DOI: 10.1148/rg.256055018
Abdominal Wall Hernias: Imaging Features, Complications, and Diagnostic Pitfalls at Multi–Detector Row CT1
Diego A. Aguirre, MD,
Agnes C. Santosa, MD,
Giovanna Casola, MD and
Claude B. Sirlin, MD
1 From the Department of Radiology, University of California, San Diego, 200 W Arbor Dr, San Diego, CA 92103-8756 (D.A.A., A.C.S., G.C., C.B.S.); and the Fundación Sante Fe de Bogotá, University Hospital, Bogotá, Colombia (D.A.A.). Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received February 3, 2005; revision requested March 7 and received April 5; accepted April 11. All authors have no financial relationships to disclose.
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Figure 1a. (a) Axial contrast material–enhanced reformatted CT image of the abdomen obtained with the patient at rest shows an umbilical hernia containing omental fat (arrows). (b) Axial contrast-enhanced reformatted CT image obtained during a Valsalva maneuver reveals that the hernia contains small bowel loops (arrowhead). Increased intra-abdominal pressure may improve the detection of small abdominal wall defects.
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Figure 1b. (a) Axial contrast material–enhanced reformatted CT image of the abdomen obtained with the patient at rest shows an umbilical hernia containing omental fat (arrows). (b) Axial contrast-enhanced reformatted CT image obtained during a Valsalva maneuver reveals that the hernia contains small bowel loops (arrowhead). Increased intra-abdominal pressure may improve the detection of small abdominal wall defects.
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Figure 2. Direct inguinal hernia in a 57-year-old man. Axial unenhanced reformatted CT image of the abdomen shows a direct inguinal hernia (arrow) medial to the inferior epigastric vessels on the right side of the groin. Note the presence of bowel loops in the hernia sac.
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Figure 3. Epigastric hernia in a 65-year-old man. Axial contrast-enhanced reformatted CT image of the abdomen shows an epigastric hernia (arrows) containing the transverse colon and small bowel loops. Note also the interparietal hernia through the right lateral aspect of the abdominal wall (arrowhead) containing the hepatic flexure of the colon.
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Figure 4. Incarcerated umbilical hernia in a 56-year-old woman. Axial contrast-enhanced reformatted CT image of the abdomen shows herniation of omental fat through the umbilical orifice (arrow). Associated stranding of herniated fat is also seen. The narrow neck of the hernia sac and the fat stranding suggest incarceration. The hernia was irreducible at physical examination, and an incarcerated hernia was confirmed at surgery.
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Figure 5. Superior lumbar hernia in a 63-year-old man who had undergone right nephrectomy for renal cell carcinoma. Axial contrast-enhanced reformatted CT image of the abdomen shows a superior lumbar hernia (incisional type) (arrows). Note the protrusion of the ascending colon into the subcutaneous tissue. The left kidney has an extrarenal pelvis, a finding that was discovered incidentally.
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Figure 6. Diffuse lumbar hernia in a 58-year-old man who had undergone left nephrectomy for renal cell carcinoma. Axial unenhanced reformatted CT image of the abdomen shows a diffuse lumbar hernia (incisional type). Note the extensive herniation of the mesentery and bowel loops through the wall defect (arrows).
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Figure 7a. Incarcerated hernia in a 78-year-old man. (a) Axial contrast-enhanced reformatted CT image of the abdomen shows herniation of stool-filled, thin-walled colon (arrow) through a narrow abdominal wall defect. The patient was asymptomatic but presented with acute abdomen 1 month later. (b) Axial contrast-enhanced reformatted CT image shows multiple ventral hernias (arrowheads). The sac of the hernia shown in a now contains extraluminal fluid and fluid-filled, mildly thickened colon and causes colonic obstruction. Incarceration with colonic obstruction was confirmed at surgery.
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Figure 7b. Incarcerated hernia in a 78-year-old man. (a) Axial contrast-enhanced reformatted CT image of the abdomen shows herniation of stool-filled, thin-walled colon (arrow) through a narrow abdominal wall defect. The patient was asymptomatic but presented with acute abdomen 1 month later. (b) Axial contrast-enhanced reformatted CT image shows multiple ventral hernias (arrowheads). The sac of the hernia shown in a now contains extraluminal fluid and fluid-filled, mildly thickened colon and causes colonic obstruction. Incarceration with colonic obstruction was confirmed at surgery.
