Surgeons Consider Not Operating When Likelihood of Success Is Low

By Christina Frangou

Chicago—Surgeons from Georgetown University Hospital are using preoperative computed tomography (CT) scans to help predict which patients can successfully undergo midline fascial approximation with component separation.

The team, led by surgeon Parag Bhanot, MD, has developed a novel approach to the preoperative CT work-up. They use axial and sagittal measurements from CT scans to calculate the transverse defect size, the defect area and the percentage of abdominal wall taken up by the defect.

Based on the results of these measurements, the team says they can more accurately predict which patients are likely to have a successful fascial reapproximation. In cases where reapproximation appears unlikely, they may not pursue surgery, he said.

“This is an issue that we all deal with as general surgeons when faced with a patient with a complex hernia. Should we should be offering these patients surgery for non-incarcerated hernias, in light of all the economic costs that are incurred when we fix these complex hernias with marginal results?” said Dr. Bhanot, MD, assistant professor of surgery at Georgetown University School of Medicine and director of the MedStar Georgetown University Hospital Comprehensive Hernia Center, Washington, D.C.

At the 2012 Clinical Congress of the American College of Surgeons, Dr. Bhanot presented a retrospective review of 54 patients (22 men and 32 women) who underwent enhanced preoperative CT scans followed by component separation for hernia repair between 2007 and 2011. Forty-eight patients underwent successful fascial closure and six required a bridged repair. Mean body mass index (BMI) and age were similar in the two groups.

The investigators used logistic regression analysis to identify individual patient characteristics or CT characteristics that could predict the likelihood a patient could undergo a successful fascial closure. Only three factors were significant: transverse defect diameter, defect area, and percentage of the abdominal wall taken up by the defect. Age, gender, weight, BMI and the vertical size of the defect had no bearing on fascial reapproximation.

Michael Rosen, MD, chief of GI and general surgery and director of the Case Comprehensive Hernia Center at Case Western Reserve University, Cleveland, said that the study addresses “a very important concept.” By trying to predict outcomes for fascial reapproximation, patients could be counseled accordingly. However, the study is very preliminary and includes too few patients to have real, clinical implications, he said. “This idea of reasonable expectation setting for patients is so important. This is a great first step in that direction but we need to look at it in a much larger series.”

Dr. Rosen added that he would not withhold reconstructive surgery based solely on a patient’s CT results. “It’s still worth giving it an attempt in the OR [operating room] for a patient who might be able to be reconstructed. A bridged repair, especially with synthetic mesh, is not always a failure. It’s still an improvement in quality of life.”

The investigators could not establish absolute cutoff values for the CT measures. However, they reported when the defect represented 20% or more of the circumference, it was likely to result in a bridging repair. Patients who had successful reapproximation had a defect size of about 10% of the circumference. The mean transverse defect size in the reapproximation group was 10.4 cm compared with 19.8 in the bridged groups. The respective defect areas were 184.2 cm2 and 420 cm2.

Dr. Bhanot and colleagues now measure these variables in all patients with a complex hernia. “If I do not think there’s a reasonable chance that even with component separation that I can get their midline approximated, I will tell the patient that I think their chances of having a good outcome with this surgery is very low and we should consider not operating,” said Dr. Bhanot.

“I’ve done that more and more as I see these patients. There is a significant percent of these patients we just do not offer surgery to, especially with the costs of some of the materials that we use.”

Component separation techniques are considered the best option for closing large midline defects. Most patients can undergo successful fascial reapproximation, but in 10% to 20% of cases patients will require a bridged repair (Plast Reconstr Surg 2011;128:698-709). Bridged repairs are associated with much higher rates of recurrences; two series report recurrence rates of 80% and 89% (Am J Surg 2008;196:47-50; Ann Plast Surg 2012;69:394-398).

Dr. Bhanot is a speaker and consultant for LifeCell. No funding was provided for this study.