Hernia Sac Volume Research Articles

Hiatal Hernia Repair: Can We Predict the Need for Mesh?

Introduction: The use of mesh for paraesophageal hernia repair is controversial due to concerns about long-term complications. This study aimed to investigate whether preoperative imaging characteristics of diaphragmatic hernia could predict the need for mesh repair. Methods: The records of all patients who underwent laparoscopic diaphragmatic hernia repair between September 2015 and September 2022 were reviewed. Patients' preoperative computerized tomography (CT) imaging was reviewed and was correlated with mesh repair. Results: A total of 53 patients were included in the study. Volumetric measurements were obtained from preoperative CT scans to assess hiatal defect area (HDA) and hernia sac volume (HSV). Mesh repair was required in 43.4% of cases, all among types II-IV. The mesh repair group had a higher mean hiatal neck height (50.8 ± 16.35 versus 43.22 ± 17.08 mm, P < .032) and higher HSV (708.53 ± 577.6 versus 346.866 ± 321.65 cm3, P < .003). There was also a borderline difference in HDA mean values (23.78 ± 17.22 versus 16.8 ± 10.41 cm2, P < .059). Conclusions: Preoperative HSV on CT scans can be a valuable predictor for the need for mesh repair during hiatal hernia surgery, aiding surgical planning and decision-making. Further research is needed to validate these findings and optimize hernia repair outcomes.

Measurements of abdominal wall defect and hernia sac volume in the treatment of incisional hernia: Application of ultrasonic volume auto-scan in 50 cases.

Abdominal incisional hernia is one of the most common complications after surgery. The preoperative evaluation of the area of abdominal wall defect and the hernia sac volume(HCV) is very important for the selection of patch size and incisional herniorrhaphy. Meanwhile the overlap range of reinforcement repair is controversial. This study aimed to explore the value of ultrasonic volume auto-scan(UVAS) in the diagnosis, classification and treatment of incisional hernia. Both the width and the area of abdominal wall defect and HCV were measured by UVAS in 50 cases with incisional hernias. In 32 of these cases, the measurements of HCV were compared with those of CT. Classification of incisional hernia based on ultrasonic images were compared with operative diagnosis. The measurements of HCV by UVAS and CT 3D reconstruction had good consistency, of which the mean ratio was 1.0084. According to the location and width of abdominal wall defect, UVAS, which showed good accuracy rate (90%, 96%), reached a good agreement in the classification of incisional hernias with operative diagnoses (Kappa=0.85, Confidence Interval [0.718,0.996]; Kappa=0.95, Confidence Interval [0.887,0.999]). The patch area should be at least two times as large as the defect area. UVAS is an accurate alternative to measure the abdominal wall defect and HCV and classify the incisional hernia, with additional benefits of no radiation exposure and instant bedside interpretation. The use of UVAS is conducive to preoperative assessment of the risk of hernia recurrence and abdominal compartment syndrome.

OC-035 AUTOMATION OF HERNIA VOLUMES - SAC DETECTION AND HERNIA VOLUMETRY USING COMPUTER VISION AND DEEP LEARNING - PUSHING FRONTIERS

Abstract Aim To identify the sac and defect using deep learning algorithms and to compute hernial sac volume in an automated fashion. Materials and methods 70 ventral hernia CT scans were used. Slices with hernia defect and sac were annotated using computer vision tools. 80% of the data was used for training and validation. 20% data was used for testing. We used a combination of 3D reconstruction algorithms and deep learning to train the models. The model output was compared to manual annotation by experts. Results The testing data showed that our novel algorithm was able tp estimate the defect with an accuracy of 90%. The mean IOU for detection of hernia sac was 88% and volume estimation accuracy was 85%. Conclusion A combination of supervised deep learning and 3D volumetry will increase the accuracy of volumetric indices and shorten the volume estimation time. In most parts of the world, the hernia sac volume is not calculated by the radiologist and the surgeon is left to estimate it using rudimentary means such as visual estimation. Automated hernia volumetry will play a major role in standardising hernia reports. We believe this is a pivotal step in creating actionable radiology reports that will help the surgeon assess the complexity and plan surgery.

