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For personal use only; all rights reserved

Abdominal Wall Hernias: Cross-

Sectional Imaging Signs of Incarceration
Determined with Sonography
Thomas Rettenbacher1 OBJECTIVE. The aim of this study was to determine with sonography whether distinct
Alois Hollerweger2 cross-sectional imaging signs exist that may differentiate between incarcerated and nonincar-
Peter Macheiner2 cerated abdominal wall hernias.
SUBJECTS AND METHODS. The sonographic appearance of 149 consecutive abdom-
Norbert Gritzmann2
inal wall hernias was prospectively investigated and correlated with subsequent surgical re-
Thaddeus Gotwald1
sults. Commercially available 4- to 10-MHz linear transducers and 2- to 5-MHz curved
Robert Frass3 transducers were used to evaluate the hernias.
Barbara Schneider4 RESULTS. Surgery revealed 126 nonincarcerated and 23 incarcerated hernias. The sono-
graphic signs suggestive of incarceration that we identified included free fluid in the hernia sac,
which was observed in 91% of the incarcerated hernias and in 3% of the nonincarcerated hernias;
bowel wall thickening in the hernia, which was detected in 88% of the incarcerated hernias and in
none of the nonincarcerated hernias; fluid in the herniated bowel loop, which was detected in
82% of the incarcerated hernias and in 3% of the nonincarcerated hernias; and dilated bowel
loops in the abdomen, which occurred in 65% of the incarcerated hernias and in none of the non-
incarcerated hernias. These imaging findings allowed the identification of incarceration in all 23
cases and led to a false-positive result in two of 126 nonincarcerated hernias.
CONCLUSION. Cross-sectional imaging signs indicating hernial incarceration included
free fluid in the hernial sac, bowel wall thickening in the hernia, fluid in the herniated bowel
loop, and dilated bowel loops in the abdomen. Sonography is an appropriate cross-sectional
imaging modality for detecting these signs that are helpful in diagnosing patients with atypi-
cal clinical presentations.

Received March 19, 2001; accepted after revision
May 11, 2001.
1
Department of Radiology II, University Hospital
Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria. Address
correspondence to T. Rettenbacher.
2
Department of Radiology, Hospital Barmherzige Brueder,
Kajetanerplatz 1, 5010Salzburg, Austria.
3
Department of Surgery, Hospital Barmherzige Brueder,
5010 Salzburg, Austria.
4
Institute of Medical Statistics, University of Vienna,
Schwarzspanierstr. 17, 1090 Wien, Austria.
AJR2001;177:1061–1066
0361–803X/01/1775–1061
© American Roentgen Ray Society
A
bdominal wall hernias are usually
suggested by the patient’s clinical
history and confirmed by findings
from a physical examination. The patient’s clini-
cal history, however, may be atypical and the
physical examination may be limited in obese
patients, in patients with severe abdominal pain
and distention, and in patients with small hernias
or with hernias located in uncommon sites [1–
14]. In these instances, diagnostic imaging is
necessary. Herniography, sonography, and CT
are the established imaging methods for con-
firming or excluding suspected abdominal wall
hernias [1–11, 15–25]. In addition, the cross-sec-
tional imaging modalities, sonography and CT,
can aid in the differential diagnosis of palpable
abdominal wall masses and can help to define
hernial contents such as fatty tissue, bowel, other
organs, or fluid [1–9, 15–19, 26, 27].
Hernial complications such as incarcera-
tion are also usually detected at clinical pre-
sentation. Cross-sectional imaging, however, is
required when the clinical presentation is mis-
leading or inconclusive, or when the surgeon
believes it is important to preoperatively assess
the contents of an incarcerated hernia [1, 12,
13]. Radiologists, therefore, should be familiar
with the imaging findings of both incarcerated
and nonincarcerated hernias. Several years
ago, we observed that an incarcerated abdomi-
nal wall hernia was usually associated with a
sonographic appearance that clearly differed
from the sonographic appearance of a nonin-
carcerated hernia. To our knowledge, no cross-
sectional imaging studies in the literature have
examined the spectrum of imaging signs of
hernial incarceration and their frequencies in a
substantial patient population. The aim of this
study was to investigate with sonography
whether distinct cross-sectional imaging signs
exist to differentiate incarcerated and nonin-
carcerated abdominal wall hernias.

