Value of CT after laparoscopic repair of postsurgical ventral hernia

Conflict resolution of the beams: CT vs. MRI in recurrent hernia detection: a systematic review and meta-analysis of mesh visualization and other outcomes

BACKGROUND

Recurrent abdominal hernias remain a significant clinical challenge, with relatively high recurrence rates despite prosthetic mesh repair. Accurate imaging modalities are essential to assess mesh positioning and detect complications. Our study aims to compare computed tomography (CT) and magnetic resonance imaging (MRI) for mesh visualization, recurrence detection, and related postoperative outcomes in recurrent hernia patients.

METHODS

A systematic review and meta-analysis were conducted, including CT scan or MRI studies, to assess mesh visualization in recurrent hernia cases. A comprehensive search of PubMed, Scopus, Embase, and Web of Science was performed up to July 2024. Data were extracted for mesh visualization, recurrence rates, seroma detection, and reoperation rates. Statistical analysis employed a random-effects model with subgroup analysis for CT and MRI modalities.

RESULTS

A total of 26 studies were included (18 for CT, and 8 for MRI). Recurrence rates were 20% (95% CI: 0-42%) for CT-based studies and 15% (95% CI: 4-26%) for MRI-based studies (p = 0.72). MRI exhibited superior mesh visualization (73%; 95% CI: 42-100%) compared to CT-(48%; 95% CI: 0-100%) (p = 0.44) studies. Seroma detection rates were similar: 12% (95% CI: 4-19%) for CT- and 10% (95% CI: 4-15%) for MRI- (p = 0.65) studies. Reoperation rates were 6% (95% CI: 1-11%) for CT- and 34% (95% CI: 3-66%) for MRI-based studies, showing a non-significant trend (p = 0.08).

CONCLUSION

CT and MRI offer distinct advantages in detecting mesh-related complications after hernia surgery. CT remains preferred for identifying recurrence and acute complications, while MRI excels in mesh visualization and soft-tissue assessment. Tailored imaging strategies based on clinical scenarios can optimize outcomes and improve postoperative care.

INCISIONAL HERNIA AFTER BARIATRIC SURGERY: ONLY THE PHYSICAL EXAMINATION IS ENOUGH?

BACKGROUND:

Incisional hernia is characterized by a bulging of the abdominal wall caused by the prolapse of intracavitary structures, such as a segment of the small intestine, through the trocar orifice. Ultrasonography and physical examination are used in the diagnosis of incisional hernia.

AIMS:

This study aimed to evaluate the difference between physical examination and abdominal ultrasonography at the diagnosis of incisional hernia in patients who underwent laparoscopic bariatric surgery.

METHODS:

A total of 123 patients who underwent Roux-en-Y gastric bypass type bariatric surgery performed by laparoscopy were analyzed for the presence or absence of hernia by physical and ultrasonography examination at each trocar incision site.

RESULTS:

In our results, a total of 7 hernias were detected by physical examination, while ultrasonography detected a total of 56 hernias in at least one of the incision sites. Lin's concordance analysis showed that the tests are not concordant. The association between body mass index and hernia detection (p=0.04 for physical examination and p=0.052 for ultrasonography) was observed. Ultrasonography detected more incisional hernias in 10-mm or larger trocars than in 5-mm trocars (p<0.0001, p<0.05). No differences were noted among the trocar types that were used.

CONCLUSIONS:

Abdominal ultrasonography showed to have a higher accuracy than physical examination, resulting in a substantial increase in incisional hernia detection at the trocar sites.

Pre- and postsurgical imaging findings of abdominal wall hernias based on the European Hernia Society (EHS) classification

Abdominal wall hernias are common and can present as technical challenges to surgeons. When large, hernias diminish quality of life. Various classifications of incisional hernias have been proposed; however, there are many terms, sometimes causing confusion (1). Radiologists must know the normal anatomy of the abdominal wall, the CT protocol, and what if any maneuvers can be performed to better identify an abdominal wall defect. The description of the radiological approach for primary and incisional wall hernias is based on the 2007 European Hernia Society classification, with particular emphasis on presurgical and postsurgical imaging findings. This classification provides a simple and reproducible method to describe hernias to offer proper surgical management. We highlight this classification so that radiologists and surgeons can have a unified language.

