppler
Intense hyperemia with inflamed
tissues that surround infected
patent urachal sinus (arrow)

Varix of long saphenous vein
• Focal dilatation of saphenous vein proximal to its passage
through cribriform fascia in the groin
• Difficult to differentiate clinically with femoral hernia
particularly if it is thrombosed
• Can be differentiated from femoral hernia on sonography

Varix of long saphenous vein
Focal varix along proximal long saphenous vein (LSV)
Just before it traverses cribriform fascia to anastomose w femoral vein
53-year-old woman with left saphenous varix
US over proximal long saphenous vein

Pseudo-aneurysm of femoral artery
Femoral artery: thick white arrow
Neck: thin white arrows
Pseudo-aneurysm: arrowheads
Transverse color Doppler US Spectral color Doppler US
Sample volume in the neck
Typical to-and-fro flow pattern

Nakashima D et al. JA Clinical Reports 2018;4:31
Arteriovenous fistula (arrow)
between right femoral artery (A) and right femoral vein (V)
Color Doppler ultrasound

Audible bruit at right femoral puncture after femoral catheterization
for radiofrequency ablation of ventricular tachycardia
Chun EJ. Ultrasonography 2018;37:164-173
High-velocity arterialized
waveform in the draining vein
Direct communication (arrow)
between CFA (A) and CFV (V)
High-velocity flow at junction of
artery & vein (arrowheads)
Spectral Doppler USColor Doppler US

Prominent xiphoid process
Hypoechoic cartilaginous xiphoid process (X) which has ventral curve
Tip is closest to overlying skin & under palpable abnormality (arrow)
49-year-old man with prominent xiphoid process
Sagittal midline epigastric sonogram

Tendinosis of adductor longus tendons
Bilateral tendinosis of adductor longus tendons
Edema and thickening of tendon (arrows)
Greater on symptomatic right side than on left side
Tendinosis in patients with athletic pubalgia bilateral but asymmetric
US not as reliable as MRI

Hematoma in rectus abdominis muscle
Acute right rectus abdominis muscle tear and hematoma
Acute pain & swelling in right groin & lower anterior abdomen
Long-axis extended field-of-view of right lower abdomen

Hematoma in internal oblique muscle
Acute tear and hematoma within internal oblique muscle (ii)
Acute pain in left lower quadrant
eo: external oblique muscle – ta: transverse abdominis muscle
Transverse extended field-of-view of left abdominal wall
Acute pain in left lower quadrant

Lipoma in inguinal canal
Short-axis US of right inguinal canal
Hyperechoic lipoma of inguinal canal
lying lateral to spermatic cord (SC)

Leiomyoma of round ligament
Leiomyoma (L) arising from round ligament (arrows)
Long-axis view of right inguinal canal
Female patient with palpable nodule in right groin

Desmoid tumors
• Arise from fibrous elements of anterior abdominal wall
aponeuroses or muscle sheaths
• Locally invasive: grow progressively, recur if not excised widely
• Do not metastasize distantly
• US: solid masses, irregularly shaped, some internal vascularity
• Difficult to distinguish from sarcomas
Except for slightly less blood flow on color or power Doppler

Desmoid tumor
Desmond tumor in anterior abdominal wall
Difficult to distinguish from sarcoma
Tumor has small amount of peripheral blood flow on color Doppler
Transverse supra-inguinal US

Desmoid tumor
Hypoechoic irregularly shaped mass
Patient refused surgery
Tender nodule few months after a pregnancy
Tumor enlarged from 1.3 to 2.4 cm
Patient accepted surgery
23 months laterTransverse supra-inguinal US

Scar granuloma
Laparotomy for cholecystitis – Abdominal wall mass 6 m later
Well-defined hypoechoic lesion (arrows) w acoustic shadowing
suggestive of scar granuloma
Clinical follow-up: no change in 5 years
Transverse sonography at surgical scar