Laparoscopic total extraperitoneal (TEP) inguinal hernia repair with preperitoneal closed-suction drainage reduced postoperative complications

BackgroundAlthough laparoscopic total extraperitoneal (TEP) inguinal hernia repair has the advantages of less bleeding, less trauma, less pain, and fast recovery, there are several issues that need to be addressed. This study aims to evaluate the effectiveness of preperitoneal closed‑suction drainage on reducing postoperative complications in TEP inguinal hernia repair.MethodsA retrospective analysis of 122 patients who underwent TEP inguinal hernia repair between June 2018 and June 2021 was performed. The patients were divided into the drainage group and the non-drainage group according to whether the drainage tube was placed or not. Clinical data, surgical procedures and outcome of these patients were collected and analyzed to assess the effectiveness of drainage.ResultsA total of 122 patients undergoing TEP surgery were screened, of which 22 were excluded. Most of the patients were male with right indirect inguinal hernia. There was no difference in the mean length of hospital stay between the two groups. Postoperative pain was alleviated by preperitoneal closed‑suction drainage 24 h after operation (p = 0.03). The rate of complications such as scrotal edema, seroma and urinary retention in the drainage group was significantly lower than that in the non-drainage group (p < 0.05). Multivariate regression analysis showed that drainage was beneficial to reduce postoperative complications (OR, 0.015; 95% CI, 0.002–0.140; p < 0.01). In addition, it was worth noting that in subgroup analysis, patients with hernia sac volume > 10 cm3 might receive more clinical benefits by placing drainage tube.ConclusionIn TEP inguinal hernia repair, placing drainage tube is a simple and feasible traditional surgical treatment, which can promote postoperative recovery without increasing the risk of infection, especially in patients with large hernia sac volume.

Computed tomography for ventral hernia: Need for a standardised reporting format.

Computed tomography for ventral hernia: Need for a standardised reporting format.

Comparison of two-dimensional measurement with three-dimensional volume rendering for the assessment of loss of domain in incisional hernia patients.

We aimed to compare simple two-dimensional (2D) measurement with comprehensive three-dimensional (3D) volume rendering to determine loss of domain (LOD), a clinically important decision-making feature for incisional hernia repair. In this single-center retrospective study, we analyzed the CT scans of a consecutive cohort of adult patients with a midline incisional hernia. The hernia sac- and abdominal cavity volumes were obtained by two different methods. The 2D method estimated the volumes using the corresponding height, width, and depth. The 3D method comprised of a volume rendering tool. For both methods, LOD was calculated according to the Sabbagh ratio (hernia sac volume / (hernia sac volume + abdominal cavity volume)). Taking the 3D method as the reference standard, the performance of the 2D method was expressed as positive predictive value (PPV) and negative predictive value (NPV) for LOD of more than- and less than 20%. The agreement between both methods was expressed as Cohen's kappa coefficient (kappa). We analyzed 92 CT scans. Agreement between both methods was high (kappa = 0.854, p = 0.0001); all 67 measurements for which the 2D method assessed LOD to be less than 20% were correctly classified (NPV = 100%), and 20 of 25 measurements for which the 2D method assessed LOD to be more than 20% were correctly classified (PPV = 80%). The 2D method can exclude patients fromperioperative actions needed for a more complex hernia. Since this method is easy to use and less time-consuming, it seems useful for the routine radiological assessment of LOD in clinical practice.

Logistic regression analysis of risk factors for intra-abdominal hypertension after giant ventral hernia repair: a retrospective cohort study.