A new technique for the 3D reconstruction of the incisional hernia: A pilot study

PURPOSE

This study aimed to accurately evaluate incisional hernias with a new three-dimensional (3D) reconstruction technology, proving surgeons more information for intuitive and accurate judgments about incisional hernia to minimize the perioperative complications and recurrence rate.

METHOD

This was a pilot study using a new technique, 3D reconstruction, based on computed tomography (CT) scans to measure abdominal wall defect, herniary area, herniary volume, abdominal cavity volume, and the volume of transverse, oblique, and recti abdominis in three patients with incisional hernias.

RESULTS

The 3D reconstruction technique made automated segmentation of the bony skeleton, skin, outer abdominal wall, vessel, and hernia sac. The hernia sac, abdominal muscles, and their anatomic relationship were clearly illustrated in 3D reconstruction images. Moreover, abdominal cavity volume; herniary diameter, area, and volume; and the volume of transverse, oblique, and recti muscles could be evaluated through 3D reconstruction images. Surgeons can also freely combine, rotate, scale, and move the 3D reconstruction mode, modify the name and transparency of the 3D reconstruction model, and observe the internal structure of the tissue and the size, shape, and location of the lesion from multiple angles for better and accurate judgments.

CONCLUSION

The herniary diameter, area, and volume and the volume of transverse, oblique, and recti abdominis can be accurately calculated through this 3D reconstruction technology. A three-dimensional vision of the abdomen through this technology can objectively and quantitatively evaluate the situation of incisional hernia, providing a more realistic means for diagnosis and treatment of incisional hernias.

Mesh expansion as the cause of bulging after abdominal wall hernia repair

•

Swelling of the abdominal wall after abdominal wall reconstruction can be caused by a recurrence or bulging of the mesh.

•

CT-scan can be useful to distinguish between a true recurrence or bulging of the mesh.

•

Bulging of a mesh can be caused by pore enlargement and expansion of the mesh.

•

The distinction between a recurrence and bulging of the mesh is therapeutically irrelevant in symptomatic patients.

•

Mesh characteristics should be considered when choosing a feasible and suitable mesh for abdominal wall reconstruction.

Background

Recurrence is the most important complication of abdominal wall reconstruction. It is possible the repair itself is intact, but bulging or expansion of mesh causes recurrent swelling’s of the abdominal wall.

Case summary

In this report, we present bulging of a polyester mesh due to central pore expansion.

Discussion

Repetitive stress and variations in intra-abdominal pressure can change tensile strength and stretches mesh materials.

Conclusion

A swelling after abdominal wall repair can be caused by bulging of the mesh. A progressive bulging might be the result of failure of the mesh implant due to elongation. Mesh characteristics should be considered when choosing a feasible and suitable mesh for abdominal wall reconstruction. Clinical distinction between recurrent hernia and mesh bulging is difficult but therapeutically irrelevant in symptomatic patients.

Multidetector CT of expected findings and early postoperative complications after current techniques for ventral hernia repair

Current techniques for ventral hernia repair (VHR) rely on prosthetic mesh implantation and are increasingly performed laparoscopically. Potentially serious iatrogenic complications may occur following VHR, though these are rare compared to the vast number of procedures performed each year. This paper provides an overview of contemporary open and laparoscopic surgical techniques and biomaterials, then reviews and illustrates the expected postoperative imaging appearances, and common and unusual early complications after VHR. Emphasis is placed on multidetector computed tomography (CT), which comprehensively visualizes the operated anterior abdominal wall and deeper intra-abdominal structures. CT consistently allows diagnosis of postoperative seromas, abdominal wall abscesses and fistulas, haemorrhages with or without active bleeding, bowel obstruction, peritonitis and recurrent hernias, and thus providing a reliable basis for an appropriate choice between conservative, interventional, or surgical treatment. Familiarity with early post-surgical CT is warranted to avoid misinterpretation of the expected imaging appearance and correctly elucidate postoperative complications after VHR.

