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---
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title: "Ventral Hernia"
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docid: "ab08cd87-4342-4825-948b-d02fc178078f"
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authors:
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- key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
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value: "Siva P. Raman, MD"
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breadcrumbs:
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-
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name: "Gastrointestinal"
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slug: "gastrointestinal"
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treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
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-
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name: "Diagnosis"
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slug: "diagnosis"
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treeNodeId: "5a7c51af-b1c6-4629-8f0e-d99e6fe57a98"
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-
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name: "Peritoneum, Mesentery, and Abdominal Wall"
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slug: "peritoneum-mesentery-and-abdominal-"
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treeNodeId: "a3fb9f00-f894-4b38-9e01-2f78406cf547"
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-
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name: "External Hernias"
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slug: "external-hernias"
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treeNodeId: "71ab3f79-4332-463c-9f60-d3dd2902d974"
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-
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name: "Ventral Hernia"
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slug: "ventral-hernia"
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treeNodeId: null
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category: "Gastrointestinal"
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documentVersionId: "b71efcc9-3851-46b2-baed-5a5cd4dfb72f"
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imageCount: 14
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lastUpdated: "03/12/25"
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pageDescription: "Ventral Hernia"
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pageKeywords: "Gastrointestinal, Diagnosis, Peritoneum, Mesentery, and Abdominal Wall, External Hernias, Ventral Hernia"
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pageTitle: "Ventral Hernia | STATdx"
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enhancedTitle: "Ventral Hernia"
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type: "DX"
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references: true
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ddx: true
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cases: 2
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breadcrumbs:
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- "Gastrointestinal"
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- "Diagnosis"
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- "Peritoneum, Mesentery, and Abdominal Wall"
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- "External Hernias"
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- "Ventral Hernia"
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---
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# KEY FACTS
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- ## Terminology
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- Ventral hernia is generic term encompassing variety of hernias through anterior and lateral abdominal wall
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- ## Imaging
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- **Epigastric** and **hypogastric** hernias occur at midline through linea alba
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- Epigastric hernias arise above umbilicus and below xiphoid process
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- Hypogastric hernias arise below umbilicus
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- **Incisional** hernias develop at prior abdominal wall incision
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- CT: Defect in musculofascial layers of abdominal wall through which omentum and bowel protrude
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- Differentiate true hernias from rectus diastasis (widening of distance between 2 sides of rectus muscles resulting in bulging of anterior abdominal wall)
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- Diastasis does not result in true musculofascial defect
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- Narrow hernia opening ("neck") may increase risk of strangulation or obstruction
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- ## Pathology
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- Ventral hernias may be either acquired or congenital
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- Incisional hernias: Acquired hernias at site of prior surgery, incision, or abdominal wall injury
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- May be related to previous abdominal surgery, laparoscopy, peritoneal dialysis, or stab wound
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- Epigastric and hypogastric hernias: Possible congenital predisposition due to weakness of linea alba
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- Acquired risk factors include obesity, increased intraabdominal pressures, and abdominal wall strains
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- ## Clinical Issues
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- Incisional hernias usually occur during first 4 months after surgery but can develop many years later
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- Ventral hernias do not close spontaneously and almost always enlarge over time
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- Incarceration and strangulation are common
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- Surgical closure is recommended (even for asymptomatic hernias) due to risk of incarceration and strangulation
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- Tension-free mesh repair is now gold standard
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- Mesh material may or may not be visible on CT depending on type of mesh material
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# TERMINOLOGY
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- ## Definitions
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- Ventral hernia (VH): Broad term encompassing variety of different hernias through anterior and lateral aspects of abdominal wall
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- Incisional hernia (IH): Hernia through site of prior abdominal wall incision
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# IMAGING
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- ## General Features
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- ### Location
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- Most occur in midline through aponeuroses
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- Epigastric hernia: At midline above umbilicus and below xiphoid process
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- Hypogastric hernia: At midline below umbilicus
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- IH: Any surgical incision may be potential site for hernia
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- ### Morphology
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- 18-22% of patients have multiple hernias
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- ## Radiographic Findings
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- Barium small bowel follow-through
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- Anterior hernia best recognized on lateral view during Valsalva maneuver
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- May be indirectly detected on frontal or oblique view by displacement of bowel loops, but finding should be confirmed on lateral view
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- Findings of bowel obstruction with transition point in hernia sac
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- Focal narrowing of bowel at exit and entry points
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- Distended bowel loops proximal to transition point in hernia sac and collapsed bowel distal to hernia
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- ## CT Findings
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- Most accurate diagnostic test for detection of VHs
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- Defect in musculofascial layers of abdominal wall through which omentum and loops of small or large bowel protrude into subcutaneous fat of anterior abdominal wall
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- Unlike rectus diastasis (which represents anterior bulging of abdominal wall at midline due to widening of rectus abdominis muscles), hernia should demonstrate true defect in abdominal wall
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- Rectus diastasis often incorrectly described as midline hernia in radiology reports
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- Increased attenuation or fat stranding within herniated fat raises possibility of internal fat necrosis or inflamed fat
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- CT can easily differentiate incarcerated hernia from other entities that may be mimics on clinical exam (such as postoperative hematoma, abscess, etc.)
