Conversion to laparotomy due to intra-abdominal adhesions during laparoscopic hernia repair: a predictive model based on computed tomography manifestations and clinical indicators

Introduction

Postoperative intra-abdominal adhesions are one of the main complications after abdominal surgery, and their prevalence ranges from 67% to 100% (1-4). The presence of adhesions may increase operating time (3), and the process of releasing adhesions may cause intestinal fistulas and vascular injuries (5,6). Laparoscopic surgery has been widely adopted as a major surgical option to treat a wide range of disorders. Although it reduces wound infection and shortens recovery time, separation of severe adhesions laparoscopically is relatively challenging. Several studies have demonstrated that extensive and matted adhesions may require conversion to laparotomy during laparoscopic surgery in many situations. For instance, up to 19% of laparoscopic nephrectomy for urolithiasis procedures were converted to open surgery because of severe adhesions of the renal hilum to adjacent organs (especially bowel adhesions) (7). The incidence of conversion to laparotomy during laparoscopic partial hepatectomy was 1.7%, with adhesions as the main cause (8). In patients who underwent laparoscopic procedures after ventral hernia repair (intraperitoneal onlay mesh repair procedures, IPOM), 10.3% were converted to open surgery due to adhesions (9). Of patients with postoperative adhesions, approximately 83% had anterior abdominal wall adhesions (10). For this reason, although surgeons generally prefer laparoscopic hernia repair for small and medium-sized hernias, some patients may also need to be passively converted to laparotomy due to severe intra-abdominal adhesions (5,11). Thus, the preoperative assessment of adhesions between the intestine and the abdominal wall in patients with ventral incisional hernias allows surgeons to assess the feasibility of laparoscopic hernia repair. It also prevents the unplanned conversion to laparotomy because of severe adhesions. Abdominal computed tomography (CT) is a routine preoperative examination for patients with ventral hernias. It provides an excellent visualization of the size of the hernia sac and the hernia contents. Scholars who used artificial pneumoperitoneum CT to evaluate abdominal adhesions discovered that the imaging diagnosis was highly consistent with surgical findings (12,13). However, since the artificial pneumoperitoneum CT technique is relatively complex and time-consuming, it is unsuitable for routine clinical applications. Abdominal adhesions exhibit certain characteristic features on routine CT images, including focal obscuration of the pro-peritoneal line of fat, unchanged location of the bowel segments on successive examinations, kinking and angulation of the bowel loops, focal peritoneal thickening and enhancement, beak sign, and asymmetric thickness of the bowel wall (14,15). To date, no published papers have employed routine abdominal CT to assess abdominal adhesions and predict conversion of laparoscopic surgery to laparotomy in incisional hernia repair. In this study, we investigated the predictive value of CT images combined with clinical indicators for conversion to laparotomy due to adhesions in laparoscopic hernia repair. Subsequently, we developed a nomogram prediction model. We present this article in accordance with the STROBE reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-2024-2525/rc).

Methods

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Beijing Chaoyang Hospital (approval No. 2023-ke-377), and informed consent was waived for the retrospective analysis. All adult patients who underwent hernia repair for ventral incisional hernia between January 2020 and December 2022 in Beijing Chaoyang Hospital were consecutively enrolled using the electronic medical records of the hospital. Inclusion criteria were: (I) abdominal CT confirmed the diagnosis of ventral hernia; (II) patients underwent hernia repair within two weeks of the CT scan. Exclusion criteria were: (I) patient directly underwent open incisional hernia repair; (II) conversion to laparotomy for reasons other than adhesions, e.g., giant hernia sac, adjacent to iliac vessels, etc.; (III) poor quality CT images affecting quantitative measurements.

The patients were divided into the laparoscopy group and the conversion to laparotomy group based on whether their procedures were converted to laparotomy due to adhesions. Significantly more patients underwent laparoscopic hernia repair than those who were converted to laparotomy. Therefore, patients who underwent laparoscopic hernia repair were randomized into laparoscopy group according to the simple random sampling method, with four times as many subjects as the conversion to laparotomy group. Ultimately, a total of 245 patients were enrolled in this study, with 49 patients in the conversion to laparotomy group and 196 patients in the laparoscopy group.