Fibrosarcomas
Fibrosarcoma of sheath of left rectus abdominis muscle
Similar appearance to fibroma but much more vascular internally
Painful and tender lump
Transverse sonogram of left rectus abdominis muscle

Lymph nodes of inguinal region
Superficial inguinal lymph nodes
3 groups: superomedial (1), superolateral (2), inferior inguinal (3)
Deep inguinal lymph nodes (4)
Located at femoral ring medial to femoral vein
Below junction with great saphenous vein

Normal lymph nodes
Two small normal lymph nodes:
1. Ovoid shape
2. Hypoechoic peripheral zone
3. Echogenic center
Transverse color Doppler sonography of groin

Reactive benign lymph node
Enkarged and elongated benign-appearing lymph node
with characteristic echogenic hilum (H)
51-year-old man with lower extremity cellulitis
Transverse US image of left groin

Metastasis lymph nodes
60-year-old man with rectal cancer
Color Doppler US of left groinTransverse US of left groin
Increased internal blood flowWell-defined ovoid
hypoechoic mass

Non-Hodgkin lymphoma
Longitudinal US
Right inguinal region
Non-Hodgkin lymphoma in a 58-year-old woman
Color Doppler US
Right inguinal region
Blood flow within the massHypoechoic mass

⑨ Normal post-operative ultrasound features

Locations of mesh in anterior abdominal wall
Anterior to fascia at rectus abdominis muscle: Onlay
At level of rectus abdominis muscle: Inlay
Between rectus abdominis & transversalis fascia: retro-rectus underlay
Intra-peritoneal deep to transversalis fascia: intra-peritoneal underlay
Mesh in black lines
F: flank muscles (external oblique, internal oblique & transversus abdominis) – Fa: fascia
Jamadar DA et al. J Ultrasound Med 2008;27:907–917.

Locations of mesh in inguinal region
I: internal oblique muscle – EOA: external oblique aponeurosis – P: pectineus muscle
Mesh often placed between
transversalis fascia (TF) posteriorly
and anterior structures, including
transverse abdominis (T), spermatic
cord (C) and inguinal ligament (IL),
and pubic bone (Pub) inferiorly
Inguinal region in parasagittal plane at pubis

Normal US features of mesh herniorrhaphy
Appearance depends on type of mesh
• Individual fibers visible within the mesh
• Echogenic line of variable thickness & variable shadowing
• Area of variable shadowing
• Mesh can have folds and rolled at the edges
Can bulge mildly outwardly in upright position & during Valsalva
• Thin newer types of mesh more difficult to identify
Every effort should be made to identify the mesh
because recurrent hernias found at edges of the mesh

Visible individual fibers of the mesh
Thick echogenic mesh with strong acoustic shadow
Individual fibers within the mesh visible
Mesh can be this well seen in only a small percentage of cases

Thick and echogenic mesh
Thick and echogenic mesh (m) with strong acoustic shadow
Individual fibers within the mesh not visible

Thin and poorly defined mesh
Thin and poorly defined mesh (m) with weak acoustic shadow
Such mesh can only be identified with high-frequency transducers,
and careful search

Mesh in small versus increased field of view
Increased field of view
allows better appreciation of mesh
(arrows) and acoustic shadowing
Incisional hernia repair with mesh after lap cholecystectomy
Increased field of viewSmall field of view
Mesh (arrows) & acoustic
shadowing (S) may be limited
with smaller field of view

Normal wrinkled mesh
Wrinkled mesh
Upright positionSupine position/quiet respiration
Bulging with straightening
of some wrinkles

Spiral clip
Characteristic sonographic appearance of spiral clip (arrows)
Clips can become tender and can cause of postherniorrhaphy pain
Fallen into disfavor and seldom used today
Edges of mesh anchored to connective tissues with spiral clips

Tack of the mesh
Echogenic tack (small arrows) at lateral margin of the mesh
Left inguinal hernia repair with mesh in a 24-year-old man

