Computed Tomography in Diagnosing Ventral Hernia Recurrence
7. Baucom RB, Beck WC, Holzman MD, Sharp KW, Nealon WH, Poulose BK. The importance of surgeon-reviewed computed tomography for incisional hernia detection: a prospective study. Am Surg. 2014;80(7):720-722. 8. Fitzgibbons RJ Jr, Ramanan B, Arya S, et al; Investigators of the Original Trial. Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg. 2013;258 (3):508-515. 9. O’Dwyer PJ, Norrie J, Alani A, Walker A, Duffy F, Horgan P. Observation or operation for patients with an asymptomatic inguinal hernia: a randomized clinical trial. Ann Surg. 2006;244(2): 167-173. 10. Li LT, Jafrani RJ, Becker NS, et al. Outcomes of acute versus elective primary ventral hernia repair. J Trauma Acute Care Surg. 2014;76(2):523-528.
Original Investigation Research
16. Cohen J. A Coefficient of agreement for nominal scales. Educ Psychol Meas. 1960;20(1): 37-46. doi:10.1177/001316446002000104.
appendicitis: definitive or detrimental? J Gastrointest Surg. 2007;11(11):1417-1421; discussion 1421-1422.
17. McGinn T, Wyer PC, Newman TB, et al. Tips for learners of evidence-based medicine: 3, measures of observer variability (kappa statistic). CMAJ. 2004;171(11):1369-1373.
26. Markar SR, Karthikesalingam A, Cunningham J, Burd C, Bond-Smith G, Kurzawinski TR. Increased use of pre-operative imaging and laparoscopy has no impact on clinical outcomes in patients undergoing appendicectomy. Ann R Coll Surg Engl. 2011;93(8):620-623.
18. Viera AJ, Garrett JM. Understanding interobserver agreement: the kappa statistic. Fam Med. 2005;37(5):360-363. 19. Corbin J, Strauss A. Grounded theory research: procedures, canons, and evaluative criteria. Qual Sociol. 1990;13(1):3-21. 20. Morse JM, Field PA. Qualitative Research Methods for Health Professionals. 2nd ed. Thousand Oaks, CA: Sage Publications; 1995.
27. Ah-Kee EY, Kallachil T, O’Dwyer PJ. Patient awareness and symptoms from an incisional hernia. Int Surg. 2014;99(3):241-246. 28. Bellows CF, Robinson C, Fitzgibbons RJ, Webber LS, Berger DH. Watchful waiting for ventral hernias: a longitudinal study. Am Surg. 2014;80(3): 245-252. 29. Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg. 1985;72(1):70-71.
11. Beadles CA, Meagher AD, Charles AG. Trends in emergent hernia repair in the United States. JAMA Surg. 2015;150(3):194-200.
21. Baucom RB, Beck WC, Phillips SE, et al. Comparative evaluation of dynamic abdominal sonography for hernia and computed tomography for characterization of incisional hernia [published online May 28, 2014]. JAMA Surg. doi:10.1001 /jamasurg.2014.36.
12. Berger RL, Li LT, Hicks SC, Davila JA, Kao LS, Liang MK. Development and validation of a risk-stratification score for surgical site occurrence and surgical site infection after open ventral hernia repair. J Am Coll Surg. 2013;217(6):974-982.
22. Harlaar JJ, Deerenberg EB, van Ramshorst GH, et al. A multicenter randomized controlled trial evaluating the effect of small stitches on the incidence of incisional hernia in midline incisions. BMC Surg. 2011;11:20.
31. Eid GM, Wikiel KJ, Entabi F, Saleem M. Ventral hernias in morbidly obese patients: a suggested algorithm for operative repair. Obes Surg. 2013;23 (5):703-709.
13. Liang MK, Goodenough CJ, Martindale RG, Roth JS, Kao LS. External validation of the ventral hernia risk score for prediction of surgical site infections. Surg Infect (Larchmt). 2015;16(1):36-40.
23. Malangoni MA, Rosen MJ. Hernias. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Elsevier Saunders; 2012: 1128.
32. Liu NW, Hackney JT, Gellhaus PT, et al. Incidence and risk factors of parastomal hernia in patients undergoing radical cystectomy and ileal conduit diversion. J Urol. 2014;191(5):1313-1318.
14. National Surgical Quality Improvement Program. http://site.acsnsqip.org/. Accessed March 26, 2015.
24. Harvey SC, Vegesna A, Mass S, Clarke J, Skoufalos A. Understanding patient options, utilization patterns, and burdens associated with breast cancer screening. J Womens Health (Larchmt). 2014;23(suppl 1):S3-S9.
