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Table 1 A spectrum of the abdominal wall lesions with the demonstration of their ultrasound features [4,5,6, 9, 11]

From: Role of high-resolution ultrasound in the assessment of abdominal wall masses and mass-like lesions

Lesion Ultrasound features
1. Hernia
a. Inguinal
An abdominal viscus, commonly the bowel loops or omentum protrudes through a defect; the location of the defect in relation to the inferior epigastric artery determines the type of hernia; thus, a defect located medial to the artery makes the diagnosis of a direct hernia and vice versa.
b. Ventral Including the supra-umbilical, umbilical, and infra-umbilical hernias where a defect is present and the omental fat or the bowel protrude through it.
c. Incisional Where a defect is present at the site of previous surgical scarring.
d. Recurrent Where a hernia reoccurs at the same site of a previous hernia repair.
2. Lipoma Rather circumscribed hypo or hyperechoic soft tissue swelling with different shapes but commonly ovoid or spindle shape with interlacing echogenic fibrous bands giving a feathery appearance.
3. Endometrioma Often following abdominal surgery (e.g., Cesarean section) and usually present as a palpable lump that is associated with menstrual cycles and sonographically has different shapes varying from simple cystic, complex cystic, and even solid mass-like lesions.
4. Hematoma The patient has a history of anticoagulation or vigorous exercise that provokes the vascular rupture of either the superior or inferior epigastric artery; on ultrasound, a recent hematoma has a rather inhomogeneous echogenic pattern with possible layering fluid or fluid-fluid levels, but older hematomas tend to be absorbed or to liquefy giving a cystic appearance.
5. Seroma Is a postoperative sequel and appears as a cyst-like lesion with acoustic enhancement but no solid components could be found inside.
6. Abscess Is a complex fluid collection with debris and low to medium level internal echoes; it may be related to a surgical wound where it is called a suture abscess and the echogenic sutures could be identified in many cases; however, it may be difficult to differentiate the abscess from hematoma and seroma based on the ultrasound picture, but irregular walls, marginal vascularity, and the surrounding inflammatory changes may help to differentiate, but sometimes, the only feasible way of differentiation is to do an aspiration.
7. Metastasis It may occur by a lymphatic spread or blood-borne tumor dissemination. Melanoma is common but other tumors like bronchogenic carcinoma or lymphoma may be also considered; on ultrasound, it appears as an ill-defined hypoechoic mass with increased internal vascularity.
8. Neurogenic tumors Either schwannoma or neurofibroma, by ultrasound, both appears as well-circumscribed fusiform or ovoid swellings with tapering ends to the parent nerve.
9. Vascular malformations It could be either a low flow or a high flow lesions where multiple intercommunicating cystic spaces are found and may show by color Doppler either a pure venous flow (low flow type) or evidence of arteriovenous shunting (high flow); sometimes, calcific phlebolith may be seen.
10. Desmoid tumor Is a myofibroblastic neoplasm that is considered as deep fibromatosis and often follows abdominal surgery or abdominal wall scarring. Gardner’s syndrome and estrogen therapy may be considered as risk factors; it appears as a poorly circumscribed hypoechoic soft tissue lesion that infiltrates the abdominal wall muscles and may present internal vascularity, and characteristically, the lesion does not cross the midline.