Clinical information was collected as follows: (I) general information, including gender, age, and body mass index (BMI); (II) whether or not the hernia sac could be completely reduced during the preoperative physical examination; (III) nature and anatomical site of the previous abdominal disease; (IV) healing assessment of the previous surgical incision, including satisfactory healing and poor healing (incision infection or delayed healing).

CT image acquisition

An un-enhanced abdominal CT scan was performed on each patient using a 64-section CT scanner (Discovery CT 750 HD, GE Healthcare, Chicago, IL, USA) with the following parameters: 120 kVp, tube current modulation, pitch: 0.984, slice thickness: 5 mm, slice spacing: 5 mm. Reconstructed images with a 1.25 mm slice thickness were obtained for further analysis.

CT image analysis

The assessment area included the hernia sac and the region within 5 cm of the hernia ring, i.e., the area to be covered by mesh during hernia repair. CT measurements and evaluations were performed blindly and independently by two experienced radiologists as follows: (I) hernia-related information, including hernia location (median or lateral), hernia defect width, and transverse diameter of the hernia sac; (II) thickness of the abdominal wall at the site of pro-peritoneal line disappearance, categorized as normal thickness (Figure 1A) or localized thickening (Figure 1B); (III) thickness of the intestinal wall at the site of pro-peritoneal line disappearance, categorized as normal thickness (Figure 1A) or asymmetric thickening (Figure 1C). The intestinal wall on the abdominal wall side is thicker than the intestinal wall on the mesenteric side; (IV) bowel-related signs, including intestinal obstruction, small-bowel feces sign (SBFS) (16), beak sign, and angulation of bowel loops.

Figure 1 Comparison of CT image signs in patients between the two groups. (A) CT image of a patient who underwent laparoscopic hernia repair. CT image shows the disappearance of the pro‑peritoneal line, and the thicknesses of the adjacent abdominal wall and the intestinal wall are normal (arrow). (B,C) CT images of patients converted to laparotomy during laparoscopic hernia repair because of adhesions. CT images show the disappearance of the pro‑peritoneal line, with localized thickening of the adjacent abdominal wall (arrow) (B) and asymmetric thickening of the adjacent intestinal wall (arrow) (C). CT, computed tomography.

Statistical analysis

Statistical analyses were performed using SAS version 9.1 (SAS, Cary, NC, USA), SPSS version 26.0 (SPSS Inc.), MedCalc version 16.1 (MedCalc Inc., Belgium), and R software version 4.2.3 (R Statistical Software, R Foundation for Statistical Computing, Vienna, Austria). The intraclass correlation coefficient (ICC) was employed to assess the repeatability of the CT measurements (17), while kappa was used to evaluate the repeatability of the CT evaluation between readers (18). Quantitative data were compared using the independent sample t-test or Wilcoxon rank sum test, while qualitative data were compared using the chi-square test or Fisher’s exact test.

Logistic regression was applied to identify predictors for conversion to laparotomy. Factors at a P value <0.2 in the univariate analysis were included in the multivariate logistic regression model by the stepwise forward method, and those with P<0.05 in the multivariate analysis were retained in the final model. A nomogram was constructed on the basis of multivariate logistic regression analysis. Receiver operator characteristic (ROC) curves were applied to analyze the predictive value of the CT predictors, clinical predictors, and the nomogram model. Differences in the areas under the curves (AUCs) were compared using the DeLong test. The model was internally validated using 1,000 bootstrap samples. Model discrimination was evaluated using the concordance index (C-index), with a C-index greater than 0.71 indicating excellent discrimination (19). Model calibration was assessed using calibration curve analysis and the Hosmer-Lemeshow test. The model net benefit was evaluated using decision curve analysis (DCA). Statistical significance was defined at a P<0.05 (two-sided).

Results

Patients’ clinical data

Figure 2 displays the process of patient selection. The median age was 65.0 years, and 74.3% of the patients were female. The median BMI was 26.5 kg/m². The most common anatomical site of prior abdominal disease was the intestine (46.1%). Malignancy was the most common prior disease nature (31.43%), followed by benign neoplasms (16.3%) and inflammatory lesions (13.5%). In 15.9% of patients, hernia sac failed to reduce completely. Table 1 presents the basic information of the two groups. The proportion of patients whose hernia sac failed to reduce completely was significantly higher in the conversion to laparotomy group (P=0.007). The differences between the two groups for the remaining clinical data were not statistically significant.

