|Year : | Volume
| Issue : | Page :
Computed tomography for ventral hernia: Need for a standardised reporting format
Jignesh A Gandhi, Pravin H Shinde, Amay M Banker, Yogesh Takalkar
Department of General Surgery, Seth GSMC and KEM Hospital, Mumbai, Maharashtra, India
|Date of Submission||20-Jan-2022|
|Date of Acceptance||06-Feb-2022|
|Date of Web Publication||16-Jul-2022|
Amay M Banker,
Department of General Surgery, Seth GSMC and KEM Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
| ¤ Introduction|| |
Ventral hernia is a very commonly performed procedure by the general surgeon. Historically, physical examination was considered the norm for the diagnosis of ventral hernia in clinical practice and research reporting. However, with advancements in imaging techniques and its widespread availability, physical examination alone is beginning to be considered inadequate. A small defect, large habitus or a pseudorecurrence (a bulge not related to a recurrence, but due to seroma, mesh or muscle diastasis) further lower the reliability of clinical examination alone. Research shows examination alone misses up to 23% of ventral hernias seen on radiological imaging and surgeon assessment alone is inferior to a routine abdominal computed tomography (CT) scan for diagnosis of ventral hernia. Underdiagnosis and misreporting of hernia may result in inappropriate management decisions and inaccurate benchmarking of surgical outcomes. Pre-operative imaging aims to define the ventral hernia size, its contents, quality of the abdominal muscles, and identify any complication (s) that would compromise repair. For this reason, CT assumes prominence over ultrasonography in the diagnosis and reporting of ventral hernia.
A variety of surgical techniques are used for the repair of ventral hernias. These techniques range from the primary approximation of the defect with suture repair, use of mesh used as an onlay, underlay, or as a bridging patch, to complex myofascial advancement techniques such as the anterior component separation and transversus abdominis release.,,, Loss of domain may even require progressive pneumoperitoneum creation or injection of Botulinum toxin to increase the abdominal wall compliance., Given the complex nature of these repairs, pre-operative CT scans play an important role in assessing the likelihood of successful repair and determining the optimal surgical approach.
Currently, there is no accepted standard of care to diagnose and report a ventral hernia. We did a thorough literature review on the use of CT scans for ventral hernia, created a multidisciplinary hernia team (MDT) with prominent radiologists and surgeons and discussed the role of CT scans in the management of ventral hernia. After completing a pilot study with around 120 patients, we created a standard CT reporting format which helped us in the management of even the most complex cases. This standard reporting format can be used by trainees and surgeons worldwide [Table 1]. This would lead to uniformity in reporting, would help in decision-making and would also help create national and international hernia registry.
|Table 1: Components of a standard computed tomography report for ventral hernia|
Click here to view
| ¤ Our Protocol|| |
Our standardised reporting format begins a brief history of the patient to understand whether it's a primary or an incisional ventral hernia. Technical details of the CT protocol are then mentioned. A plain CT scan usually provides majority of information related to the hernia and the use of intravenous contrast is necessary only when dealing with complex cases such as recurrence or the presence of an intra-abdominal pathology with vascular compromise. We follow a standard protocol for reviewing a CT Scan. We start from the abdominal wall and report the hernia characteristics first before proceeding with the description of the intra-abdominal organs and other pathologies that may be present. We first describe the location and size of the hernia defect and classify it as recommended by the European Hernia Society. In addition to the maximum width, we report the craniocaudal dimension also, so that the surgeon can determine the size of mesh that needs to be available. If the hernia defect is very large, the abdominal cavity might lose its volume to the hernia sac. In such cases, a return of the hernia contents may lead to abdominal hypertension and systemic compromise. Specialists would like to know the relationship between hernia sac volume and the residual abdominopelvic cavity volume, a metric termed 'loss of domain.' This loss of domain is calculated as per the Tanaka Index. A brief mention of the Component Separation Index and Carbonell's index, in such complex cases, aids the surgeon in determining the best surgical treatment.,,
This is followed by a brief description of the contents of the hernia sac and the presence of complications (strangulation/obstruction) if any. Patients seen at specialist centres have often had a prior surgical correction and pre-operative imaging can help identify the nature of this. For example, is a mesh in place, and if so in what plane. Whether the component separation is performed, and whether there are adhesions and/or fistula? The peritoneum and individual fascial layers are extremely thin on CT, so the precise plane of mesh placement is often difficult to ascertain. However, this type of information is important because muscle planes that have been separated previously are usually not available for a re-do operation due to adhesions. The abdominal wall muscles are evaluated next with mention of their perceived muscle quality, their thickness, and symmetry. Abdominal wall thickness is a metric that has been researched but measured in many different ways. The most quoted work is from Blair et al., who found that increased abdominal wall thickness was associated with better post-operative outcomes. Rectus abdominins diastasis has several implications during surgical repair and is reported as per the Beer classification. Since research has repeatedly shown biological age to be more important than chronological age in determining post-operative outcomes, we also propose calculation of the sarcopenia index in selected cases. This was corroborated by a study by Barnes et al. who showed that the presence of sarcopenia was associated with a significant increase in post-operative complication rates. Rest of the reporting is as per usual. We have attached our sample reporting format for the readers perusal [Figure 1].
