Surgical Endoscopy and Other Interventional Techniques

https://doi.org/10.1007/s00464-021-08476-0

Validation of a simple technique of volumetric analysis of complex

incisional hernias without 3D CT scan reconstruction
Mazen R. Al‑Mansour1,2   · Jacqueline Wu1 · Greg Gagnon3 · Alexander Knee4 · John Romanelli1 · Neal E. Seymour1

Received: 5 January 2021 / Accepted: 28 March 2021

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract
Purpose  Volumetric analysis is being increasingly utilized in the preoperative evaluation of complex incisional hernias.
Three-dimensional (3D) reconstruction of abdominal computed tomography (CT) scan has been used to obtain surface area
(SA) and volume (Vol.) measurements, while others have used simple mathematical formulas to obtain SA and Vol. esti-
mates without 3D reconstruction. Our objective was to assess the correlation of SA and Vol. measurements and estimates
of complex incisional hernias.
Methods  We conducted a retrospective agreement study of adults who underwent abdominal wall reconstruction from 2007
to 2018. Demographics, hernia characteristics, and operative data were collected from the medical record.
SA and Vol. measurements were obtained after 3D CT reconstruction. Linear CT variables were obtained independently by
two surgeons and SA and Vol. estimates were calculated. Because both surgeons reported similar results, only lead author
values are reported in the abstract. We used Pearson’s correlation coefficient (r) to assess inter-rater agreement and the agree-
ment between SA and Vol. measurements and estimates.
Results  A total of 108 patients were eligible for analysis. The mean age was 57 ± 11 years and 53 (49%) were female. 42
(39%) hernias were recurrent, 10 (9%) patients had a stoma, and 9 (8%) had a history of open abdomen. The mean defect
width was 11 ± 4 cm and mean defect surface area (DSA) was 150 ± 95 ­cm2. Inter-rater agreement of SA and Vol. estimates
was high (r ≥ 0.80). There was high correlation between SA and Vol. measurements and estimates for DSA, hernia sac volume
(HSV), abdominal cavity volume (ACV), and HSV/ACV ratio (r = 0.81, 0.89, 0.94 and 0.91, respectively).
Conclusion  SA and Vol. estimates demonstrated high level of agreement with SA and Vol. measurements using 3D recon-
struction. SA and Vol. estimates can be obtained using simple mathematical formulas using easily obtained linear variables
negating the need for the time and effort consuming 3D reconstruction.

Keywords  Abdominal wall reconstruction · Component separation · Loss of domain · Volumetry · CT scan · Hernia

Abdominal computed tomography (CT) is routinely per-
formed for preoperative planning ahead of surgical repair
of complex incisional hernias. Preoperative CT has been
shown to help predict both intraoperative and postoperative
* Mazen R. Al‑Mansour
mazen.al-mansour@surgery.ufl.edu
1
Department of Surgery, University of Massachusetts Medical
School-Baystate, Springfield, MA, USA
2
Department of Surgery, University of Florida, 1600 SW
Archer Rd, Gainesville, FL 32610, USA
3
Department of Clinical Engineering, Baystate Medical
Center, Springfield, MA, USA
4
Department of Medicine, University of Massachusetts
Medical School-Baystate, Springfield, MA, USA
outcomes such as primary fascial closure, the need to use
component separation techniques, and wound infection [1,
2]. In the past few years, volumetric CT analysis has been
increasingly used to predict operative outcomes and to aid
in preoperative patient optimization including wound infec-
tions, respiratory complications, and determining the need
for preoperative adjuncts (such as preoperative progres-
sive pneumoperitoneum or botulinum toxin A injection of
abdominal musculature) [3–5].
Surface area (SA) and Volume (Vol.) values can be meas-
ured with high accuracy following three-dimensional (3D)
reconstruction of abdominal CT using different special-
ized software programs. Various studies have utilized Vol.
measurements in the preoperative evaluation of complex
incisional hernias [6, 7]. This process, however, is time and