AJR:177, November 2001 1061


Subjects and Methods
Patient Population
The prospective part of this study includes 236
consecutive patients (102 females and 134 males;
17–90 years old; mean age, 57 years) who under-
went diagnostic sonography between May 1997
and September 2000. These patients were referred
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by the surgery department for sonography of the
abdominal wall and the abdomen when their clini-
cal presentations were suggestive of an abdominal
wall hernia but their physical examinations were
inconclusive ( n = 187), or when the surgeon be-
lieved it was important to preoperatively deter-
mine the contents of a suspected hernia ( n = 49).
This procedure has been a common practice at our
hospital since 1991.
Also included in our study were six patients in
whom sonography revealed complicated abdomi-
nal wall hernias that were clinically not suspected.
Three of the patients were referred for sonography
because of abdominal pain and vomiting of un-
clear origin; two patients, because of a clinically
unclear abdominal wall mass; and one patient, be-
cause of suspicion for acute appendicitis.
Imaging Techniques
All sonographic examinations included in this
study were performed by four radiologists experi-
enced in gastrointestinal sonography. The patients
were not specially prepared for the sonographic ex-
amination. Sonography was performed on patients
in a supine position, and the Valsalva’s or coughing
maneuvers were almost always performed during
the examination to confirm or exclude a hernia. At
least four images on several planes were obtained
of each hernia and documented on film with a mul-
tiformat camera. Commercially available sono-
graphic equipment included an HDI 3000 unit with
2- to 4-MHz curved array, 4- to 7-MHz linear ar-
ray, and 5- to 10-MHz linear array transducers
(Advanced Technology Laboratories, Bothell, WA)
and an AU4 unit with 3.5- to 5.0-MHz curved array
and 7.5- to 10.0-MHz linear array transducers (Es-
aote, Florence, Italy). Color Doppler sonography
was performed using the previously mentioned lin-
ear array transducers. Color Doppler settings were
adjusted for maximal blood flow sensitivity. These
settings included a wall filter of 50 Hz, a pulse rep-
etition frequency of 1000, maximum power, and
the highest possible gain at a usable ratio of signal-
to-background noise. To evaluate the peristalsis of
herniated bowel loops, the sonographic transducer
was held motionless over the hernia for approxi-
mately 2 min.
Interpretation of Sonographic Findings
In this study, the sonographic detection of
bowel, other abdominal organs, or fatty tissue in
the abdominal wall, as well as the sonographic vi-
sualization of a lesion connecting with the abdo-
men, was required to interpret a lesion as an
abdominal wall hernia. Several years before the
study began, the authors observed on sonography
1062
Rettenbacher et al.
that incarcerated abdominal wall hernias were of-
ten associated with distinct imaging signs. On the
basis of this experience, a study protocol was de-
signed in which the investigators were requested
to prospectively evaluate the following points by
sonography: the contents of the hernias, such as
fatty tissue, bowel, or other organs; the presence or
absence of free fluid in the hernial sac; the wall
thickness of the herniated bowel loop; the pres-
ence or absence of fluid in the herniated bowel
loop; the diameter of small bowel in the abdomen;
the presence or absence of color Doppler signals
in the hernial contents; and the presence or ab-
sence of peristalsis in the herniated bowel loop.
Immediately after the imaging was performed, the
cross-sectional signs were noted on a prepared
sheet of paper. In addition, the sonographic signs
were then independently reviewed by the four in-
vestigating radiologists, and a consensus opinion
regarding the signs was made. The study protocol