The poor interobserver reliability of CT scans for diagnosing and reporting ventral hernia has important implications in patient care. In a study by Holihan et al. they found most disagreements in the diagnosis and reporting of ventral hernia stemmed from a lack of standardised approach to reading CT scans. They recommended that a systematic approach to reading CT scans for ventral hernias needed to be developed and disseminated. The authors strongly agree with the results of Holihan et al. study and we propose a standard reporting format which can be used by trainees and specialists worldwide. Further studies which are designed to assess the impact of standardised reporting of CT scans on clinical outcomes are recommended.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| ¤ References|| |
Poulose BK, Shelton J, Phillips S, Moore D, Nealon W, Penson D, et al.
Epidemiology and cost of ventral hernia repair: Making the case for hernia research. Hernia 2012;16:179-83.
Holihan JL, Karanjawala B, Ko A, Askenasy EP, Matta EJ, Gharbaoui L, et al.
Use of computed tomography in diagnosing ventral hernia recurrence: A blinded, prospective, multispecialty evaluation. JAMA Surg 2016;151:7-13.
Carter SA, Hicks SC, Brahmbhatt R, Liang MK. Recurrence and pseudorecurrence after laparoscopic ventral hernia repair: Predictors and patient-focused outcomes. Am Surg 2014;80:138-48.
Baucom RB, Beck WC, Holzman MD, Sharp KW, Nealon WH, Poulose BK. Prospective evaluation of surgeon physical examination for detection of incisional hernias. J Am Coll Surg 2014;218:363-6.
Gandhi J, Banker A, Chaudhari S, Shinde P. Role of indocyanine green to mitigate wound complications in component separation technique for ventral hernia repair-our early experience. World J Surg 2021;45:3073-9.
Gandhi JA, Shinde P, Kothari B, Churiwala JJ, Banker A. Endoscopic pre-aponeurotic repair (EPAR) technique with meshplasty for treatment of ventral hernia and rectus abdominis diastasis. Indian J Surg 2020:1-5. [Doi: 10.1007/S12262-020-02189-9].
Gandhi J, Shinde P, Chaudhari S, Banker A, Deshmukh V. Decalogue of transversus abdominis release repair- technical details and lessons learnt. Pol Przegl Chir 2021;93:16-25.
Krpata DM, Blatnik JA, Novitsky YW, Rosen MJ. Posterior and open anterior components separations: A comparative analysis. Am J Surg 2012;203:318-22.
Elstner KE, Read JW, Rodriguez-Acevedo O, Ho-Shon K, Magnussen J, Ibrahim N. Preoperative progressive pneumoperitoneum complementing chemical component relaxation in complex ventral hernia repair. Surg Endosc 2017;31:1914-22.
Soltanizadeh S, Helgstrand F, Jorgensen LN. Botulinum toxin a as an adjunct to abdominal wall reconstruction for incisional hernia. Plast Reconstr Surg Glob Open 2017;5:e1358.
Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, et al.
Classification of primary and incisional abdominal wall hernias. Hernia 2009;13:407-14.
Tanaka EY, Yoo JH, Rodrigues AJ Jr., Utiyama EM, Birolini D, Rasslan S. A computerized tomography scan method for calculating the hernia sac and abdominal cavity volume in complex large incisional hernia with loss of domain. Hernia 2010;14:63-9.
Blair LJ, Ross SW, Huntington CR, Watkins JD, Prasad T, Lincourt AE, et al.
Computed tomographic measurements predict component separation in ventral hernia repair. J Surg Res 2015;199:420-7.
Christy MR, Apostolides J, Rodriguez ED, Manson PN, Gens D, Scalea T. The component separation index: A standardized biometric identity in abdominal wall reconstruction. Eplasty 2012;12:e17.
Parikh KR, Al-Hawary M, Millet JD, Burney R, Finks J, Maturen K. Incisional hernia repair: What the radiologist needs to know. AJR Am J Roentgenol 2017;209:1239-46.
Beer GM, Schuster A, Seifert B, Manestar M, Mihic-Probst D, Weber SA. The normal width of the linea alba in nulliparous women. Clin Anat 2009;22:706-11.
Barnes LA, Li AY, Wan DC, Momeni A. Determining the impact of sarcopenia on postoperative complications after ventral hernia repair. J Plast Reconstr Aesthet Surg 2018;71:1260-8.