Intra-abdominal hypertension (IAH) is a classical complication after giant ventral hernia surgery and may lead to abdominal compartment syndrome (ACS). Assessment of risk factors and prevention of IAH/ACS are essential for hernia surgeons. We performed a retrospective study including 58 giant ventral hernia patients in our center between Jan 1, 2017, and Mar 1, 2022, we recorded age, gender, chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD), hypertension, type 2 diabetes mellitus (T2DM), hypoproteinemia, body mass index (BMI), the ratio of hernia sac volume to abdominal cavity volume (HSV/ACV), defect width, tension reduction procedure (TRP), positive fluid balance (PFB) and IAH of these patients and analyzed the data using univariate and multivariate logistic regression to screen the risk factors for IAH after surgery. The multivariate analysis showed that HSV/ACV ≥ 25%, hypoproteinemia, and PFB were independent risk factors for the occurrence of IAH after giant ventral hernia repair (P = 0.025, 0.016, 0.017, respectively). We did not find any correlation between postoperative IAH and the patient's age, gender, COPD, CHD, hypertension, T2DM, BMI, defect width, TRP, and PFB. Identifying risk factors is of great significance for the early identification and prevention of IAH/ACS. We found that HSV/ACV ≥ 25%, hypoproteinemia, and PFB were independent risk factors for IAH after giant ventral hernia repair.

Preoperative botulinum A toxin as an adjunct for abdominal wall reconstruction: a single-center early experience at an Academic Center in New York.

the botulinum toxin A (BTA) has been used to achieve a chemical component separation, and it has been used with favorable outcomes for the repair of complex ventral hernia (CVH) with and without loss of domain (LD). The aim of this study is to describe our early experience with the chemical component separation in the United Sates. a retrospective observational study of all patients who underwent ventral hernia repair for CVH with or without LD between July 2018 and June 2020. Preoperative BTA was injected in all patients via sonographic guidance bilaterally, between the lateral muscles to achieve chemical denervation before the operation. Patient demographics, anatomical location of the hernia, perioperative data and postoperative data are described. 36 patients underwent this technique before their hernia repair between July 2018 to June 2020. Median age was 62 years (range 30-87). Median preoperative defect size was 12cm (range 6-25) and median intraoperative defect size was 13cm (range 5-27). Median preoperative hernia sac volume (HSV) was 1338cc (128-14040), median preoperative abdominal cavity volume (ACV) was 8784cc (5197-18289) and median volume ration (HSV/ACV) was 14%. The median OR time for BTA administration was 45 minutes (range 28-495). Seroma was the most common postoperative complication in 8 of the patients (22%). Median follow up was 43 days (range 0-580). preoperative chemical component separation with BTA is a safe and effective adjunct to hernia repair in CVH repairs where a challenging midline fascial approximation is anticipated.

Outcomes and CT scan three-dimensional volumetric analysis of emergent paraesophageal hernia repairs: predicting patients who will require emergent repair.

IntroductionElective repair versus watchful waiting remains controversial in paraesophageal hernia (PEH) patients. Generation of predictive factors to determine patients at greatest risk for emergent repair may prove helpful. The aim of this study was to evaluate patients undergoing elective versus emergent PEH repair and supplement this comparison with 3D volumetric analysis of hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) to determine risk factors for increased likelihood of emergent repair.MethodsA retrospective review of a prospectively enrolled, single-center hernia database was performed on all patients undergoing elective and emergent PEH repairs. Patients with adequate preoperative computed tomography (CT) imaging were analyzed using volumetric analysis software.ResultsOf the 376 PEH patients, 32 (8.5%) were emergent. Emergent patients had lower rates of preoperative heartburn (68.8%vs85.1%, p = 0.016) and regurgitation (21.9%vs40.2%, p = 0.04), with similar rates of other symptoms. Emergent patients more frequently had type IV PEHs (43.8%vs13.5%, p < 0.001). Volumetric analysis was performed on 201 patients, and emergent patients had a larger HSV (805.6 ± 483.5vs398.0 ± 353.1cm3, p < 0.001) and HDA (41.7 ± 19.5vs26.5 ± 14.7 cm2, p < 0.001). In multivariate analysis, HSV increase of 100cm3 (OR 1.17 CI 1.02–1.35, p = 0.022) was independently associated with greater likelihood of emergent repair. Post-operatively, emergent patients had increased length of stay, major complication rates, ICU utilization, reoperation, and mortality (all p < 0.05). Emergent group recurrence rates were higher and occurred faster secondary to increased use of gastropexy alone as treatment (p > 0.05). With a formal PEH repair, there was no difference in rate or timing of recurrence.ConclusionsEmergent patients are more likely to suffer complications, require ICU care, have a higher mortality, and an increased likelihood of reoperation. A graduated increase in HSV increasingly predicts the need for an emergent operation. Those patients presenting electively with a large PEH may benefit from early elective surgery.