33. Holihan JL, Alawadi Z, Martindale RG, et al. Adverse events after ventral hernia repair: the vicious cycle of complications. J Am Coll Surg. 2015; 221(2):478-485.
15. Muysoms FE, Miserez M, Berrevoet F, et al. Classification of primary and incisional abdominal wall hernias. Hernia. 2009;13(4):407-414.
30. Cevese PG, D'Amico DF, Biasiato R, et al. Peristomal hernia following end-colostomy: a conservative approach. Ital J Surg Sci. 1984;14(3): 207-209.
25. Musunuru S, Chen H, Rikkers LF, Weber SM. Computed tomography in the diagnosis of acute
Invited Commentary
Computed Tomographic Imaging in the Diagnosis of Recurrent Ventral Hernia Melissa Anne Mallory, MD; Stanley W. Ashley, MD
Ventral hernias (VHs) are common in the United States, with more than 350 000 repairs performed annually.1 Nevertheless, consensus regarding the optimal technique for VH repair is lacking and recurrence rates remain high (approaching 50% in some series), suggesting we are not quite ready to close the book on VH management. Considerable debate persists in VH management, particularly in cases of recurrence. Although the treatment of symptomatic recurrence detected on physical examination is usually surgical repair, management dilemmas arise for Related article page 7 symptomatic patients without palpable hernias and asymptomatic patients with detectable hernias. In these settings, computed tomography (CT) as an adjunct to physical examination may be beneficial. Although data suggest CT may jamasurgery.com
be superior to examination, especially for obese patients or small hernias, no standardized criteria for diagnosis of recurrent herniation exist.2,3 In this month’s JAMA Surgery, Holihan et al2 address the value of CT by examining its reliability for detecting VH recurrence in 100 patients who received CT scans following VH repair. Because most patients were never subsequently explored, the accuracy of CT could not be fully assessed. Therefore, the authors examined the interobserver reliability of 6 radiologists and 3 surgeon reviewers. When reviewers were blinded to symptoms, physical examination, and details of the previous repair, discordance regarding CT interpretation existed in 73% of cases. This result is striking, although not unexpected in the absence of standardized diagnostic criteria. Although identifying recurrence on CT is straightforward when obvious organ or tissue pro(Reprinted) JAMA Surgery January 2016 Volume 151, Number 1
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a The Houston Academy of Medicine User on 08/31/2016
13
Research Original Investigation
Computed Tomography in Diagnosing Ventral Hernia Recurrence
trusion is present, many hernias spontaneously reduce in the supine imaging position, requiring recurrence detection to be based solely on identification of the fascial defect. Additional challenges arise for mesh-based repairs because certain prostheses are not visible on CT, and when used to bridge defects without approximating fascia, they may be indistinguishable from recurrences.4 Finally, the presence of eventration, fluid collections, and/or scarring above intact repairs can complicate interpretation. The disagreement among observers in the unblinded consensus group who were given clinical history and allowed multidisciplinary discussion was considerably less (only 10%), and the interobserver reliability of CT for VH diagnosis signifiARTICLE INFORMATION
REFERENCES
Author Affiliations: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts.
1. Poulose BK, Shelton J, Phillips S, et al. Epidemiology and cost of ventral hernia repair: making the case for hernia research. Hernia. 2012; 16(2):179-183.
Corresponding Author: Stanley W. Ashley, MD, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115 (
[email protected]). Published Online: September 23, 2015. doi:10.1001/jamasurg.2015.2587. Conflict of Interest Disclosures: None reported.
14
cantly improved. Causes for persistent disagreement were discussed and the emerging trends provide some of the study’s most salient conclusions (Table 2 in the article2), offering insight into ways of improving VH diagnosis. The 90% agreement observed after multidisciplinary discussion and clinical history review in the consensus group suggests that CT can be a reliable method of diagnosing VH recurrence but should not be used in isolation. This study demonstrates the benefit of imaging to assist, not replace, patient examination and assessment for VH detection. The success of CT for recurrent VH diagnosis requires communication between surgeon and radiologist, and multidisciplinary care is again at the forefront of optimal patient management.
2. Holihan JL, Karanjawala B, Ko A, et al. Use of computed tomography in diagnosing ventral hernia recurrence: a blinded, prospective, multispecialty evaluation [published online September 23, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.2580.
3. 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(3): 363-366. 4. Rakic S, LeBlanc KA. The radiologic appearance of prosthetic materials used in hernia repair and a recommended classification. AJR Am J Roentgenol. 2013;201(6):1180-1183.
JAMA Surgery January 2016 Volume 151, Number 1 (Reprinted)
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a The Houston Academy of Medicine User on 08/31/2016
jamasurgery.com