Figure 2 Flowchart of the study population. CT, computed tomography.

Patient CT characteristics

There was good to excellent inter-rater ICC regarding all the CT indicators (Table 2). The CT parameters of the two groups were compared in Table 1. The proportion of patients with localized abdominal wall thickening (P<0.001), asymmetric intestinal wall thickening (P<0.001), intestinal obstruction (P=0.031), SBFS (P=0.002), beak sign (P=0.009), and angulation of bowel loops (P=0.030) were all significantly higher in the conversion to laparotomy group. Besides, hernia defect width (P<0.001) and transverse diameter of the hernia sac (P<0.001) were both larger in the conversion to laparotomy group.

Risk factors for conversion to laparotomy and the nomogram prediction model

The clinical data and CT parameters were evaluated using logistic regression analysis (Table 3). Univariate logistic regression identified the following indicators as predictors for conversion to laparotomy: inability to completely reduce the hernia sac [odds ratio (OR) =2.736, 95% confidence interval (CI): 1.294–5.784, P=0.008], localized abdominal wall thickening (OR =14.781, 95% CI: 7.094–30.798, P<0.001), asymmetric intestinal wall thickening (OR =7.440, 95% CI: 3.061–18.085, P<0.001), intestinal obstruction (OR =5.717, 95% CI: 1.236–26.444, P=0.026), SBFS (OR =4.769, 95% CI: 1.859–12.234, P=0.001), beak sign (OR =4.500, 95% CI: 1.498–13.515, P=0.007), angulation of bowel loops (OR =4.341, 95% CI: 1.204–15.647, P=0.025), hernia defect width (OR =1.308, 95% CI: 1.161–1.474, P<0.001), and transverse diameter of the hernia sac (OR =1.188, 95% CI: 1.097–1.287, P<0.001). Multivariate logistic regression analysis revealed BMI (OR =0.868, 95% CI: 0.774–0.973, P=0.016) as a protective factor for conversion to laparotomy, and the inability to completely reduce the hernia sac (OR =3.574, 95% CI: 1.278–9.995, P=0.015), localized abdominal wall thickening (OR =11.613, 95% CI: 4.907–27.482, P<0.001), asymmetric intestinal wall thickening (OR =7.508, 95% CI: 2.457–22.944, P<0.001), intestinal obstruction (OR =11.765, 95% CI: 1.969–70.284, P=0.007), and hernia defect width (OR =1.317, 95% CI: 1.130–1.536, P<0.001) as risk factors for conversion to laparotomy. A nomogram for predicting conversion to laparotomy caused by adhesions was constructed on the basis of multivariate logistic regression analysis (Figure 3).

Figure 3 Nomogram for calculating the risk of conversion to laparotomy due to adhesions. (A) Nomogram. (B) An example of nomogram. For each of the six variables, draw a vertical line to the ‘points’ axis at the top of the chart. Sum the points for the variables and locate the total score on the ‘total points’ axis. Draw a vertical line from this axis down to the bottom scale to predict the risk of conversion to laparotomy. BMI, body mass index.

Evaluation of the nomogram prediction model

The ROC curves showed that the AUCs of clinical indicators (including BMI and inability to completely reduce the hernia sac), CT indicators (including localized abdominal wall thickening, asymmetric intestinal wall thickening, intestinal obstruction, and hernia defect width), and the nomogram prediction model were 0.648 (95% CI: 0.585–0.708, P<0.001), 0.865 (95% CI: 0.816–0.905, P<0.001), and 0.890 (95% CI: 0.844–0.926, P<0.001), respectively (Table 4). The AUC of the nomogram prediction model was not significantly different from that of the CT indicators (Z=1.631, P=0.103), but it was significantly higher than that of the clinical indicators (Z=5.099, P<0.001) (Figure 4A). The C-index of the nomogram prediction model was 0.876, indicating a satisfactory degree of discrimination. The calibration curves of the model showed good consistency between the predicted and actual probability (Figure 4B), and the Hosmer-Lemeshow statistic suggested good model fit (χ²=4.551, P=0.804). DCA showed that using this risk nomogram to predict conversion to laparotomy would be effective if the threshold probability was greater than 4.0% (Figure 4C).