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Figure 8a. Incarcerated hypogastric hernia in a 55-year-old woman who presented with abdominal distention. (a) Axial unenhanced reformatted CT image of the abdomen shows the herniation of small bowel loops through a narrow defect in the abdominal wall (arrow). Fat stranding is seen in the hernia sac. (b) Coronal unenhanced reformatted CT image better depicts proximal small bowel obstruction (arrowheads). Arrow indicates an abdominal wall defect. Incarcerated hypogastric hernia was confirmed at surgery.
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Figure 8b. Incarcerated hypogastric hernia in a 55-year-old woman who presented with abdominal distention. (a) Axial unenhanced reformatted CT image of the abdomen shows the herniation of small bowel loops through a narrow defect in the abdominal wall (arrow). Fat stranding is seen in the hernia sac. (b) Coronal unenhanced reformatted CT image better depicts proximal small bowel obstruction (arrowheads). Arrow indicates an abdominal wall defect. Incarcerated hypogastric hernia was confirmed at surgery.
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Figure 9a. Strangulated hernia in a 56-year-old man. (a) Axial contrast-enhanced reformatted CT image of the abdomen shows a strangulated left inguinal hernia with a C-shaped con-figuration (arrows). Note the bowel wall thickening, severe fat stranding, mesenteric engorgement, and extraluminal fluid confined to the hernia sac, findings that suggest strangulation. (b) Sagittal contrast-enhanced reformatted CT image of the abdomen more clearly shows a hernia defect (arrowhead). In this case, mural enhancement of herniated bowel is normal (similar to that of intraabdominal bowel loops). Normal mural enhancement does not exclude strangulation, whereas abnormal enhancement strongly suggests it.
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Figure 9b. Strangulated hernia in a 56-year-old man. (a) Axial contrast-enhanced reformatted CT image of the abdomen shows a strangulated left inguinal hernia with a C-shaped con-figuration (arrows). Note the bowel wall thickening, severe fat stranding, mesenteric engorgement, and extraluminal fluid confined to the hernia sac, findings that suggest strangulation. (b) Sagittal contrast-enhanced reformatted CT image of the abdomen more clearly shows a hernia defect (arrowhead). In this case, mural enhancement of herniated bowel is normal (similar to that of intraabdominal bowel loops). Normal mural enhancement does not exclude strangulation, whereas abnormal enhancement strongly suggests it.
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Figure 10a. Strangulated hernia in a 44-year-old man. (a) Axial contrast-enhanced reformatted CT image of the abdomen shows a strangulated umbilical hernia (arrows) causing small bowel obstruction (arrowheads). A herniated bowel loop with a C-shaped configuration, discrete mesenteric engorgement, and ascitic fluid within the hernia sac are also seen. (b) Sagittal contrast-enhanced reformatted CT image of the abdomen more clearly demonstrates the amplitude of the umbilical defect (thin arrows), air-fluid levels in herniated bowel loops, and dilatation of intraabdominal bowel loops secondary to small bowel obstruction (arrowhead). Note the ascitic fluid within the scrotum (thick arrow), a finding that is characteristic of inguinoscrotal hernia.
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Figure 10b. Strangulated hernia in a 44-year-old man. (a) Axial contrast-enhanced reformatted CT image of the abdomen shows a strangulated umbilical hernia (arrows) causing small bowel obstruction (arrowheads). A herniated bowel loop with a C-shaped configuration, discrete mesenteric engorgement, and ascitic fluid within the hernia sac are also seen. (b) Sagittal contrast-enhanced reformatted CT image of the abdomen more clearly demonstrates the amplitude of the umbilical defect (thin arrows), air-fluid levels in herniated bowel loops, and dilatation of intraabdominal bowel loops secondary to small bowel obstruction (arrowhead). Note the ascitic fluid within the scrotum (thick arrow), a finding that is characteristic of inguinoscrotal hernia.
