Originally published by our sister publication General Surgery News
University of Florida, Tampa
The art of a physical exam has been passed down from one generation of physicians to the next. In the hernia world, it was thought that a physical exam was all you needed to accurately gauge the severity and complexity of a hernia. However, this line of thinking has certainly evolved as the complexity of both hernia pathology and surgical techniques increased exponentially. Recent studies also suggest the sensitivity of the physical exam is limited by a patient’s history or previous abdominal wall surgery.1
The accuracy of the physical exam to differentiate between seroma, previous mesh use, or bulging subcutaneous tissue, and a true hernia recurrence is low.2-4 Furthermore, studies have demonstrated that physical exams have a sensitivity of 77% and a negative predictive value of 77% for the diagnosis of incisional hernias. The sensitivity and specificity fall to 73% and 69%, respectively, in obese patients.5
Hernia radiology, a significant adjunct to the patient history and physical exam, has also evolved in importance. In past years, radiology was often used simply for the confirmation of a hernia. More recently, hernia radiology has emerged as a vital tool for the workup of hernias. The radiology often provides the surgeon with a road map that will offer guidance in operative planning and also raise awareness of possible pitfalls that could occur during surgery. For instance, preoperative planning in a patient with a history of mesh placement is of significant importance. Understanding the type of mesh, location of the mesh, and its relation to other vital organs, such as bowel, can assist in altering the surgical approach. Hernia radiology has become so important to the workup of a hernia patient that Dr. Docimo—along with Dr. Jeffrey Blatnik and Dr. Eric Pauli—co-edited a textbook, “Fundamentals of Hernia Radiology,” a hernia-based radiology source with surgeons being the target audience.
Correct Interpretation of Radiographic Studies
As radiographic studies are used more frequently at all stages in the treatment of hernias, a thorough understanding of hernia radiology and proper interpretation is required to minimize the chance of errors. A study conducted by Holihan demonstrated disagreement between all nine reviewers and the radiology report regarding the presence or absence of ventral hernia in 100 CT scans. Disagreement persisted following open discussion among the group in 10 of the cases.3
Eric Pauli, MD, a professor of surgery at Penn State Milton S. Hershey Medical Center, in Hershey, and a leader in the field of hernia radiology, expresses concern regarding the discrepancy between radiology reports and what is found intraoperatively. “Radiology reports are wrong a lot. Hernias are commonly inaccurately described, and very commonly missed entirely. You need the patient, the exam, the history, the old operative notes and the imaging. Only the surgeon has all of that and often in the same place at the same time,” Dr. Pauli told the author. Such discrepancy between surgeons and radiologist demonstrates the importance of ensuring proper steps are taken to make sure radiographic interpretation is a vital component of all surgical training programs.
Need for Reporting Standardization
A significant barrier to improving our use of radiology in the field of hernia is a lack of standardization in reporting techniques. Radiologists often do not use standardized reporting techniques when evaluating abdominal wall hernias and, as a result, can generate reports that focus on clinically irrelevant hernia-related information while neglecting the clinically vital information.6 To improve the standardization of hernia radiology reporting, Claus et al recently published a study focused on introducing the new concept known as DECOMP. DECOMP is composed of four aspects that should be included in all radiology reports related to hernia: DEfect, COntent, Musculature and Previous events. Dr. Pauli, a co-author of the publication, explained: “We just tried to come up with a method of standardizing hernia radiology reports so that the critical information is being reported. Surgeons will still need to read the images themselves to get a plan. But you shouldn’t get ‘ventral hernia’ as the report, which could mean a 2-mm epigastric thing or [it could mean] a loss-of-domain hernia.”
Regarding the defect aspect of the report, the precise location of the defect in relation to various reference points is critical. The authors suggested the umbilical stalk, xiphoid and pubic symphysis be used as a reference for midline hernias; costal margin, iliac crest, semilunaris line and the midline should be used as a reference for lateral hernias. The size and number of defects and their locations must also be included.6 A description of the hernia contents must focus on whether viscera, such as small bowel, or fat is present within the hernia sac. Additional information regarding whether the small bowel is incarcerated or strangulated can change the urgency or emergency status of a case. The content section of the report should also include information regarding the volume of the hernia sac in relation to the volume of the abdominal cavity to determine the extent, if any, of loss of domain. The muscular section should focus on whether or not the patient has diastasis recti, the width of the rectus muscles, whether there is muscular atrophy or rupture present, and whether an intraparietal hernia exists. Lastly, the previous events section should focus on any evidence of previous surgical events, such as evidence suggesting a component separation or the presence of mesh.6
Hernia Radiology in Practice and Training
A continued push toward standardizing radiology reports regarding hernia pathology demonstrates the importance of hernia radiology in the day-to-day practice of surgeons who perform hernia repair across the entire spectrum of the disease.
Ryan Juza, MD, an assistant professor of surgery at the University of Wisconsin–Madison, who specializes in complex hernia repair, stresses the importance of hernia radiology in his practice. “Most of my practice is recurrent or complex hernia. I need to be able to deconstruct the abdominal wall anatomy to better plan for my reconstruction,” Dr. Juza told this author. Regarding training future surgeons in the nuances of hernia radiology, Dr. Juza feels strongly about training residents in the proper techniques to develop their radiographic acumen. “I think it’s an important part of training to be able to read your own imaging. Preoperatively, we discuss anticipated anatomy, key landmarks or findings that we can look for intraoperatively. Postoperatively, I try and circle back to see if our pre-op interpretation was accurate and see what else we learned that we may not have recognized on the preoperative imaging.”
As the field of hernia repair continues to evolve, our surgical techniques will continue to become more complex. Thorough planning and the proper execution of a surgical plan will depend on the surgeon’s ability to not only perform a thorough physical exam but also on the ability to correctly interpret radiographic findings and leverage this information to improve their clinical outcomes.
References
- Wechter ME, Pearlman MD, Hartmann KE. Obstet Gynecol. 2005;106(2):376-383.
- Hojer AM, Rygaard H, Jess P. Eur Radiol. 1997;7(9):1416-1418.
- Holihan JL, Karanjawala B, Ko A, et al. JAMA Surg. 2016;151(1):7-13.
- Kushner B, Starnes C, Sehnert M, et al. Hernia. 2021;25(4):963-969.
- Baucom RB, Beck WC, Holzman MD, et al. J Am Coll Surg. 2014;218(3):363-366.
- Claus CMP, Cavalieiri M, Malcher F, et al. Rev Col Bras Cir. 2022;49:e20223172.