was approved by the ethics committee.
Statistical Analysis
Surgical results were considered the gold standard
for this study. A hernia was diagnosed as incarcerated
at surgery if there was evidence of a compromise in
the blood supply of the hernial contents. To enable
statistical correlation of imaging signs with surgical
results in all patients, we evaluated only those hernias
in which sonography was performed and the diagno-
sis was confirmed by surgery.
For each sonographic sign, 2  2 contingency
tables were used to calculate the estimates for sen-
sitivity, specificity, positive and negative predictive
values, and accuracy. Data analyses were per-
formed using the statistical software package ver-
sion 8.0 (SAS Institute, Cary, NC) for Windows
(Microsoft, Redmond, CA).
Results
In 141 of 236 prospectively investigated pa-
tients, sonography revealed one lesion (n = 117)
and two lesions (n = 24) suggestive of abdomi-
nal wall hernias. One hundred twenty-nine of
the 141 patients with sonographically diag-
nosed hernias underwent surgical hernia repair,
with a total of 147 hernias repaired. In 143
of 147 hernias with surgical treatment, sono-
graphic diagnosis of a hernia was correct,
whereas four of the 147 presented as an extra-
peritoneal lipoma at surgery.
In 77 of 236 prospectively imaged patients,
sonography did not reveal any abnormal find-
ings. Sixteen of the patients underwent surgery
despite normal findings on sonography because
the clinical presentation remained suggestive of
a hernia. Surgery revealed a nonincarcerated
hernia in six patients and no abnormal findings
in 10 patients.
In 18 of 236 patients, sonography revealed
an abdominal wall lesion other than a hernia,
including a lipoma in five patients, an en-
larged lymph node in five patients, a metasta-
sis in three patients, a suture granuloma in
three patients, and an abscess in two patients.
The statistical analysis of imaging signs
included 149 hernias in 131 patients in
whom sonography and surgery were per-
formed. A final diagnosis based on the surgi-
cal results included 126 nonincarcerated
hernias and 23 incarcerated hernias. The lo-
cation of all 149 abdominal wall hernias is
given in Table 1. The contents of the nonin-
carcerated hernias were fatty tissue alone in
54 patients, fatty tissue and bowel in 47 pa-
tients (Fig. 1), bowel alone in 16 patients,
and urinary bladder in three patients. The
contents of the incarcerated hernias were
fatty tissue alone in six patients, fatty tissue
and bowel in four patients, and bowel alone
in 13 patients. In 15 of 17 patients with in-
carcerated hernias containing bowel, blood
circulation improved during surgery. There-
fore, resection of the incarcerated bowel
loop was necessary in only two patients. In
three of six patients with incarcerated her-
nias containing only fatty tissue, resection of
the fatty tissue was performed.
The sonographic signs of incarceration in-
vestigated for this study and their frequen-
cies are given in Table 2.
The sensitivity, specificity, positive and neg-
ative predictive values, and accuracy of each
sonographic sign as a finding positive for her-
nial incarceration are shown in Table 3.
Concomitant free fluid in the hernia was
the only sonographic sign of incarceration
that we found when fatty tissue alone was
present in a hernial sac (Fig. 2). In these
cases, this finding indicated incarceration
with a sensitivity of 100% (6/6) and a specific-
ity of 96% (52/54) because free fluid was found
in two of 54 nonincarcerated hernias containing
fatty tissue alone. If bowel was present in a
Location of 23 Incarcerated
TABLE 1 and 126 Nonincarcerated
Abdominal Wall Hernias
Location I Hernias NI Hernias
Right groin 3 50
Left groin 5 48
Right thigh 6 7
Left thigh 1 5
Right obturator 1 0
Umbilicus 5 10
Incisional 2 6
Note.—I = Incarcerated, NI = Nonincarcerated.
AJR:177, November 2001
 Sonography of Abdominal Wall Hernias