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Figure 11. Lumbar hernia in a 33-year-old man who had sustained injury in a high-impact motor vehicle accident. The patient was a front-seat passenger and was wearing a seat belt at the time of the accident. Axial contrast-enhanced CT scan of the abdomen shows a trauma-related lumbar hernia. Note the protrusion of colon (arrow), the mild mesenteric haziness, and the traumatic disruption of the abdominal wall musculature (arrowheads). Traumatic abdominal wall hernia is usually an indication for emergent laparotomy in the setting of acute trauma.
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Figure 12a. Diaphragmatic hernia in a 33-year-old man who had sustained injury in a motor vehicle accident. (a, b) Axial contrast-enhanced reformatted CT images of the chest and abdomen show an acute diaphragmatic hernia, along with small bowel loops (arrows in a) and mesenteric fat (arrowheads in b) in the chest. Note the collapse of the left lung and the presence of chest tubes. (c) Coronal thick-slab reformatted image shows the herniation of bowel loops into the chest (straight arrow). Note the diminished mural enhancement of the herniated loops in the chest (arrowheads) compared with the nonherniated loops in the abdomen (curved arrows). The diminished enhancement suggests strangulation, a finding that was confirmed at surgery.
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Figure 12b. Diaphragmatic hernia in a 33-year-old man who had sustained injury in a motor vehicle accident. (a, b) Axial contrast-enhanced reformatted CT images of the chest and abdomen show an acute diaphragmatic hernia, along with small bowel loops (arrows in a) and mesenteric fat (arrowheads in b) in the chest. Note the collapse of the left lung and the presence of chest tubes. (c) Coronal thick-slab reformatted image shows the herniation of bowel loops into the chest (straight arrow). Note the diminished mural enhancement of the herniated loops in the chest (arrowheads) compared with the nonherniated loops in the abdomen (curved arrows). The diminished enhancement suggests strangulation, a finding that was confirmed at surgery.
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Figure 12c. Diaphragmatic hernia in a 33-year-old man who had sustained injury in a motor vehicle accident. (a, b) Axial contrast-enhanced reformatted CT images of the chest and abdomen show an acute diaphragmatic hernia, along with small bowel loops (arrows in a) and mesenteric fat (arrowheads in b) in the chest. Note the collapse of the left lung and the presence of chest tubes. (c) Coronal thick-slab reformatted image shows the herniation of bowel loops into the chest (straight arrow). Note the diminished mural enhancement of the herniated loops in the chest (arrowheads) compared with the nonherniated loops in the abdomen (curved arrows). The diminished enhancement suggests strangulation, a finding that was confirmed at surgery.
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Figure 13. Incisional hernia in a 64-year-old man who had undergone midline abdominal incision for gallbladder resection several years earlier. Axial contrast-enhanced CT scan of the abdomen shows post-surgical changes anterior to the liver and an incisional (epigastric) hernia containing the left hepatic lobe (arrows).
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Figure 14a. Inguinal hernia in a 64-year-old man. Axial contrast-enhanced CT scan (a) and sagittal reformatted CT image (b) of the lower abdomen show herniation of the bladder through a right inguinal hernia (arrows). The bladder herniation is more clearly delineated on the sagittal image.
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Figure 14b. Inguinal hernia in a 64-year-old man. Axial contrast-enhanced CT scan (a) and sagittal reformatted CT image (b) of the lower abdomen show herniation of the bladder through a right inguinal hernia (arrows). The bladder herniation is more clearly delineated on the sagittal image.
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Figure 15a. Inguinal hernia in a 67-year-old man with retro-peritoneal liposarcoma. (a) Axial contrast-enhanced reformatted CT image of the abdomen shows a large, soft-tissue retro-peritoneal mass (arrows). (b) Axial contrast-enhanced reformatted CT image obtained inferior to a shows herniation of the mass through the right inguinal canal (arrows). (c) Sagittal contrast-enhanced reformatted CT image helps confirm herniation of the mass through the inguinal canal (arrows) and more clearly delineates the hernia defect.