Validation of a simple technique of volumetric analysis of complex incisional hernias without 3D CT scan reconstruction.

Volumetric analysis is being increasingly utilized in the preoperative evaluation of complex incisional hernias. Three-dimensional (3D) reconstruction of abdominal computed tomography (CT) scan has been used to obtain surface area (SA) and volume (Vol.) measurements, while others have used simple mathematical formulas to obtain SA and Vol. estimates without 3D reconstruction. Our objective was to assess the correlation of SA and Vol. measurements and estimates of complex incisional hernias. We conducted a retrospective agreement study of adults who underwent abdominal wall reconstruction from 2007 to 2018. Demographics, hernia characteristics, and operative data were collected from the medical record. SA and Vol. measurements were obtained after 3D CT reconstruction. Linear CT variables were obtained independently by two surgeons and SA and Vol. estimates were calculated. Because both surgeons reported similar results, only lead author values are reported in the abstract. We used Pearson's correlation coefficient (r) to assess inter-rater agreement and the agreement between SA and Vol. measurements and estimates. A total of 108 patients were eligible for analysis. The mean age was 57 ± 11years and 53 (49%) were female. 42 (39%) hernias were recurrent, 10 (9%) patients had a stoma, and 9 (8%) had a history of open abdomen. The mean defect width was 11 ± 4cm and mean defect surface area (DSA) was 150 ± 95cm2. Inter-rater agreement of SA and Vol. estimates was high (r ≥ 0.80). There was high correlation between SA and Vol. measurements and estimates for DSA, hernia sac volume (HSV), abdominal cavity volume (ACV), and HSV/ACV ratio (r = 0.81, 0.89, 0.94 and 0.91, respectively). SA and Vol. estimates demonstrated high level of agreement with SA and Vol. measurements using 3D reconstruction. SA and Vol. estimates can be obtained using simple mathematical formulas using easily obtained linear variables negating the need for the time and effort consuming 3D reconstruction.

Hernia sac volume is important in predicting difficulty in ventral hernia surgery

Hernia sac volume is important in predicting difficulty in ventral hernia surgery

