Nicole Cherng, MD, Kashayar Rafatzand, MD, Gabriela Santos-Nunez, MD, James Carroll, MD, Philip Cohen, MD, Richard Perugini, MD. University of Massachusetts Medical School
Introduction: Multiple techniques and variations have been described for complex abdominal wall hernia repair, and include rationale for types of synthetic mesh, location of mesh, and the performance of and type of lateral release. Decisions to utilize these techniques stem from surgeon preference and severity of the defect. Commonly accepted grading systems rely on CT in the relaxed state, and thus are limited to defect location and dimension. Such systems are inadequate in differentiating severity of physiologic impact. We developed a protocol utilizing dynamic MRI (dMRI) to image the abdominal wall in relaxed state and in Valsalva, which enables quantification of abdominal wall muscle dysfunction, improving the assessment of subjects with complex abdominal wall hernia and impacting surgeon decision-making.
Methods: A registry was created under IRB approved protocol of patients presenting for repair of abdominal wall hernias with a preoperative dMRI. From relaxed state images, the hernia was categorized using the European Hernia Society (EHS) scoring system. Valsalva images were compared with the relaxed images to assess degree of rectus dysfunction (0 = no hernia, 1 = diastasis only, 2 -5 = hernia with increasing degree of rectus dysfunction). We compared our system of grading abdominal wall dysfunction to the EHS system.
Results: We evaluated 21 subjects, with a male to female ratio of 11:10, a median age of 60 years (range 34-74), and a median BMI of 30 (range 25.6-43.1). Five hernia were classified as functional class 2 (minimal rectus dysfunction). For these subjects, the recti contracted and hernia defect was stable to decreasing with Valsalva. Three underwent open Rives Stoppa (RS) repair with retro-rectus mesh, one underwent laparoscopic repair with sublay mesh, and one underwent external oblique release (EOR) with onlay mesh. Seven hernia were classified as most severe physiologic dysfunction (class 5). The recti were atrophic and elongated with Valsalva. Four underwent RS repair with retro-rectus mesh, and three underwent EOR with onlay mesh. Eleven hernia were EHS W2 (width 4-10 cm). In these subjects, dMRI differentiated between normal rectus function and severe rectus dysfunction.
Conclusions: We present our initial experience with dMRI in the evaluation of complicated abdominal wall hernia. dMRI offers an improved assessment of physiologic dysfunction of the abdominal wall. We identified variation in surgeon technique in subjects with similar severity of hernia in this small series, and plan to utilize dMRI for both preoperative stratification and for post-operative assessment of physiologic outcomes.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95103
Program Number: P585
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster
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