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Figure 15b. Inguinal hernia in a 67-year-old man with retro-peritoneal liposarcoma. (a) Axial contrast-enhanced reformatted CT image of the abdomen shows a large, soft-tissue retro-peritoneal mass (arrows). (b) Axial contrast-enhanced reformatted CT image obtained inferior to a shows herniation of the mass through the right inguinal canal (arrows). (c) Sagittal contrast-enhanced reformatted CT image helps confirm herniation of the mass through the inguinal canal (arrows) and more clearly delineates the hernia defect.
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Figure 15c. Inguinal hernia in a 67-year-old man with retro-peritoneal liposarcoma. (a) Axial contrast-enhanced reformatted CT image of the abdomen shows a large, soft-tissue retro-peritoneal mass (arrows). (b) Axial contrast-enhanced reformatted CT image obtained inferior to a shows herniation of the mass through the right inguinal canal (arrows). (c) Sagittal contrast-enhanced reformatted CT image helps confirm herniation of the mass through the inguinal canal (arrows) and more clearly delineates the hernia defect.
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Figure 16. Lumbar hernia containing peritoneal metastases in a 55-year-old man with known gastric carcinoma. Axial contrast-enhanced CT scan of the abdomen shows malignant ascites and multiple peritoneal metastases (black arrowheads). There is also a small lumbar hernia (arrow) containing ascites and a peritoneal metastasis (white arrowhead). Increased intraabdominal pressure, caused in this case by malignant ascites, increases the risk for abdominal wall hernias. These hernias tend to occur in the lumbar region and the lower abdomen, which are considered to be areas of relative anatomic weakness.
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Figure 17a. Omental infarction extending to an inguinal hernia in a 48-year-old man. (a) Axial contrast-enhanced CT scan of the abdomen shows a severe inflammatory process in the right lower quadrant. Note the mesenteric fluid and fat stranding (arrows), which cause mass effect. (b) Sagittal contrast-enhanced reformatted CT image shows extension of the inflammatory process (arrow) into a right inguinal hernia sac (arrowhead). Extensive omental infarction was demonstrated at surgery.
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Figure 17b. Omental infarction extending to an inguinal hernia in a 48-year-old man. (a) Axial contrast-enhanced CT scan of the abdomen shows a severe inflammatory process in the right lower quadrant. Note the mesenteric fluid and fat stranding (arrows), which cause mass effect. (b) Sagittal contrast-enhanced reformatted CT image shows extension of the inflammatory process (arrow) into a right inguinal hernia sac (arrowhead). Extensive omental infarction was demonstrated at surgery.
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Figure 18a. Hernia repair with PTFE mesh in a 54-year-old man. (a) Axial contrast-enhanced CT scan of the abdomen shows a large, incisional type lateral hernia containing small bowel loops (arrows). The patient subsequently underwent surgical correction of the hernia. (b) Axial maximum-intensity-projection image obtained after surgical repair shows hyperattenuating PTFE mesh in the abdominal wall (arrowheads).
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Figure 18b. Hernia repair with PTFE mesh in a 54-year-old man. (a) Axial contrast-enhanced CT scan of the abdomen shows a large, incisional type lateral hernia containing small bowel loops (arrows). The patient subsequently underwent surgical correction of the hernia. (b) Axial maximum-intensity-projection image obtained after surgical repair shows hyperattenuating PTFE mesh in the abdominal wall (arrowheads).
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Figure 19a. Hernia repair with use of tissue expanders in a 49-year-old man with an incisional hernia. Axial contrast-enhanced reformatted CT images of the abdomen obtained 2 weeks (a), 8 weeks (b), and 12 weeks (c) after the implantation of tissue expanders show a large incisional hernia (arrowheads in a and b) and demonstrate the progression of treatment with the expanders (arrows in a and b). Note the progressive stretching of the skin and subcutaneous tissue, allowing hernia repair with mesh (arrows in c) and closure of the wall defect. A small fluid collection (arrowhead in c) is present at the previous site of an expander.
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Figure 19b. Hernia repair with use of tissue expanders in a 49-year-old man with an incisional hernia. Axial contrast-enhanced reformatted CT images of the abdomen obtained 2 weeks (a), 8 weeks (b), and 12 weeks (c) after the implantation of tissue expanders show a large incisional hernia (arrowheads in a and b) and demonstrate the progression of treatment with the expanders (arrows in a and b). Note the progressive stretching of the skin and subcutaneous tissue, allowing hernia repair with mesh (arrows in c) and closure of the wall defect. A small fluid collection (arrowhead in c) is present at the previous site of an expander.