MDCT imaging in Spigelian hernia, clinical, and surgical implications

ObjectiveSpigelian hernia is an uncommon congenital or acquired defect in the transversus abdominis aponeurosis with non-specific symptoms posing a diagnostic challenge. There is a paucity of radiology literature on imaging findings of Spigelian hernia. The objective of this study is to explore the role of MDCT in evaluating Spigelian hernia along with clinical and surgical implications. Materials and methodsIn this IRB approved, HIPAA compliant retrospective observational analysis MDCT imaging findings of 43 Spigelian hernias were evaluated by two fellowship-trained radiologists. Imaging features evaluated were: presence of Spigelian hernia, laterality, relation to “hernia belt” (between 0 and 6 cm cranial to an imaginary axial line between both anterior superior iliac spines), the hernia neck and sac sizes, hernia content, and other coexistent hernias (umbilical, incisional, inguinal). Patient's demographics (age, gender, BMI, conditions with increased intra-abdominal pressure) were also recorded for any correlation. Results60% (26/43) of Spigelian hernias were located below the hernia belt while 33% (14/43) within the hernia belt and 7% (3/43) above the hernia belt. The most common subtype of Spigelian hernia encountered was interparietal (84%). The mean hernia neck diameter was 3.4 cm, mean hernia sac volume was 329 cc. Hernia content included: fat (43/43) bowel (23/43), fluid (3/43). 3 patients had no clinical history provided, the remaining 37 patients' clinical presentation was asymptomatic in 73% (27/37), acute abdominal pain in 5% (2/37) and chronic abdominal pain in 22% (8/37). None of the hernia were incarcerated and none of the patients underwent emergent surgery. No significant correlation was noted between Spigelian hernia and causes of increased intra-abdominal pressure. 90% of our patients had other abdominal hernias. 30.9 was the mean BMI (20.8–69.1). ConclusionMost of the Spigelian hernia occurred below the traditionally described hernia belt and the majority are of interparietal subtype that can be best diagnosed with MDCT in contrast to physical examination.

The Effects of Preoperative Botulinum Toxin A Injection on Abdominal Wall Reconstruction

BackgroundFascial closure significantly reduces postoperative complications and hernia recurrence after abdominal wall reconstruction (AWR), but can be challenging in massive ventral hernias. MethodsA prospective single-institution cohort study was performed to examine the effects of preoperative injection of botulinum toxin A (BTA) in patients undergoing AWR for midline or flank hernias. ResultsA total of 108 patients underwent BTA injection with average 243 units, mean 32.5 days before AWR, without complications. Comorbidities included diabetes (31%), history of smoking (27%), and obesity (mean body mass index 30.5 ± 7.7). Hernias were recurrent in 57%, massive (mean defect width 15.3 ± 5.5 cm; hernia sac volume 2154 ± 3251 cm3) and had significant loss of domain (mean 46% visceral volume outside abdominal cavity). Contamination was present in 38% of patients. Fascial closure was achieved in 91%, with 57% requiring component separation techniques (CSTs). Subxiphoidal hernias needed a form of CST in 88% compared with 50% for hernia not extending subxiphoidal (P < 0.001). Mesh augmentation was used in 98%. Postoperative complications occurred in 40%: 19% surgical site occurrences, 12% surgical site infections, and 7% respiratory failure requiring intubation, 2% mesh infection and no fascial dehiscence. Recurrence was identified in seven patients after mean 14 months of follow-up. Patients undergoing AWR with CST had more surgical site occurrences (29 versus 7%, p0.003) and respiratory failures (18 versus 0%, P = 0.002) than patients who did not require CST. ConclusionsIn patients with massive ventral hernias, the use of preoperative BTA injections for AWR is safe and is associated with high fascial closure rates and excellent recurrence rates.

Long-term results of botulinum toxin type A in complex abdominal wall repair and review of the literature.

Administration of botulinum toxin (BTX) is being used in cases of complex ventral hernia for the reconstruction of the linea alba and closure of the abdominal wall. However, there are no published results regarding the long-term effects of BTX and its implication in hernia recurrence. Our purpose is to evaluate the outcomes in hernia recurrence of the administration of BTX in complex ventral hernia repair. 36 patients underwent elective surgery for complex ventral hernia and were evaluated retrospectively. The study included patients with a transverse hernia defect ≥ 100mm and loss of domain hernias, receiving BTX injections 6weeks prior to elective surgery. Global results and long-term recurrence were analysed. There were no complications related to BTX administration. The mean transverse hernia defect was 139.44 ± 50.98mm, the mean abdominal cavity volume (ACV) was 10.19 ± 3.33dm3, the mean hernia sac volume (HSV) was 1.93 ± 1.79dm3, presenting a mean volume ratio (VR) of 20.71 ± 19.76%. Primary closure was achieved in 28 patients (77.8%), 21 of whom (75%) needed an anterior component separation technique. Recurrence rate was 11.4% at 2-years follow-up. BTX administration is a safe and feasible method for abdominal wall expansion prior to complex incisional hernia repair, achieving high rates of primary closure. Long-term follow-up shows good results in terms of recurrence in these patients.

