The abdominal wall lesions had been identified as a very common entity that could be seen in the clinical and radiological examinations. Nevertheless, the clinical findings in the abdominal wall lesions often had a low specificity and in many situations, and the clinically suspected intra-abdominal masses might be surprisingly arising from the abdominal wall .
The imaging workup of the abdominal wall lesions could be performed by different modalities; however, the ultrasound had predominated in this regard, being widely available, noninvasive, and of low cost; moreover, it provides a high spatial resolution of the abdominal wall layers. The real-time examination obtained through the ultrasound gives the opportunity for assessing the patient while performing the straining maneuvers as well as in the standing position if there was an indication for this [4, 6, 7].
The current study included 54 patients, 28 were females (51.9%) and 26 were males (48.1%); thus, we had the same gender distribution as Jayaram et al., Babu et al., and Devareddy et al., who also had studied abdominal wall lesions by high-resolution ultrasound examination [7,8,9].
Babu et al. conducted a research in 2018 to evaluate the role of high-resolution ultrasound in the evaluation of the anterior abdominal wall lesions. Their study included 50 patients (66.7% females and 33.3% males) .
Another study was done by Jayaram et al. to evaluate the role of ultrasound scanning in the diagnosis of equivocal ventral hernias in comparison to the operative findings, and their study was larger with a total of 348 patients (56.9% females and 43.1% males) included .
We agreed with Babu et al. in their explanation for the female gender predominance as the Caesarean section and the abdominal hysterectomies are considered as the most common surgical procedures that are performed worldwide .
In our study, a hernia was the most frequently encountered abdominal wall lesion (57.4%). These results were consistent with Babu et al., who had the same results (58% of their patients) .
Devareddy et al. had also reported that a hernia was the most frequently encountered abdominal wall lesion (70%), and this was also concordant with our results .
In our study, the age of hernia patients was in the range of 20–50 years, and this went with the studies done by Babu et al. and Devareddy et al.; however, one of our cases showed a younger age (1-year-old female), and it was clinically diagnosed as a congenital inguinal hernia, but the ultrasound examination revealed a hydrocele of canal of Nück.
Regarding the type of a hernia, the current study showed that the predominant type of hernia was the ventral hernia (48.3%) followed by the inguinal hernia (38.7%), then the incisional hernia (9.6%), and Spigelian hernia (3.2%); this was discordant with the results reported by Babu et al. who had documented that the incisional hernia was the frequent one (44%) followed by the ventral type (14%), and this could be explained by the small sample size in both studies (our study was conducted on 54 patients while theirs was on 50 patients); thus, a small sample size may explain this difference, and a larger sample size may be required for a reproducible and more representative data .
Discordance with Devareddy et al.’s study had been noted, who had reported that the incisional hernia (56%) was the most common type followed by the ventral hernia (14%) ; this difference may be explained by a relatively low percentage of postoperative patients (25.9%) (who had a previous history of old operations as a predisposing factor for incisional hernia) among the cases of our study compared to theirs, where they were concerned with the abdominal wall lesions in the postoperative patients.
There is an agreement with the study done by El-Sayed et al., who conducted their study on 50 patients and found that a ventral hernia was the most common abdominal wall lesion; they had emphasized on the important role of the ultrasound in the hernia evaluation, especially if there were any suspected complication, and highlighted its role as a confirmatory diagnostic tool when the clinical and other imaging studies were inconclusive .
In the present study, we had only one case of complicated hernia that was a strangulated one, and this was confirmed intra-operatively; we can explain this as these complications are surgical emergencies and usually the patients seek the medical advice at the ER and immediate exploration and reduction are to be done urgently, but our patients were mostly referred from the outpatient clinics and rarely from the ER if ever.
Usually, the clinical diagnosis of a hernia is correct and this was seen in our study where 32 cases were diagnosed as a hernia by the clinical examination, but the ultrasound examination revealed only 31 cases, and this discrepancy was in only one case; it was diagnosed clinically as a postoperative recurrent hernia, but the ultrasound examination revealed a postoperative seroma that was surgically evacuated, and this could enhance the points of strength of the role of ultrasound examination (Fig. 5).
Regarding the accuracy measures for the high-resolution ultrasound validity in the diagnosis of the abdominal wall and groin hernias compared to the operative, histopathology, and CT findings, the current study had a sensitivity of 100%, specificity 100%, a positive predictive value of 100%, and a negative predictive value of 100% with a diagnostic accuracy of 100%.
There is a slight difference with Jayaram et al. who had reported sensitivity of 91.8%, specificity of 80%, and positive predictive value of 97.8%  and with Devareddy et al. who had reported a sensitivity of 100%, specificity of 75%, a positive predictive value of 97.4%, a negative predictive value of 100%, and a diagnostic accuracy of 97.6% ; however, Babu et al. had also reported a diagnostic accuracy of 97.6% .
This difference could be attributed to the limited number of patients in our study that had included 54 patients and the different correlative modalities where we used the operative, histopathological, and the CT findings as gold standards while their studies had used only the operative and the biopsy findings.
However, there was an agreement by these different studies [7,8,9,10] that the high-resolution ultrasound had encouraging results regarding its role in the assessment of abdominal wall masses and mass-like lesions with an accuracy of over 97%.
We had some limitation in the current study: the first one was the limited number of patients since we conducted our study on 54 patients only, and the second one was the relatively low percentage of postoperative patients (25.9%) who are at risk for incisional hernia. So, further research with a large number of patients and including a higher proportion of postoperative patients is considered.