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- CT can identify signs of resultant obstruction with abrupt narrowing of bowel entering hernia sac, decompression of bowel exiting sac, and proximal bowel dilatation
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- Narrow opening of hernia sac (i.e., hernia "neck") may increase risk of strangulation/obstruction and should be described in radiology report
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- ## Ultrasonographic Findings
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- Usually depicts hernia and fascial defect with detection aided by ability to have patient perform Valsalva maneuver during real-time scanning
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- ## Imaging Recommendations
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- ### Best imaging tool
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- CECT: Consider having patient perform Valsalva during scan
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# DIFFERENTIAL DIAGNOSIS
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- [Umbilical Hernia](/document/umbilical-hernia/ff51faeb-9832-4e87-a6cc-ca45673d754f)
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- May be classified as type of VH
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- Opening in linea alba at level of umbilicus in midline
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- Can be present in either children or adults
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- Usually congenital defect in children due to patent umbilical ring, although defect may close spontaneously at 12-18 months of age
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- Adult form is acquired due to increased intraabdominal pressure, often in obese patients or multiparous/pregnant women
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- ## Diastasis of Rectus Abdominis Musculature
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- "Stretching" and attenuation of anterior abdominal wall fascia at midline causing widening of rectus abdominis muscles (> 2 mm separation)
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- Results in anterior bulging and protuberance of anterior abdominal wall
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- Not true hernia, as there is no fascial defect, but can be difficult to differentiate from true hernia on clinical exam
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- Typically present in obese patients or multiparous women
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- ## Pannus
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- Subcutaneous fat and skin protruding over lower abdomen may simulate hernia
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- No evidence of discrete facial or muscular defect to suggest hernia
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- [Hematoma or Abscess in Abdominal Wall](/document/abdominal-incision-and-injection-s-/1ca34a11-7dd7-4f66-96a3-8b201c64d2c5)
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- Collection of blood or fluid within subcutaneous fat of anterior abdominal wall
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- No defect in fascial layer or evidence of protrusion of omental fat or bowel
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# PATHOLOGY
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- ## General Features
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- ### Etiology
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- Depending on type of hernia, VHs may be due to either acquired or congenital factors
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- IHs: Acquired hernias at site of prior surgery, incision, or abdominal wall injury
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- May be related to previous abdominal surgery, laparoscopy, peritoneal dialysis, or stab wound
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- Risk factors include older age, ascites, COPD, emergency surgery, and wound infections
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- Epigastric and hypogastric hernias: Possible congenital predisposition due to congenital weakness of linea alba
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- Acquired risk factors include obesity, increased intraabdominal pressures, and abdominal wall strains
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- Factors which increase likelihood of hernia occurrence
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- Patient-related: Collagen biochemistry, obesity, age > 65 years, pulmonary disease, uremia, diabetes, steroids, malignancy, trauma
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- Technical factors: Wound infection, suture material, types of incisions and closures
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# CLINICAL ISSUES
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- ## Presentation
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- Bulge or swelling on abdominal wall ± abdominal pain
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- Can become larger and more painful with exertion
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- Some patients may have clinically occult VHs with 1st clinical presentation being related to small bowel obstruction
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- May be difficult to detect in patients with obesity, pain, or scarring
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- Valsalva maneuver may elicit hernia
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- IHs: Tend to occur during first 4 months after surgery but can develop many years later
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- Progressive enlargement is common