Right Colectomy with Absorbable Mesh Repair as a Salvage Solution for the Management of Giant Incisional Hernia with Loss of Domain: Results of a Bicentric Study.

Incisional hernia (IH) may occur in 20% of patients after laparotomy. The hernia sac volume may be of significance, with reintegration of visceral contents potentially leading to repair failure or abdominal compartment syndrome. The present study aimed to evaluate a two-step surgical strategy comprising right colectomy for hernia reduction with synchronous absorbable mesh repair followed by definitive non-absorbable mesh repair in recurrence. Patients operated between 2012 and 2017 at two university centers were retrospectively included. Volumetric evaluation of the IH was performed by CT imaging. Eleven patients were included. The mean BMI was 43kg/m2 (23-52kg/m2). Progressive preoperative pneumoperitoneum was performed in 82% of patients, with complications in 22%. The mean volumetric ratio of the volume of the hernia to the volume of the abdominal cavity was 70% (48-100%). The first parietal repair was performed using an synthetic absorbable mesh (36%), a biologic mesh (27%), or a slowly absorbable mesh (36%). No patients died as a result of the procedure. Seven (64%) patients developed grade III-IV complications, including one case of an anastomotic fistula. Recurrence occurred in eight (73%) patients after the first repair. Of these, four (50%) patients were reoperated using a non-absorbable mesh, leading to solid repair in 75% of cases. After 27 ± 18months of follow-up, the residual IH rate was 46%. Right colectomy for volume reduction in IH with loss of domain potentially represents an appropriate salvage option, supporting bowel reintegration and temporary hernia repair with absorbable material.

Is transversus abdominis muscle release sustainable for the reconstruction of peritoneal volumes? A retrospective computed tomography study

BACKGROUND: Incisional hernia (IH) is the most frequent complication of laparotomy with an increasing incidence over time. A large amount of them present in complex forms with large defects or even loss of domain. There is still no consensus regarding the optimal surgical approach for this IHs. The posterior component separation with transversus abdominis release (TAR) alone or in combination with augmentation of the abdominal wall became the standard of repair in large IHs (LIH). No clear evidence that TAR alone can recreate the normal volume of the peritoneal cavity is available. We assessed if it is possible to reconstruct normal peritoneal volume (PV) by TAR. MATERIALS AND METHODS: In this retrospective study, data from LIH patients with midline defects equal or larger than 10 cm width, and computed tomography scans available before and 1-week after TAR with complete fascial closure were analyzed. Hernia sac volume (HSV), abdominal cavity volume (ACV), and (PV = HSV + ACV) were evaluated before surgery. Peritoneal index (PI) was calculated as HSV/PV ratio. PV was measured at 7 days post-TAR (PVTAR). The compliance of the abdominal wall (Cab) was calculated as the ratio between the difference of the PV before surgery and after TAR and the difference between preoperative intra-abdominal pressure (IAP) and postoperative IAP. RESULTS: 23 consecutive patients with a mean age of 64 years were included in the study. The mean value of the HSV was 3,775 cm3 and of the ACV 8377 cm3. PI varied between 0.22 and 0.4. A statistically insignificant difference was recorded between PV and PVTAR(P = 0.7). Patients with PI ≥0.3 had the volume of the peritoneal cavity lesser than patients with PI CONCLUSIONS: TAR is able to recreate normal PV in LIH patients with PI

Effects of CT examination in different body positions on the evaluation of abdominal incisional hernia volume