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Figure 19c. Hernia repair with use of tissue expanders in a 49-year-old man with an incisional hernia. Axial contrast-enhanced reformatted CT images of the abdomen obtained 2 weeks (a), 8 weeks (b), and 12 weeks (c) after the implantation of tissue expanders show a large incisional hernia (arrowheads in a and b) and demonstrate the progression of treatment with the expanders (arrows in a and b). Note the progressive stretching of the skin and subcutaneous tissue, allowing hernia repair with mesh (arrows in c) and closure of the wall defect. A small fluid collection (arrowhead in c) is present at the previous site of an expander.
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Figure 20a. Recurrent paraumbilical hernia in a 48-year-old man who had undergone surgical correction of the hernia with PTFE mesh 3 months earlier. (a) Axial contrast-enhanced reformatted CT image of the abdomen shows a recurrent paraumbilical hernia (arrows). (b) Sagittal reformatted CT image shows the protrusion of mesenteric fat inferior to the lower edge of the mesh (arrowheads). Recurrent hernia was confirmed at surgery.
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Figure 20b. Recurrent paraumbilical hernia in a 48-year-old man who had undergone surgical correction of the hernia with PTFE mesh 3 months earlier. (a) Axial contrast-enhanced reformatted CT image of the abdomen shows a recurrent paraumbilical hernia (arrows). (b) Sagittal reformatted CT image shows the protrusion of mesenteric fat inferior to the lower edge of the mesh (arrowheads). Recurrent hernia was confirmed at surgery.
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Figure 21a. Seroma in a 50-year-old woman who had undergone surgical correction of a paraumbilical hernia. Axial contrast-enhanced reformatted CT images of the abdomen obtained immediately (a) and 4 weeks (b) after surgery demonstrate a seroma (arrows) subjacent to PTFE mesh (arrowheads). Note the interval enlargement of the seroma despite the regression of postoperative changes. Immediately after surgery, fluid collections at the surgical bed may be heterogeneous due to the presence of peritoneal fluid and blood secondary to surgical trauma.
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Figure 21b. Seroma in a 50-year-old woman who had undergone surgical correction of a paraumbilical hernia. Axial contrast-enhanced reformatted CT images of the abdomen obtained immediately (a) and 4 weeks (b) after surgery demonstrate a seroma (arrows) subjacent to PTFE mesh (arrowheads). Note the interval enlargement of the seroma despite the regression of postoperative changes. Immediately after surgery, fluid collections at the surgical bed may be heterogeneous due to the presence of peritoneal fluid and blood secondary to surgical trauma.
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Figure 22. Infected fluid collection in a 55-year-old woman who had undergone surgical correction of an umbilical hernia. Axial contrast-enhanced CT scan of the abdomen obtained 6 weeks after surgery shows a fluid collection (arrows). Note the presence of gas within the collection (arrowhead) and the fat stranding around the collection, findings that are suspicious for infection. Infection was confirmed at microbiologic analysis of fluid obtained with imaging-guided aspiration.
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Figure 23. Fluid collection related to collapsed mesh in a 55-year-old woman who had undergone surgical correction of an interparietal hernia. Axial contrast-enhanced reformatted CT image of the abdomen obtained 12 weeks after surgery shows collapsed PTFE mesh (arrowheads) with an associated fluid collection (arrows). In some mesh-related complications, the mesh may have atypical morphologic features, especially if there are associated fluid collections.
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Figure 24. Abdominal wall metastasis in a 54-year-old cirrhotic man with a large hepatocellular carcinoma (not shown). Axial contrast-enhanced CT scan of the abdomen demonstrates an enhancing subcutaneous nodule (arrow) adjacent to the left rectus abdominis muscle. Histopathologic analysis revealed metastatic hepatocellular carcinoma. Such a metastasis could conceivably simulate an epigastric hernia at physical examination.