hernia, all four sonographic signs of incar-
ceration could be applied (Figs. 3 and 4).
Each of the incarcerated hernias with bowel
displayed at least two signs of incarceration.
The combination of at least two of the four
identified signs allowed the detection of in-
carceration with a sensitivity of 100% (17/17)
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nosis may be difficult when the clinical
presentation is atypical or when the physical
examination is limited. During a period of 3
years, we registered six patients with incarcer-
ated hernias that were not suspected by the cli-
nician and in whom sonography helped to
establish the correct preoperative diagnosis of
preparing a patient for surgery. This finding is
especially an advantage in elderly and multi-
morbid patients. In contrast, incarcerated bowel
calls for immediate surgery to prevent bowel
necrosis and the subsequent necessity to resect
the affected bowel loop. Although several stud-
ies, predominantly case reports, noted that

and a specificity of 100% (63/63) because the
combined signs were never observed in nonin-
carcerated hernias in our series.
All 23 incarcerated abdominal wall hernias
were correctly interpreted preoperatively as in-
carcerated by the investigating radiologists,
whereas two of 126 nonincarcerated hernias
were considered incarcerated and were therefore
false-positive for incarceration on sonography.
During the time of the study, no incarcerated
hernias were overlooked on sonography.
In the six patients in whom sonography diag-
nosed an incarcerated hernia that was clinically
not suspected and who underwent surgical re-
pair, the sonographic signs included free fluid in
the hernia sac in five patients, bowel wall thick-
ening in the hernia in four patients, fluid in the
herniated bowel loop in five patients, dilated
bowel loops in the abdomen in three patients,
absence of blood flow in the hernial contents in
two patients, and absence of peristalsis in the
hernia in four patients (Fig. 3).
Discussion
Although hernial incarceration was usually
assessed accurately by the clinician, its diag-
this life-threatening condition (Fig. 3). Because sonography and CT can identify complications
an incarcerated hernia presents as a complex such as hernial incarceration [1, 2, 12, 15, 17,
mass on cross-sectional imaging and usually 27–29], no study, to our knowledge, has evalu-
differs considerably in appearance from a non- ated the spectrum of imaging signs of incarcer-
incarcerated hernia, radiologists performing ated hernias in a substantial patient population.
abdominal imaging should be familiar with the Free fluid in the hernia sac was a sensitive
spectrum of imaging signs of this entity. In ad- and specific criterion of incarceration in our
dition, cross-sectional imaging is necessary series (Tables 2 and 3 and Figs. 2–5). Free
when the surgeon believes it is important to pre- fluid is an eye-catching finding on sonography
operatively define the contents of an incarcer- because of the great difference in echogenicity
ated hernia to determine the timing of surgery. If between the usually echo-free fluid and the other
fatty tissue, fluid, or both are present in the in- hernial contents or surrounding tissue (Figs.
carcerated hernia, time is not a limiting factor in 2–5). This single sign immediately indicated
Frequency of Occurrence of Each Sonographic Sign as Criterion of Hernial
TABLE 2
Incarceration in 126 Nonincarcerated and 23 Incarcerated Hernias
Sonographic Sign Incarcerated (%) Nonincarcerated (%)
Free fluid in hernial sac 91 (21/23) 3 (4/126)
Bowel wall thickness in hernia  4 mm 88 (15/17) 0 (0/63)
Fluid within herniated bowel loop 82 (14/17) 3 (2/63)
Dilated bowel loops in abdomen 65 (11/17) 0 (0/63)
Absence of blood flow within hernia 22 (5/23) 25 (31/126)
Absence of peristalsis within hernia 76 (13/17) 38 (24/63)
Note.—Seventeen of 23 incarcerated hernias and 63 of 126 nonincarcerated hernias contained bowel. Numbers in
parentheses represent cases.

Fig. 1.—49-year-old man with nonin-

carcerated left inguinal hernia.Longi-
tudinal sonogram shows fatty tissue
(short arrows) and gas-filled bowel
loop (curved arrows). Note reverber-
ation artifacts behind gas surface
(long straight arrows).