Objective To investigate the effects of computed tomography (CT) examination in different body positions on the evaluation of abdominal incisional hernia volume. Methods The retrospective case-control study was conducted. The clinical data of 23 patients with abdominal incisional hernia who were admitted to the Sixth Affiliated Hospital of Sun Yat-sen University from February to September in 2017 were collected. There were 14 males and 9 females, aged from 47 to 75 years, with an average age of 63 years. All patients underwent CT scan in supine position and lateral position. The volume of hernia sac, abdominal cavity and the volume ratio of hernia sac to abdominal cavity in different body positions were measured by multi-planar reconstruction and volume reappearance on the workstation. Observation indicators: (1) situations of CT examination of patients with abdominal incisional hernia in different positions; (2) correlation analysis of volume ratio increment of hernia sac to abdominal cavity between different positions by CT examination in patients with abdominal incisional hernia. Measurement data with normal distribution were expressed as Mean±SD, and comparison between groups was performed using the pared t test. Count data were expressed as absolute numbers or percentages. Pearson correlation was used to analyze the volume ratio increment of hernia sac to abdominal cavity between different positions by CT examination in patients with abdominal incisional hernia. Results (1) Situations of CT examination of patients with abdominal incisional hernia in different positions: CT examination of 23 patients with abdominal incisional hernia showed that the contents of hernia increased and the abdominal wall deformed in the lateral position compared with conventional supine position, with manifestations as shortened abdominal transverse diameter and longer vertical diameter. The volume of the hernia sac in supine position and in lateral position by CT examination was (623±293)mL and (869±425)mL, respectively, showing a significant difference (t=-7.959, P<0.05). The volume of abdominal cavity in supine position and in lateral position by CT examination was (6 445±1 438)mL and (6 283±1 348)mL, respectively, showing a significant difference (t=2.762, P<0.05). The volume ratio of hernia sac to abdominal cavity in supine position and in lateral position by CT examination was 0.096±0.040 and 0.138±0.061, showing a significant difference (t=-8.093, P<0.05). The volume ratio of hernia sac to abdominal cavity in lateral position increased by 0.042 compared with that in supine position, with an increasing rate of 43.8%. All the 23 patients had volume ratio of hernia sac to abdominal cavity less than 20% in supine position by CT examination, however, 4 patients had volume ratio of hernia sac to abdominal cavity more than 20% in lateral position by CT examination. (2) Correlation analysis of volume ratio increment of hernia sac to abdominal cavity between different positions by CT examination in patients with abdominal incisional hernia: results of Pearson correlation analysis showed a positive correlation of volume ratio of hernia sac to abdominal cavity between supine position and lateral position by CT examination (r=0.742, P<0.05). Conclusions The volume of incisional hernia is influenced by different body positions. Compared with supine position, lateral position by CT examination has a more accurate reflection of abdominal incisional hernia. Key words: Hernia; Incisional hernia; Body position; Computed tomography, X-ray; Hernia sac volume; Abdominal cavity volume; Volume ratio

CT Abdomen with Valsalva's Maneuver Facilitates Grip-Based Incisional Hernia Repair

Background: Grip-based incisional hernia repair needs the accurate determination of the hernia defect area and of the distensibility of the hernia area. Both parameters can be derived using computerized tomography of the abdomen at rest and during Valsalva’s maneuver. The two existing ways of1 analysis are compared for the first time on ten patients. Methods: Consecutive patients scheduled for repair of incisional hernia were included. The indication for the CT scan of the abdomen was the clinical uncertainty about the area of instability of the abdominal wall. The scans were evaluated by five different observers (technician, radiologist, surgeons) using two different ways previously reported in the literature. Results: In all ten patients, new information was generated significantly changing the incisional hernia repair. Both evaluation methods yielded the same results in principal with one being more consistent. Further analysis of the latter method demonstrated both inter-observed and intra-observed variations. After 12 observations, the variation was below 5 % even in the most unstable abdominal walls. The hernia defect area increased upon elevation of the intraabdominal pressure with the hernia sac volume widening up to fivefold. Conclusions: Grip-based incisional hernia repair critically depends on the mesh: defect area ratio and on the distensibility of the abdominal wall. Both parameters can be reliably assessed using 4 computerized tomography of the abdomen at rest and with Valsalva’s maneuver. The application of intravenous contrast can be omitted for the acquisition of data.