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Figure 25. Desmoid tumor in a 34-year-old woman. Axial contrast-enhanced reformatted CT image of the abdomen shows a desmoid tumor (arrows) invading the left rectus abdominis muscle. Although desmoid tumors are histologically benign, they demonstrate locally aggressive features.
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Figure 26. Rectus sheath hematoma in a 33-year-old hemophilic patient. Axial unenhanced CT scan of the abdomen shows a hematoma of the left rectus abdominis muscle (arrows). The lesion simulated an abdominal wall hernia at physical examination. A hyperattenuating blood collection and extensive subcutaneous edema are also seen.
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Figure 27. Eventration in a 65-year-old woman. Axial contrast-enhanced reformatted CT image shows bulging of the abdominal wall (arrowheads) and severe atrophy of the wall muscles. These findings mimic a large ventral hernia, but absence of a full-thickness defect or hernia sac permits the correct diagnosis of abdominal wall eventration.
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Figure 28a. Gas collection within the abdominal wall in an 83-year-old woman with acute colonic perforation from colonic ischemia. (a) Axial contrast-enhanced CT scan of the lower abdomen shows free gas dissecting into the abdominal wall (arrowheads), a finding that could conceivably simulate a ventral wall hernia at physical examination. (b) Axial contrast-enhanced CT scan obtained at a higher level than a shows pneumatosis intestinalis in the ascending and transverse colon (arrows). Extensive pneumoperitoneum is also seen (arrowheads).
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Figure 28b. Gas collection within the abdominal wall in an 83-year-old woman with acute colonic perforation from colonic ischemia. (a) Axial contrast-enhanced CT scan of the lower abdomen shows free gas dissecting into the abdominal wall (arrowheads), a finding that could conceivably simulate a ventral wall hernia at physical examination. (b) Axial contrast-enhanced CT scan obtained at a higher level than a shows pneumatosis intestinalis in the ascending and transverse colon (arrows). Extensive pneumoperitoneum is also seen (arrowheads).
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Figure 29. Mycobacterium avium-intracellulare in a 25-year-old immunodeficient man who presented with a painful inguinal mass. Findings at physical examination were nonspecific. Axial contrast-enhanced CT scan of the lower abdomen shows a low-attenuation lymph node in the right inguinal region (arrow). Innumerable low-attenuation lymph nodes were seen in the abdomen. These findings suggested mycobacterial infection. M avium-intracellulare was confirmed at microbiologic analysis.
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Figure 30a. Varicocele in a 45-year-old man. (a) Axial contrast-enhanced reformatted CT image through the inguinal regions shows a right-sided varicocele (arrow) simulating an inguinal hernia. (b) Coronal thick-section MPR image delineates the course of the varicocele (arrows) to the level of a renal cell carcinoma (arrowheads) arising from the right kidney.
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Figure 30b. Varicocele in a 45-year-old man. (a) Axial contrast-enhanced reformatted CT image through the inguinal regions shows a right-sided varicocele (arrow) simulating an inguinal hernia. (b) Coronal thick-section MPR image delineates the course of the varicocele (arrows) to the level of a renal cell carcinoma (arrowheads) arising from the right kidney.
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Figure 31a. Enlarged abdominal wall vasculature in a 55-year-old cirrhotic man with portal hypertension. Axial (a) and sagittal (b) contrast-enhanced maximum-intensity-projection images show a recanalized paraumbilical vein (arrows) simulating an umbilical hernia. Innumerable subcutaneous varices are also seen (arrowheads), particularly in the area surrounding the umbilicus. The sagittal image more clearly delineates portosystemic collateral vessels extending into the chest than does the axial image.
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Figure 31b. Enlarged abdominal wall vasculature in a 55-year-old cirrhotic man with portal hypertension. Axial (a) and sagittal (b) contrast-enhanced maximum-intensity-projection images show a recanalized paraumbilical vein (arrows) simulating an umbilical hernia. Innumerable subcutaneous varices are also seen (arrowheads), particularly in the area surrounding the umbilicus. The sagittal image more clearly delineates portosystemic collateral vessels extending into the chest than does the axial image.
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Copyright © 2005 by the Radiological Society of North America.