Fig. 2.—37-year-old woman with in-

carceratedumbilical hernia.Longitudi-
nalsonogramshowsherniacontaining
fattytissue(longarrows)andconsider-
able amount of septate collection of
free fluid(short arrows).
1 2

AJR:177, November 2001 1063


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to the investigator that a hernial complication
had a high probability of being present. In the
literature, we found two sonographic studies
mentioning that an incarcerated hernia may
contain free fluid [1, 15]. Motta et al. [27] re-
ported three cases determined by sonography
of torsion of an inguinal hernial sac filled with
only a multiseptate fluid. Several cross-sec-
tional imaging studies dealing with imaging
signs of hernial incarceration [1, 2, 12, 17, 28]
did not mention free fluid as a sign, although
three of them [1, 2, 17] showed images of in-
carcerated hernias with a considerable amount
of free fluid in the hernial sac without describ-
ing this as a criterion of incarceration. In our
series, two of four patients with free fluid in a
Fig. 4.—56-year-old man with incarcerated right inguinal hernia.
A and B, Longitudinal (A) and transverse (B) sonograms show dilated, fluid-filled small-bowel loop (long arrows) and considerable amount of free fluid in hernia (short arrows).
1064
Rettenbacher et al.
Fig. 3.—87-year-old woman with in-
carcerated right femoral hernia.
Longitudinal sonogram shows fluid-
filled small-bowel loop with moder-
ate wall thickening (long arrows)
and small amount of free fluid in her-
nia (short arrows). Patient suffered
from vomiting and diffuse abdominal
pain. Incarcerated hernia was clini-
cally not suspected. Surgery con-
firmed sonographic findings.
nonincarcerated hernia had free fluid in the ab-
domen and also in the hernia caused by liver
cirrhosis. This finding can be a pitfall. Free
fluid in an incarcerated hernia may be ex-
plained by transudation into the hernial sac
caused by the compromised blood supply of
hernial contents. The fluid in the hernial sac
may be clear or sanguineous at surgery [27].
Wall thickening of herniated bowel was an-
other important sonographic sign of incarcera-
tion in our patients (Fig. 3). Wall thickening
indicated incarceration of the hernias contain-
ing bowel with an excellent specificity but with
limited sensitivity (Table 3). A cutoff point of
4 mm for wall thickening in this study was ob-
tained for nondilated bowel loops in particular.
A B
In dilated bowel loops, wall thickening may
sometimes remain undiagnosed with a cutoff
point of 4 mm (Fig. 4) and result in a reduced
sensitivity. Some sonographic and CT studies
reported in the literature state that wall thicken-
ing of the herniated bowel loop is suggestive of
hernial incarceration [1, 15, 17, 28]. Percent-
ages of occurrence, to our knowledge, are not
available. Wall thickening of incarcerated
bowel may be predominantly explained by
blood congestion and edema.
Another sign of hernial incarceration that we
investigated was fluid in the herniated bowel
loop (Figs. 3 and 4). The free fluid indicated in-
carceration of the hernias containing bowel with
high specificity but limited sensitivity (Table 3).
To our knowledge, this sign has not been re-
ported previously in the literature. However, we
found a sonographic image in a study showing
fluid in an incarcerated bowel loop that was not
mentioned in the text [2]. This sonographic im-
age of an incarcerated hernia shows fluid in the
herniated bowel loop with bowel wall thicken-
ing and free fluid in the hernial sac [2]. The rea-
son for the presence of fluid in an incarcerated
bowel loop may be exudation into the bowel lu-
men, causing excess fluid in the bowel in cases
of bowel obstruction.
An indirect sign of an incarcerated hernia was
evidence of dilated, fluid-filled bowel loops in
the abdomen. This sign indicated incarceration
of the hernias containing bowel with excellent
specificity but limited sensitivity (Table 3). De-
spite the relatively low percentage of occurrence
AJR:177, November 2001
 Sonography of Abdominal Wall Hernias