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- 5-10% remain clinically silent for several years
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- Most IH are incidental findings at imaging
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- Advanced stage: Persistent bulging mass resulting from herniated fat and bowel
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- More common with vertical than transverse incisions
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- Can occur through laparoscopy port (usually small opening with increased chance of strangulation)
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- Symptoms out of proportion to objective findings if incarceration or strangulation occurs
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- ## Demographics
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- ### Epidemiology
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- > 80% of VHs result of prior surgery
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- Occur after 0.2-26% of abdominal procedures
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- ## Natural History & Prognosis
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- VHs do not close spontaneously and almost always enlarge over time
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- Complications: Incarceration and strangulation are frequent with incisional, hypogastric, and epigastric hernias
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- ## Treatment
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- Some debate about treatment of asymptomatic VHs, but, in principle, surgical closure of hernias is recommended due to risk of incarceration and strangulation
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- Repair techniques include open suture, open mesh, and laparoscopic mesh repairs
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- Repair with simple suture (rather than mesh) has high risk of recurrence but may still be utilized for smaller hernias
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- Tension-free mesh repair is now gold standard and is most commonly utilized technique
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- Polypropylene mesh is isodense to surrounding tissues and not well visualized on CT, while polytetrafluoroethylene (PTFE) mesh tends to be visible on CT as linear hyperdense material
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- Surgical complications in up to 50%, most commonly recurrence of hernia
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- Laparoscopic and mesh repair have lower recurrence rates (< 5%)
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# DIAGNOSTIC CHECKLIST
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- ## Consider
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- Report size of hernia opening (i.e., hernia "neck") and whether there is any thinning or atrophy of surrounding abdominal wall musculature
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- These features can be useful in assessing risk of strangulation and likely success of hernia repair
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a0cbf1c6-67dd-4a09-bf68-d01d188c4f65
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## References
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# Selected References
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1. [Morrell DJ et al: Radiographic identification of thoracoabdominal hernias. Hernia. 26(1):287-95, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=34125302%5Bpmid%5D)
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1. [Kushner B et al: Identifying critical computed tomography (CT) imaging findings for the preoperative planning of ventral hernia repairs. Hernia. 25(4):963-69, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=33025298%5Bpmid%5D)
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1. [Smith J et al: Ventral hernia. StatPearls, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=29763102%5Bpmid%5D)
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1. [Patil AR et al: Mind the gap: imaging spectrum of abdominal ventral hernia repair complications. Insights Imaging. 10(1):40, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30923952%5Bpmid%5D)
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1. [Halligan S et al: Imaging complex ventral hernias, their surgical repair, and their complications. Eur Radiol. 28(8):3560-9, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29532239%5Bpmid%5D)
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1. [Jin J et al: Laparoscopic versus open ventral hernia repair. Surg Clin North Am. 88(5):1083-100, viii, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18790156%5Bpmid%5D)
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1. [Jamadar DA et al: Characteristic locations of inguinal region and anterior abdominal wall hernias: sonographic appearances and identification of clinical pitfalls. AJR Am J Roentgenol. 188(5):1356-64, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17449782%5Bpmid%5D)
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1. [Zafar HM et al: Anterior abdominal wall hernias: findings in barium studies. Radiographics. 26(3):691-9, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16702448%5Bpmid%5D)
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1. [Aguirre DA et al: Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics. 25(6):1501-20, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=16284131%5Bpmid%5D)
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1. [Aguirre DA et al: Abdominal wall hernias: MDCT findings. AJR Am J Roentgenol. 183(3):681-90, 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=15333356%5Bpmid%5D)