• Artifact seen behind a strongly reflective medium
Appears as rapidly alternating red and blue signal
• Observed just deep to near-field interface of implanted mesh
• Color Doppler gain increased to point of “flare-out” then
decreased to clear region of interest, leaving twinkling artifact
• Differentiate twinkling produced by adjacent bowel from
twinkling associated with implanted mesh
Girish G et al. J Ultrasound Med 2011;30:1059–1065.
Twinkling artifact
May help to identify the mesh

Twinkling artifact in implanted mesh
Twinkling artifact (curved arrows)
extending from mesh to deep tissues
Contour of mesh still visible (straight
arrows) but linear surface not seen
Mesh of right inguinal hernia in 47-year-old man – Inguinal pain
2–5 MHz curvilinear transducer
Echogenic wavy linear surface
of mesh (arrows) is seen with
posterior acoustic shadowing (S)
Color Doppler US

Twinkling artifact in implanted mesh
68-year-old man – Right inguinal mesh – Inguinal discomfort
Echogenic linear mesh (straight arrows)
Somewhat difficult to see
Subtle acoustic shadowing (S)
Minimal Twinkling artifact (curved arrow)
2–5 MHz transducer Cranial to mesh implant
Adjacent bowel with twinkling
artifact (curved arrows)
A potential pitfall

⑩ Complications of hernia repair

Complications of hernia repair
• Seroma
• Hematoma
• Abscess
• Mesh migration
• Mesh impingement on adjacent structures
• Pain from the tacks holding the mesh in place
• Testicular ischemia
• Hernia recurrence

Seroma after inguinal hernia repair
Very large seroma around the mesh (m)
Right groin pain & swelling 10 days after herniorrhaphy

Repair of ventral midline incisional hernia
Anechoic fluid collection (S) at superficial surface of
the wavy echogenic mesh (arrows) after
Seroma after midline incisional hernia repair

Hematoma after inguinal hernia repair
Scrotal swelling & pain 11 days after inguinal hernia repair
Marked distension of right IC (white arrows)
Caused by heterogeneous fluid collection (*) extending into scrotum
Inguinal canal is inflamed with thickened walls

Hematoma after inguinal hernia repair
Huge hematoma filling the entire inguinal canal
from the groin to upper pole of testis
Pain, swelling & ecchymosis 2 weeks after inguinal herniorrhaphy

Stitch abscess
Pain & redness in left groin weeks after successful herniorrhaphy
Stitchs within center of a hyperemic complex fluid collection
Subacute stitch abscess

Tubular hypoechoic structure
Thick & irregular walls of
wound abscess (curved arrows)
Wound abscess after incisional hernia repair
50-year-old woman with wound abscess
Wavy echogenic structure
Abdominal wall mesh (arrows)
Prior incisional hernia repair
Jamadar DA et al. AJR 2007;188:1356–1364

Enterocutaneous fistula after mesh placement
53-year-old woman with mesh in anterior abdominal wall
Cutaneousous opening (O) and hyperemic echogenic phlegmon (P)
Lying superficial to 2 layers of wavy echogenic mesh (arrows)

Testicular ischemia
Large hematoma in left inguinal canal after herniorrhaphy
Patient with pain radiating into left scrotum
Split-screen images of testes
Swollen and edematous
left testis
Spectral Doppler of left testis
Decreased velocities/increased impedance
Compression of spermatic cord
Need to evacuate hematoma

Recurrent hernia after mesh repair
Large piece of mesh used to repair a large ventral hernia
detached along its right edge (arrowhead) allowing
a recurrent hernia to protrude from under detached edge (arrows)

Small fat-containing recurrent inguinal hernia (dotted line)
arising from inferomedial edge of the mesh (m)
where recurrent inguinal hernias most commonly arise
Short-axis view

Color Doppler US
Mesh repair for midline incisional hernia
Blood flow in hernia lying on
lateral margin of the mesh
(arrows)
Fat-containing hernia (H) at left lateral
margin of the mesh (arrows)
Neck of hernia: N & curved arrow
Transverse US image

Ultrasound of Groin & Abdominal Hernias

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