Figure 4 ROC, calibration curve, and DCA of the nomogram. (A) The AUC of the nomogram prediction model increases to 0.890 from 0.648 and 0.865 for clinical indicators (P<0.001) and CT signs (P=0.103), respectively. (B) Calibration curve of the nomogram. The calibration curve demonstrated excellent consistency between the predicted result of the nomogram and the actual situation. (C) DCA curve of the nomogram. The diagonal gray line represents the clinical benefit of conversion to laparotomy. The horizontal black line represents the clinical benefit of laparoscopic hernia repair. The blue line represents the DCA obtained from the nomogram. AUC, areas under the curve; CT, computed tomography; DCA, decision curve analysis; ROC, receiver operator characteristic.

Discussion

In this study, we compared the CT and clinical indicators in patients who underwent laparoscopic hernia repair and those who were converted to laparotomy due to the detection of adhesions during laparoscopic hernia repair. Our findings confirmed that localized abdominal wall thickening, asymmetric intestinal wall thickening, intestinal obstruction, hernia defect width, BMI, and inability to completely reduce the hernia sac were independent predictors for conversion to laparotomy. Ultimately, we established a nomogram prediction model based on the above six predictors, by which the risk of conversion to laparotomy caused by adhesions could be estimated for each patient. Internal validation verified superior performance of the prediction mode.

Pathophysiologically, adhesion tissue consists of fibrous connective tissue, that may contain blood vessels and nerves (20). Adhesions do not involve volume changes, and their physical properties are the same as those of the surrounding tissue (such as the intestinal wall and abdominal wall muscle). As a result, adhesive tissue is typically invisible in CT images, and it is difficult to diagnose the severity and extent of adhesions with routine CT (13). Intra-abdominal adhesions can cause a range of indirect CT signs, such as focal obscuration of the pro-peritoneal line of fat, localized peritoneal thickening, asymmetric thickness of the bowel wall, kinking and angulation of bowel loops, beak sign, intestinal obstruction, and SBFS (14,15). The presence of these indirect signs may be correlated with the degree of adhesion severity.

Our study showed that localized abdominal wall thickening and asymmetric intestinal wall thickening were both risk factors for conversion to laparotomy due to adhesions in laparoscopic hernia repair. One study constructing a mouse model of intra-abdominal adhesions showed that an intact peritoneum did not present with friction-induced injury (21). However, when mesothelial cells were absent due to prior surgery, motion-induced friction produced an acute inflammatory response followed by activation of the fiber system and tissue repair, which eventually led to adhesion formation. When the adhesions were thick enough, localized thickening of the abdominal wall sometimes appeared on CT images. Similarly, this pathophysiological process of trauma-inflammation-fibrosis-adhesion occurred when the intestine was subjected to friction, even when the intestinal serosa was intact (21). Under this condition, CT images show asymmetric thickening of the intestinal wall, with the abdominal wall side being thicker than the mesangial side (14). When using asymmetric intestinal wall thickening to predict conversion to laparotomy caused by adhesions, accuracy is affected by the lumen filling condition. When using localized abdominal wall thickening to predict conversion to laparotomy caused by adhesions, we detected some false positive cases. The following reasons may have caused this situation: (I) there may have been a small amount of encapsulated effusion between the abdominal wall and the bowel with a density similar to that of fibrosis. This could have been mistaken for localized thickening of the abdominal wall; (II) the patients with incisional hernia may have experienced uneven thinning of the abdominal wall muscles, and the relatively thicker areas were mistaken for adhesions.

