Diagnostic Accuracy of High-Resolution Ultrasonography in the Evaluation of Anterior Abdominal Wall Lesions at a Tertiary Care Hospital in Odisha: A Hospital-Based Observational Study

Anterior abdominal wall lesions frequently mimic intra-abdominal pathologies and commonly present as palpable masses, particularly in individuals with a thick abdominal wall or increased subcutaneous fat. Differentiating abdominal wall lesions from intra-abdominal conditions often poses a diagnostic challenge because clinical examination findings are frequently nonspecific. In many cases, ultrasonographic evaluation of the abdominal wall becomes necessary to determine whether a suspected mass originates from the abdominal wall or the abdominal cavity. Occasionally, a clinically suspected intra-abdominal lesion is found to arise from the abdominal wall, while in other instances, abdominal wall abnormalities are detected incidentally during sonographic examination performed for unrelated indications. Furthermore, evaluation of the abdominal wall is particularly important in patients presenting with chronic abdominal pain, especially when a positive Carnett’s sign suggests an abdominal wall origin of pain.[1,2]

The assessment of anterior abdominal wall pathology remains challenging for both clinicians and radiologists because of the wide spectrum of diseases and the availability of multiple imaging modalities for evaluation. Diagnostic approaches range from plain abdominal radiography to advanced imaging techniques such as ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI).

The introduction of high-frequency, high-resolution ultrasonographic probes has substantially improved the evaluation of abdominal wall lesions by allowing detailed visualization of the individual layers of the abdominal wall. High-resolution sonography can accurately determine whether a lesion is located within the abdominal wall or inside the abdominal cavity, thereby improving diagnostic confidence. Since physical examination findings alone have low specificity, sonographic evaluation is frequently recommended, particularly in patients with a positive Carnett’s sign or clinically suspected abdominal wall pathology.

High-resolution ultrasonography has emerged as a preferred imaging modality for evaluating anterior abdominal wall lesions because of its accessibility, cost-effectiveness, absence of ionizing radiation, and high diagnostic accuracy. A broad spectrum of pathological conditions may involve the anterior abdominal wall, ranging from simple fluid collections and hernias to complex neoplastic lesions. Early and accurate diagnosis using high-resolution ultrasonography, often complemented by cross-sectional imaging, has significantly improved clinical decision-making and surgical management.

Therefore, the present study was undertaken to evaluate the spectrum of anterior abdominal wall lesions and to assess the diagnostic accuracy of high-resolution sonography using a high-frequency linear array probe in the diagnosis of anterior abdominal wall lesions.

The present study included 75 clinically suspected cases of anterior abdominal wall lesions evaluated by high-resolution ultrasonography. The highest proportion of patients belonged to the 20–40 years age group (44%), followed by patients aged more than 40 years (36%), while younger individuals aged less than 20 years constituted 20% of cases (Table 1).

Among the clinically suspected anterior abdominal wall lesions, the most common indication for high-resolution sonographic evaluation was incisional hernia, followed by ventral hernia and anterior abdominal wall swelling/lump, which often represented non-specific clinical diagnoses and were later characterized accurately on sonography.

Table 1: Age-wise Distribution of Anterior Abdominal Wall Lesions (n = 75)

Table 2: High-Resolution Sonographic Diagnosis of Anterior Abdominal Wall Lesions (n = 75)

High-resolution ultrasonography most frequently detected incisional hernia, accounting for 32 cases (42.7%), followed by ventral hernia in 11 cases (14.7%). Other lesions included lipoma, hematoma, post-operative seroma, dermoid cyst, desmoid tumour, inflammatory lesions, and rare soft tissue neoplasms (Table 2).

Table 3: Histopathological / Post-Operative Diagnosis of Anterior Abdominal Wall Lesions (n = 75)

Histopathological or post-operative confirmation was obtained in 68 out of 75 cases (90.7%) whenever indicated. Sonographic diagnosis correlated accurately with surgical or histopathological findings in the majority of patients, yielding an overall diagnostic accuracy of 97.1% (Table 4).

Table 4: Diagnostic Validity of High-Resolution Sonography

Sensitivity = 97.0% , Specificity = 100% , Positive Predictive Value (PPV) = 100% , Negative Predictive Value (NPV) = 50.0% , Diagnostic Accuracy = 97.1%

The present study evaluated 75 cases of anterior abdominal wall lesions over a two-year period at SCB Medical College and Hospital, Cuttack, Odisha, with emphasis on the diagnostic utility of high-resolution ultrasonography (HRUSG). Literature focusing specifically on anterior abdominal wall lesions in the Indian setting remains limited, particularly from tertiary care institutions in eastern India. The present study highlights the role of HRUSG in the characterization and diagnosis of various anterior abdominal wall pathologies and demonstrates its high diagnostic performance in routine clinical practice.