Use of computed tomography volumetric measurements to predict operative techniques in paraesophageal hernia repair.

Despite advances in diagnostic imaging capabilities, little information exists concerning the impact of physical dimensions of a paraesophageal hernia (PEH) on intraoperative decision making. The authors hypothesized that computerized volumetric analysis and multidimensional visualization to measure hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) would correlate to operative findings and required surgical techniques performed. Using volumetric analysis software (Aquarius iNtuition, TeraRecon, Inc), HDA and HSV were measured in PEH patients with preoperative computerized tomography (CT) scans, and used to predict the likelihood of intraoperative variables. Multidimensional rotation of images enabled visualization of the entire hiatal defect in a plane mimicking the surgeon's view during repair. The intrathoracic hernia sac was outlined producing volume measurements based on a summation of exact dimensions. A total of 213 PEHR patients had preoperative CT imaging, with 14.1% performed emergently. Primary cruroplasty was performed in 89.2%, salvage gastropexy in 10.3%, and diaphragmatic relaxing incisions in 4.2%. Median HDA was 25.7cm2 (IQR17.8-35.6cm2); median HSV was 365.0cm3 (IQR150.0-611.0cm3). Incremental 5cm2 increase in HDA was associated with greater likelihood of presenting emergently (OR 1.27; 95%CI 1.124-1.428, p = 0.0001), incarceration (OR 1.27; 1.074-1.499, p = 0.005), gastric volvulus (OR 1.13; 1.021-1.248, p = 0.02), and requiring either relaxing incision (OR 1.43; 1.203-1.709, p < 0.0001) or salvage gastropexy (OR 1.13; 1.001-1.274, p = 0.04). Similarly, HSV increases of 100cm3 were associated with 23% greater likelihood of emergent repair (CI 1.121-1.353, p < 0.0001), and were more likely to require a relaxing incision (OR 1.18; 1.043-1.339, p = 0.009) or salvage gastropexy (1.19; 1.083-1.312, p = 0.0003). Utilization of CT volumetric measurements is a valuable adjunct in preoperative planning, allowing the surgeon to anticipate complexity of repair and operative approach, as incremental increases in HSV by 100cm3 and HDA by 5cm2 are more likely to require complex techniques or bailout procedures and/or present emergently.

Large Incisional Hernias Increase in Size

BackgroundPatients with an incisional hernia often wait a significant period of time from the first referral to hernia surgery because of waiting lists, watchful waiting, or the need for preoperative optimization. It is unknown if hernia dimensions or patient-reported symptoms increase during this period. The aim of the study was to examine if incisional hernias increase in size during the time from initial assessment to surgical repair. Materials and methodsA prospective controlled trial was performed on patients referred to a regional hernia center for repair of an incisional hernia with a transverse fascial defect of >7 cm. All patients underwent computed tomography scans and answered the Hernia-Related Quality of Life Score questionnaire and International Physical Activity Questionnaire at first assessment and again 30 ± 2 wk later or immediately before hernia repair. Changes in fascial defect sizes and hernia sac volume were assessed along with the patient-reported outcomes. ResultsA total of 35 patients were included. The median fascial defect area increased from 117.3 cm2 (interquartile range 46.5-181.2) to 150.4 cm2 (62.5-199.0), P < 0.001, and the median hernia sac volume increased from 5.11 L (2.28-8.09) to 6.25 L (3.03-10.38), P < 0.001. There were no significant changes in the patient-reported outcomes. ConclusionsIncisional hernias expand during the period from the first assessment to actual hernia repair.