TEACHING POINTS

• Open and laparoscopic repair of ventral hernias rely on prosthetic mesh implantation. • Potentially serious iatrogenic complications occasionally occur after ventral hernioplasty. • Multidetector CT consistently evaluates the operated abdominal wall and deeper structures. • Familiarity with the expected early postoperative imaging appearance is required. • Complications include seroma, infections, haemorrhage, bowel obstruction, peritonitis, and recurrence.

Detection of recurrent hernia and intraabdominal adhesions following incisional hernia repair: a functional cine MRI-study

BACKGROUND

To non-invasively identify incisional hernia repair implanted synthetic meshes with MRI, and also focusing on the evaluation of postsurgical complications such as adhesions.

METHODS

A total of 43 patients underwent either laparoscopic intraperitoneal onlay-mesh or open abdominal wall repair using preperitoneal layers. The patients were examined using a true-fast-imaging-with-steady-state-precession (trueFISP)-sequence in transverse/sagittal orientation with a section-by-section dynamic depiction of induced visceral slide. A 9-segment-abdominal-map was used to document the adhesion location/type. The MR-images were analysed regarding hernia relapse, layer-morphology, rectus-abdominis muscle-condition, and abdominal wall mobility. In 12 patients pre- and postsurgery-MRI was performed.

RESULTS

Time range between surgery and examination was 6-36 months. In all laparoscopy-patients the meshes were identified. For open surgery the mesh was not visualized in 20, but was seen in 6 cases. A total of 11 cases showed a recurrent hernia. Seventy intraabdominal adhesions were detected. Fifteen patients had restricted mobility. 20 patients showed an rectus-abdominis-muscle-asymmetry. Comparing pre- and post-op-MRI, 6 out of 8 patients with open repair showed thick scar-plaques. Three patients with open repair had new adhesion-formations postoperatively.

CONCLUSION

Functional cine MRI is suitable for follow-up studies in patients after hernia repair to detect and evaluate the implanted meshes. Typical complications like intestinal adhesions and abdominal wall dysmotility can be assessed as well.

Functional cine MRI of the abdomen for the assessment of implanted synthetic mesh in patients after incisional hernia repair: initial results

The aim of our study was to develop a method that allows the visualisation and evaluation of implanted mesh in patients after incisional hernia repair with MRI. Furthermore, we assessed problems typically related with mesh implantation like adhesions and muscular atrophy. We enrolled 28 patients after incisional hernia repair. In 10 patients mesh implantation was done by laparoscopy (expanded polytetrafluoroethylene=ePTFE mesh) and in 18 by laparotomy (polypropylene mesh). Functional MRI was performed on a 1.5-T system in supine position. Sagittal and axial TrueFISP images of the entire abdomen were acquired with the patient repeatedly straining. Evaluation included: correct position and intact fixation of the mesh, furthermore visceral adhesions, recurrent hernia and atrophy of the rectus muscle. The ePTFE mesh was visible in all cases; the polypropylene mesh was not detectable. In seven of the ten ePTFE meshes the fixation was not intact; two recurrent hernias were detected. Twenty of 28 patients had intraabdominal adhesions. In 5 cases mobility of the abdominal wall was reduced, and 16 patients showed an atropy of the rectus muscle. Functional cine MRI is a suitable method for follow-up studies in patients after hernia repair. ePTFE meshes can be visualized directly, and typical complications like intestinal adhesions and abdominal wall dysmotility can be assessed reliably.