Congenital anterior abdominal wall defects such as omphalocele, gastroschisis, cloacal exstrophy, and prune belly syndrome are generally detected during antenatal ultrasonography, particularly in the second trimester (18–24 weeks of gestation). Although such lesions can be evaluated using low-frequency probes during fetal imaging, the present study focused primarily on acquired anterior abdominal wall lesions assessed using high-frequency linear transducers (7–12 MHz). Therefore, congenital lesions identified during antenatal scans were not included in the study population.

Patients were broadly categorized into three age groups: <20 years, 20–40 years, and >40 years. The majority of cases in the present study belonged to the 20–40 years age group (44%), followed by individuals aged more than 40 years (36%). Similar observations have been reported in previous studies, where abdominal wall lesions, particularly hernias, were more commonly encountered among young and middle-aged adults due to increased physical activity, prior surgical interventions, and greater healthcare-seeking behavior. The predominance of lesions in this economically productive age group may also reflect increased awareness and early reporting of symptoms.

Among the clinically suspected anterior abdominal wall lesions, incisional hernia was the most common indication for high-resolution sonographic evaluation and represented the most frequently diagnosed lesion (42.7%), followed by ventral hernia (14.7%). HRUSG proved particularly useful in differentiating clinically nonspecific abdominal wall swellings and lumps, which were subsequently characterized accurately through sonographic findings and, where necessary, histopathological confirmation. This observation reinforces the importance of ultrasonography in lesion characterization and localization, often outperforming clinical examination alone.

The sonographic diagnosis of incisional and ventral hernias was relatively straightforward because high-resolution sonography clearly demonstrated fascial defects, reducibility, and hernial contents in real time. Additionally, the use of colour Doppler facilitated assessment of vascular compromise and helped distinguish strangulated from uncomplicated hernias. Similar findings have been documented in earlier studies.[3–7]

Lipomas constituted another important category of anterior abdominal wall lesions in the present study. All lipomatous lesions showed characteristic sonographic appearances, including well-defined margins, oval morphology, and iso- to mildly hyperechoic echotexture relative to surrounding musculature. HRUSG demonstrated high accuracy in identifying these lesions, thereby minimizing unnecessary invasive procedures.

Other less frequent lesions included desmoid tumours, dermoid cysts, pyomyositis, resolving abscesses, neurofibromas, metastatic lesions, and abdominal wall sarcoma. Desmoid tumours typically appeared as well-defined hypoechoic masses with increased internal vascularity on colour Doppler, particularly in patients with previous abdominal surgery, findings consistent with previous reports.

Histopathological and post-operative correlation was available in the majority of cases (90.7%), and sonographic findings demonstrated excellent agreement with final diagnosis. In the present study, high-resolution ultrasonography achieved an overall diagnostic accuracy of 97.1%, with high sensitivity and specificity. These findings suggest that HRUSG provides diagnostic reliability comparable to surgical and histopathological evaluation for most anterior abdominal wall lesions.

Hernias continue to represent the most common abdominal wall pathology encountered in sonographic practice. Depending on anatomical location and contents, they may demonstrate varying sonographic appearances. High-frequency transducers allow excellent visualization of fascial defects and herniated contents, while real-time imaging enables dynamic assessment of reducibility. Ventral hernias are typically observed in regions of weakened linea alba and frequently contain omental fat, although bowel loops may occasionally be present.[3,4]

Incisional hernias are recognized as a common delayed complication of abdominal surgery and may occur following both open and laparoscopic procedures. Many patients present within the first postoperative year, while others remain asymptomatic and are incidentally detected during imaging. Sonography plays an essential role in confirming the diagnosis, assessing hernia contents, and monitoring the integrity of mesh repair when present.[5–7]

Although less frequently encountered, Spigelian and inguinal hernias may occasionally present diagnostic difficulties clinically. High-resolution sonography, especially when combined with colour Doppler imaging, significantly improves lesion detection and characterization by accurately delineating anatomical defects and vascular landmarks.[8–11]

High-resolution ultrasonography is a highly effective and reliable imaging modality for evaluating anterior abdominal wall lesions. It demonstrates excellent diagnostic accuracy in differentiating hernias from cystic and solid abdominal wall lesions and in distinguishing abdominal wall pathologies from intra-abdominal abnormalities. The advantages of HRUSG include its non-invasive nature, absence of ionizing radiation, cost-effectiveness, widespread availability, reproducibility, and high diagnostic accuracy. Therefore, high-resolution ultrasonography should be considered a first-line imaging modality in the evaluation of anterior abdominal wall lesions at tertiary care settings such as SCB Medical College and Hospital, Cuttack, Odisha.

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