Sensitivity, Specificity, Positive and Negative Predictive Values, and Accuracy of Each Sonographic Sign as Criterion of
TABLE 3
Hernial Incarceration in 126 Nonincarcerated and 23 Incarcerated Hernias
Positive Predictive Negative Predictive
Sonographic Sign Sensitivity (%) Specificity (%) Accuracy (%)
Value (%) Value (%)
Free fluid in hernia sac 91 (21/23) 97 (122/126) 51 (21/41) 100 (610/612) 96 (143/149)
Bowel wall thickening within hernia 88 (15/17) 100 (63/63) 100 (15/15) 99 (315/317) 97 (78/80)
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Fluid within herniated bowel loop 82 (14/17) 97 (61/63) 58 (14/24) 99 (305/308) 94 (75/80)
Dilated bowel loops in abdomen 65 (11/17) 100 (63/63) 100 (11/11) 98 (315/321) 92 (74/80)
Absence of blood flow within hernia 22 (5/23) 75 (95/126) 3 (5/160) 96 (475/493) 67 (100/149)
Absence of peristalsis within hernia 76 (13/17) 62 (39/63) 10 (13/133) 98 (195/199) 65 (52/80)
Note.—Seventeen of 23 incarcerated hernias and 63 of 126 nonincarcerated hernias contained bowel. Numbers in parentheses represent cases.

Fig. 5.—50-year-old man with nonin-

carcerated right inguinal hernia.Longi-
tudinal sonogram shows fatty tissue
(shortarrows)andsmallamountof free
fluid (long arrows).
presentation of patients at the time of sono-
graphic imaging.
In summary, several cross-sectional imaging
signs of hernial incarceration, such as free fluid
in the hernial sac, bowel wall thickening in the
hernia, fluid in the herniated bowel loop, and di-
lated bowel loops in the abdomen are identifi-
able on sonography. These signs, indicating
hernial incarceration in a high percentage of
cases, are helpful in patients whose clinical pre-
sentations are inconclusive or misleading.

in our series, dilated, fluid-filled bowel loops are
worth mentioning as an important sign because
they may be the only conspicuous cross-sec-
tional imaging finding in patients who clinically
present exclusively with vomiting, diffuse ab-
dominal pain, or both. We observed this situation
in three patients. Almost all patients with an in-
carcerated hernia containing bowel can be ex-
pected to have complete bowel obstruction. For
the absence of this sign in a relatively high per-
centage of patients (35% in the present study),
we suggest the following explanations: incarcer-
ation is not complete and some chyme passes
through, the time from the onset of incarceration
to diagnostic imaging is too short to develop di-
latation of bowel loops in the abdomen, and a
Richter’s hernia is present in which only part of
the bowel wall is herniated. Evidence of bowel
obstruction in the abdomen in patients with in-
carcerated hernias containing bowel is described
in detail in the literature [12, 17, 18, 28–31]. To
our knowledge, however, percentages of occur-
rence are not available.
Our data suggest that the absence of blood
flow in the contents of a hernia should not be
taken as a sign of incarceration because most
incarcerated hernias in our series (78%) had
detectable blood flow on color Doppler sonog-
raphy (Tables 2 and 3). The patients in whom
color Doppler sonography did not detect
blood flow in the incarcerated bowel loop
included the two patients with incarcerated
hernia and bowel necrosis.
Our study results show that the absence of
peristalsis should not be considered a sign of
incarceration because nonincarcerated her-
nias did not show peristalsis during the
sonographic investigation in a relatively
high percentage of patients (Table 2). Our
data, however, suggest that if peristalsis is
present in an incarcerated hernia on sonog-
raphy, bowel resection at surgery is probably
not necessary.
Gas in the bowel wall or free gas, either in
the abdomen or the hernia sac, was consid-
ered a sign of a complicated hernia [17, 28].
In our series, however, no patient had such an
advanced stage of an incarcerated hernia.
A limitation of our study was that we had
only two incarcerated hernias with bowel ne-
crosis. The spectrum of imaging signs of in-
carcerated hernias with this advanced stage
of disease could therefore not be assessed
adequately. Another limitation could be that
the investigators were aware of the results of
the physical examination and the clinical
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