Abdominal Wall Hernias: Imaging Features, Complications, and Diagnostic Pitfalls at Multi–Detector Row CT

Abdominal wall hernias are a common imaging finding in the abdomen and may be complicated by strangulation, incarceration, or trauma. Because of the risk of developing complications, most abdominal wall hernias are surgically repaired, even if asymptomatic. However, post-surgical complications are also common and include hernia recurrence, infected and noninfected fluid collections, and complications related to prosthetic material. Multi-detector row computed tomography (CT) with its multiplanar capabilities is particularly useful for the evaluation of unrepaired and surgically repaired abdominal wall hernias. Multi-detector row CT provides exquisite anatomic detail of the abdominal wall, thereby allowing accurate identification of wall hernias and their contents, differentiation of hernias from other abdominal masses (tumors, hematomas, abscesses), and detection of pre- or postoperative complications. These findings improve the communication of imaging results to clinicians and help optimize treatment planning. Knowledge of multi-detector row CT findings in unrepaired and surgically repaired abdominal wall hernias and their complications is essential for making the correct diagnosis and may help guide clinical management.

Laparoscopic ventral hernia repair with the Goretex Dualmesh: long-term results and review of the literature

Since 1993 laparoscopy has become a popular technique of repair of ventral hernias. The authors review the long-term results of a systematic laparoscopic repair of ventral hernias and discuss the current problems compared to open repair. Between 1997 and 2003, 146 patients had a laparoscopic ventral hernia repair using an intraperitoneal Goretex Dualmesh with a 3-5-cm mesh overlap secured with a combination of nonabsorbable sutures and staples. A total of 155 attempts of laparoscopic repair was performed with four conversions. The 151 laparoscopic operations were completed in 105.8 min with a mesh implant being of 341 cm(2). There were two postoperative deaths and two patients had to be reoperated on. Mesh infection was diagnosed in two cases. Mean length of stay was 4.9 days. During a follow- up of 26.6 months eight patients (5.8%) developed a recurrence. Laparoscopic ventral hernia repair is a reproducible technique. Most of the comparative studies have shown an overall lower rate of complications after laparoscopic repair compared to open but with a 2-4% risk of bowel injury. The two other benefits of the laparoscopy are reduced postoperative pain and shorter hospital stay. The recurrence rate is usually between 2 and 7% but no difference has been found compared to open repair. Laparoscopic ventral hernia repair using the Goretex Dualmesh is a reliable operation with a low rate of conversion to open. Despite the risk of serious bowel injury, laparoscopy achieves as good results as the mesh open repair on the long term with the benefit of a decreased complication rate and a shorter hospital stay.

Recurrences after laparoscopic ventral hernia repair: results and critical review

We describe the whole cohort of patients operated on laparoscopically for ventral hernias at our institution. Information on early results, complications, and long-term follow-up was collected prospectively. Of 90 operations attempted, five (5.8%) required conversion. Of the remaining 85 patients, 65 (76%) had an incisional hernia, while 20 (24%) had primary defects. Three trocars were routinely employed (Hasson and two 5-mm). The prosthetic mesh used was ePTFE inserted through the first trocar and fixed using helicoidal staplers. Patients were periodically followed in the outpatient clinic for at least 12 months postoperatively and contacted at the time of this review. Mean operative time was 101 min. We had three small bowel injuries repaired laparoscopically. Postoperative pain was limited. Bowel movements, deambulation, and discharge were prompt. We had six (7%) urinary retentions, eight (9%) seromas, three (3.5%) cases of pneumonia, two (2%) cases of postoperative vomiting, and one (1%) prolonged ileus, which resolved spontaneously on postoperative day 2. Mean postoperative stay was 4 days. One patient was readmitted after 4 weeks with incomplete obstruction, resolved conservatively. There were three recurrences (3.5%), which developed within 1 year of the operation, and a trocar-site herniation (1%). The technique appears safe and efficacious.