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1. [Millikan KW: Incisional hernia repair. Surg Clin North Am. 83(5):1223-34, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=14533912%5Bpmid%5D)
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1. [Yahchouchy-Chouillard E et al: incisional hernias. I. Related risk factors. Dig Surg. 20(1):3-9, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=12637797%5Bpmid%5D)
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1. [Thoman DS et al: Current status of laparoscopic ventral hernia repair. Surg Endosc. 16(6):939-42, 2002](http://www.ncbi.nlm.nih.gov/pubmed/?term=12163959%5Bpmid%5D)
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## Differential diagnosis
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### Abdominal Wall Mass
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DDX:d51e2268-67b6-4a60-9222-f5a86f61ddec
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### Defect in Abdominal Wall (Hernia)
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DDX:5af046fa-59ef-45b5-952b-acbcdee36196
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### Epigastric Pain
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DDX:20f944e9-a7b2-4b52-a7bf-8a002cb5b2de
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### Left Upper Quadrant Mass
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DDX:fd065ba5-e8b9-47d7-b09f-89f963b58f5c
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### Small Bowel Obstruction
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DDX:ad8209f0-71e5-4496-860f-d2724ca22892
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## Cases
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- {'cases': [{'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'b1a5c325-202a-46ad-9307-174d7bd28dcc', 'description': 'A series of axial NECT sections (#1-8) shows small metallic anchors (curved arrows, #1) and a sheet of tissue density material (curved arrows, #2,4) linking them within or just deep to the anterior abdominal wall musculofascial plane, which appears quite thin. Just lateral and caudal to this is a bulge through the anterolateral abdominal wall (arrows, #4-8) that contains omental fat and portions of the small intestine. The proximal small bowel is dilated and filled with fluid and gas (open arrows, #3,6), while the portion near the hernia has gas and particulate debris within it (open arrow, #5). The small bowel distal to the hernia is collapsed (curved arrows, #5,7).\n\nA series of sagittal (#9-10) and coronal (#11-13) reformations demonstrates the hernia (arrows, #9,11-13) with a dilated small bowel proximal to the hernia (open arrows, #10,12-13) and a collapsed bowel distal to it (curved arrows, #9,13).\n\nComment: This is a typical case of failed ventral hernia repair in an obese, deconditioned woman, resulting in small bowel obstruction. In such patients, the musculofascial tissues are often so weak and attenuated that surgical repair of the hernia, even with mesh and anchor reinforcement, often fails.', 'history': 'Patient presented with crampy abdominal pain and recurrent bulge in abdominal wall.', 'imagePoolId': '3915cf9b-3022-4b75-a223-34030358363e', 'name': 'Recurrent with bowel obstruction', 'teachingPoint': None, 'demographics': '79 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '5b93dfda-24ae-461d-a0d7-d1f0fa7838ed', 'description': 'CT shows a ventral incisional hernia with bowel obstruction.\n\nAxial CECT shows a "knuckle" of small bowel herniated through a defect (arrow, #1) in the anterior abdominal wall. The small intestine proximal to the herniated segment is dilated (open arrow, #2), while that which is distal to the hernia is collapsed (curved arrow, #2), indicating that the herniated bowel is obstructed.', 'history': 'Elderly man with abdominal pain and distention.', 'imagePoolId': '20cc95e2-c6b3-4542-915d-4a8916aa9e28', 'name': 'Causing bowel obstruction', 'teachingPoint': None, 'demographics': '77 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'fd858e55-b9f0-458d-a959-190cc77cf7f1', 'description': 'CT shows a large defect in the anterior abdominal wall, containing non-obstructed bowel.\n\nThere is a wide gap (arrow, #1) between the thin rectus muscles, through which a long segment of small bowel has herniated. Due to the atrophy of the rectus muscles and the wide opening, the herniated bowel is not obstructed.\n\nComment: Ventral hernias are most common in obese women following abdominal surgery. The rectus muscles are often atrophic from lack of use, and sometimes from the surgical procedure itself, that may disrupt the nerve and vascular supply of the abdominal wall musculature. Long segments of bowel may herniate, and the diagnosis may often be inapparent to the referring physician, as the abdomen is usually soft to palpation and bowel obstruction in this setting is uncommon.', 'history': 'Elderly woman with abdominal distention, and a palpable "mass"', 'imagePoolId': '4f238777-3ffd-4af0-9c40-f14a606301d1', 'name': 'Large, without bowel obstruction', 'teachingPoint': None}], 'caseType': 'typical', 'name': 'TYPICAL'}
|
||||