Intraperitoneal adhesions inhibit intestinal peristalsis, which may prevent the movement of the bowel contents and increase the formation of small bowel feces (16). Thus, we hypothesized that the presence of SBFS indicated the presence of severe intestinal adhesions. In this study, there was a significant difference in the incidence of SBFS between laparoscopy group and conversion to laparotomy group, which is 5.1% and 20.4% respectively. However, multivariate logistic regression analysis did not reveal a significant relationship in this regard. This may be because approximately 70.0% of patients with SBFS in the laparoscopy group had a history of small bowel surgery, while only 20.0% in the conversion to laparotomy group had a similar history. Weakened peristalsis may have also occurred at small bowel anastomosis sites. False positives may have appeared when the bowel anastomosis was near the hernia. Therefore, in patients without prior small bowel surgery, SBFS may be an effective predictor for conversion to laparotomy caused by adhesions.

Hernia defect width is an important reference index for the classification of ventral hernias and is relevant to the choice of surgical procedure, such as whether hernia repair can be performed laparoscopically (22), or whether component separation technique is required (23). Our study confirmed that hernia defect width was an independent risk factor for conversion to laparotomy caused by adhesions. Specifically, larger hernia defect widths signified more serious intra-abdominal adhesions. This may be because incisional hernias usually involve peritoneal defects with non-smooth surfaces, which are vulnerable to frictional damage. A larger hernia defect width may provide a broader area for friction between the abdominal wall and the bowel, potentially increasing the risk of adhesion formation. As a result, there is a greater risk of adhesions occurring.

Our study findings revealed that the inability to completely reduce the hernia sac during pre-operative examinations was a risk factor for conversion to laparotomy caused by adhesions. The size of the hernia sac varies with body position or intra-abdominal pressure, causing repeated friction between the hernia contents and the hernia sac (especially the hernia neck). Fibrous tissue proliferation then occurs, causing adhesions, which limit the mobility of the hernia contents. A previous study found significant adhesions between the intra-abdominal contents and the hernia sac in patients with irreducible inguinal hernias (24). This indicates that the inability to completely reduce the hernia sac is indicative of significant adhesions. In this study, we detected some false positives, which may have been caused by large hernias. Therefore, we hypothesized that the inability to reduce the hernia sac completely has superior predictive value in small and medium incisional hernias.

Although inflammation is indispensable for the formation of abdominal adhesions, our study revealed that neither a prior history of intra-abdominal inflammation nor incision infection was a predictor for conversion to laparotomy. Although intra-abdominal inflammation may exacerbate the severity of adhesions, adhesions primarily occur mainly between intra-abdominal organs, and adhesions between the abdominal wall and the bowel are not involved or are only mildly involved. Similarly, when surgical site infection is superficial and does not involve the peritoneum or the abdominal cavity, the inflammation caused by infection does not increase adhesions between the abdominal wall and the abdominal contents.

The main limitation of this study is that it is a retrospective study. The surgeons did not record the location and extent of the adhesions during surgery, making it impossible to compare the adhesions shown on the CT images with those found intraoperatively. Besides, adhesions between the bowel and the abdominal wall are associated with previous surgical procedures, such as length of surgery, peritoneal closure, suture material type and their gauge, etc. The absence of the above information may lead to imperfect prediction model. Furthermore, surgeons usually estimate the severity of adhesions preoperatively, and patients with suspected severe adhesions (e.g., those with a history of multiple open abdominal surgeries) would have directly undergone open surgery and not been included in this study. This would have inevitably led to patient selection bias. Therefore, we may have underestimated the predictive value of the nomogram prediction model. Finally, our study enrolled only patients with ventral incisional hernias who underwent laparoscopic hernia repair at a single high-volume tertiary academic medical center. Given the disparities in physician expertise, surgical equipment configuration, and perioperative management standards across hospitals of different levels, the findings of this study may not be directly generalizable to primary care hospitals.

Conclusions

In summary, the results of our study indicate that localized abdominal wall thickening, asymmetric intestinal wall thickening, intestinal obstruction, and hernia defect width shown on CT images are independent risk factors for conversion to laparotomy due to adhesions. The nomogram prediction model constructed on the basis of abdominal CT and clinical indicators has high predictive value for conversion to laparotomy, and can identify patients who may not be suitable candidates for laparoscopic hernia repair.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-2024-2525/rc

Data Sharing Statement: Available at https://qims.amegroups.com/article/view/10.21037/qims-2024-2525/dss

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2024-2525/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Beijing Chaoyang Hospital (approval No. 2023-ke-377), and informed consent was waived for the retrospective analysis.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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