- {'cases': [{'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'f6c0b08d-d5be-4f70-806b-eb29c5bbab52', 'description': 'CT shows herniation of bowel through a laparoscopy port, with bowel obstruction.\n\nCT shows distended proximal small bowel (open arrow, #1). The dilated bowel could be followed into a hernia (arrow, #2, 3) that represented one of the sites of instrument access for the laparoscopic appendectomy. Bowel distal to the hernia site is collapsed.\n\nComment: This case is very similar to a spigelian hernia, given the location lateral to the rectus muscle. The small size of the opening in the musculo-fascial layer makes it more likely that any bowel that herniated through the opening will become strangulated and obstructed.', 'history': 'Abdominal distension and pain weeks after an uneventful appendectomy.', 'imagePoolId': 'c5bb855f-5bce-4b44-8014-b2033f2c6366', 'name': 'Through a laparoscopy port site', 'teachingPoint': None}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '8897331d-27b7-43df-9727-225ed346a981', 'description': 'CT shows a ventral hernia with strangulated and obstructed small bowel.\n\nAxial CECT images (#1-3) show massively dilated proximal small bowel. Ascites (open arrow, #2) is also noted and suggests bowel ischemia. The site of obstruction is a ventral hernia (arrow, #1). Collapsed distal bowel is noted (curved arrow, #3).', 'history': 'Abdominal pain and distention.\n', 'imagePoolId': 'dab54e30-67fb-4f08-959c-242e1617b166', 'name': 'With strangulated bowel', 'teachingPoint': None}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '6244d3e3-e8b5-4551-a1fb-edd9a5c197b8', 'description': 'CT shows a right flank incisional hernia.\n\nCT shows a portion of the ascending colon herniating through a defect (curved arrow, #1, 2) in the right abdominal wall musculature, at the site of prior incision. There are no signs of strangulation or bowel obstruction.', 'history': 'Flank pain 2 years following partial nephrectomy.', 'imagePoolId': 'd69e67b7-ae25-4d46-beab-40cef59186bf', 'name': 'Through flank incision', 'teachingPoint': None}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '0155a085-5adb-4477-a2f8-0a0a27f23b6c', 'description': 'Axial CECT images (#1, 2) show bowel herniated into the right rectus sheath (curved arrow). The rectus muscle is atrophic and replaced with fat, common in elderly patients who have had a muscle-splitting laparotomy. A surgical clip (arrow, #1) indicated prior surgery in the region.', 'history': 'Elderly woman with right lower abdominal pain.', 'imagePoolId': 'cc6cc37f-57f2-4b8b-8eab-fb8e941ca86b', 'name': 'Within the rectus sheath', 'teachingPoint': None}], 'caseType': 'variant', 'name': 'VARIANT'}
|
||||
|
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|
||||
## Images
|
||||
|
||||
|
||||
### Selected Images
|
||||
|
||||
|
||||
*Axial CECT demonstrates a hernia <img src='img/arrows/WS.png'/> containing omental fat arising in the midline above the umbilicus and below the xiphoid, characteristic of an epigastric hernia.*
|
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|
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|
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*Axial CECT demonstrates a ventral hernia containing a loop of small bowel <img src='img/arrows/WS.png'/>. Notice the mildly dilated upstream small bowel <img src='img/arrows/WC.png'/>, compatible with obstruction. The patient was taken to surgery to relieve the obstruction.*
|
||||
|
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|
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*Axial CECT demonstrates a ventral hernia in the right lower quadrant containing the patient's transplant kidney <img src='img/arrows/WS.png'/>, ostensibly representing an incisional hernia related to the patient's prior transplant surgery.*
|
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|
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|
||||
*Axial CECT demonstrates a small bowel containing hernia <img src='img/arrows/WS.png'/> in the left lower quadrant at a previous laparoscopic port site. Note the presence of some dilated proximal small bowel loops <img src='img/arrows/WC.png'/>, compatible with obstruction.*
|
||||
|
||||
|
||||
### Additional Images
|
||||
|
||||
|
||||
*Axial CECT shows herniation of small bowel through a wide ventral hernia at the site of a prior paramedian surgical incision.*
|
||||
|
||||
|
||||
*Axial CECT shows ventral hernia containing ascites and varices in a patient with cirrhosis (umbilicus at a lower section).*
|
||||
|
||||
|
||||
*Axial CECT shows a lateral ventral hernia.*
|
||||
|
||||
|
||||
*Axial CECT shows a lateral incisional hernia containing colon.*
|
||||
|
||||
|
||||
*Axial CECT in an older obese woman with a bulge that increases with straining shows a large defect in the anterior abdominal wall <img src='img/arrows/WS.png'/> containing nonobstructed bowel.*
|
||||
|
||||
|
||||
*Axial CECT shows a ventral incisional hernia with bowel obstruction. Axial CECT shows a "knuckle" of small bowel herniated through a defect <img src='img/arrows/WS.png'/> in the anterior abdominal wall.*
|
||||
|
||||
|
||||
*Axial CECT in the same patient shows that the small intestine proximal to the herniated segment is dilated <img src='img/arrows/WO.png'/>, while that which is distal to the hernia is collapsed <img src='img/arrows/WC.png'/>, indicating that the herniated bowel is obstructed.*
|
||||
|
||||
|
||||
*Axial CECT demonstrates a hernia <img src='img/arrows/WS.png'/> containing small bowel arising in the midline above the umbilicus and below the xiphoid, characteristic of an epigastric hernia. The bowel within the hernia appears normal, without evidence of obstruction or ischemia.*
|
||||
|
||||
|
||||
*Axial CECT in the same patient shows dilated bowel leading up to the hernia and collapsed bowel <img src='img/arrows/WC.png'/> leaving the hernia. As suggested by the ascites <img src='img/arrows/WO.png'/>, the obstructed bowel was ischemic but proved viable at surgery.*
|
||||
|
||||
|
||||
*Axial CECT in a middle-aged woman with nausea and vomiting shows a ventral hernia <img src='img/arrows/WS.png'/> with strangulated, obstructed small bowel as well as ascites <img src='img/arrows/WO.png'/>, suggesting bowel ischemia.*
|
||||
|
||||
Reference in New Issue
Block a user