13
Vol.:(0123456789)

effort consuming and requires specialized training. Tanaka
et al. used Vol. estimates based on the presumption that the
hernia sac and abdominal cavity are ellipsoid in shape [8].
This allows using simple linear variables and mathematical
formulas to obtain SA and Vol. estimates. We have recently
published a study evaluating linear and volumetric CT vari-
ables in predicting tension-free midline approximation in
patients undergoing abdominal wall reconstruction [9]. This
study represents a secondary analysis of the same sample
with the objective of evaluating the correlation between SA
and Vol. measurements and estimates.
Materials and methods
We conducted a single center retrospective agreement
study of a cohort of patients that underwent abdominal wall
reconstruction with component separation at our institu-
tion. Approval was obtained from the institutional review
board (IRB). We queried our surgical database to identify
patients aged 18 years or greater with a midline hernia who
Fig. 1  3D reconstruction of abdominal CT scan for a patient with a large incisional hernia and a colostomy
13
Surgical Endoscopy
underwent abdominal wall reconstruction with component
separation between 1/1/2007 and 6/30/2018. Patients were
excluded if they had a non-midline hernia, emergency cases,
or if they did not have an accessible preoperative CT scan.
Additional exclusions included abdominal wall reconstruc-
tion indications that would make volumetric analysis irrel-
evant (abdominal wall reconstruction for mesh infection,
pain following laparoscopic repair and abdominal wall
defect resulting from resection of metastatic abdominal wall
tumor). Demographics, hernia characteristics, and operative
data were collected from the medical record. Study data
were collected and managed using REDCap electronic data
capture tools [10].
The most recent preoperative CT scan of the abdomen
and pelvis was used. SA and Vol. measurements were per-
formed after 3D reconstruction of the CT scan. A clinical
engineer (G.G.) with expertise in 3D reconstruction of
CT scans performed the CT segmentation using 3DSlicer
(version 4.9.0) software (Fig. 1). The SA and Vol. meas-
urements were then obtained using Autodesk Meshmixer
(version 3.4.35) software. Two surgeons (M.A. and J.W.)
Surgical Endoscopy

Table 1  Definitions of CT scan linear variables

Measure Definition

Sac ­widtha Greatest horizontal distance between the lateral margins of the hernia sac on both sides
Sac ­lengthb Greatest vertical distance between the cranial and the caudal margins of the hernia sac
Sac height Greatest anteroposterior distance between the apex of the sac and the line connecting the rectus muscles
Defect ­widtha Greatest horizontal distance between the lateral margins of the hernia defect on both sides
Defect ­lengthb Greatest vertical distance between the cranial and the caudal margins of the hernia defect
Abdominal cavity width Horizontal distance from the parietal peritoneum on both flanks measured at the level of the transverse process of L3
Abdominal cavity length Vertical distance from the highest point of the diaphragm to the tip of coccyx
Abdominal cavity depth Anteroposterior distance from line that connects the rectus muscles to the line connecting the L3 transverse processes
a
 If multiple sacs/defects are present, the distance between the most laterally located margins of the most lateral sac/defect is used
b
 If multiple sacs/defects are present, the distance between the cranial margin of the most cranial sac/defect and the caudal margin of the most
caudal sac/defect is used

Fig. 2  European Hernia Society A classification of midline incisional hernias and B guide of measuring incisional hernia width and length when
multiple defects exist

with expertise in abdominal wall reconstruction inde-

pendently reviewed the CT scans to obtain the linear
variables using the annotation tools in Synapse (PACS)
software (v5.5.002). Prior to collecting this data, the two
surgeons reviewed a few CT scans together to ensure con-
sistent measuring technique using the definitions listed in
Table 1. The European Hernia Society guidelines were
used to classify the hernias and to guide definition of
linear variables [11] (Fig. 2). After data collection, we Fig. 3  A Area of an ellipse and B Vol. of ellipsoid
reviewed values for data entry errors by creating a differ-
ence score between the two reviewers. Values where the
difference score was > 2 standard deviations away were area (DSA), hernia sac volume (HSV) and abdominal cav-
reviewed and re-measured. ity volume (ACV) were then calculated using the following
In order to obtain SA and Vol. estimates, the hernia formulas (Fig. 3):
defect(s) were presumed to be elliptical and the hernia sac
and abdominal cavity to be ellipsoid in shape. Defect surface

13
 Surgical Endoscopy

DSA = 𝜋 (defect width∕2) (defect length∕2) the agreement was high for abdominal cavity dimensions
= 𝜋∕4 × defect width × defect length (r = 0.85–0.91). The inter-rater agreement for SA and Vol.
estimates was good for DSA (r = 0.8) and excellent for HSV,
HSV = 4∕3𝜋 (hernia sac width∕2) (hernia sac length∕2)(hernia sac height∕2)
≈ hernia sac width × hernia sac length × hernia sac height∕2

ACV = 4∕3𝜋 (abdominal cavity width/2)(abdominal cavity length/2)(abdominal cavity depth/2)

≈ abdominal cavity width × abdominal cavity length × abdominal cavity depth/2

ACV, and HSV/ACV ratio (r = 0.90, 0.92 and 0.84, respec-

We initially summarized patient and hernia characteristics
using frequencies and percentages for categorical variables
or means and standard deviations for continuous variables.
We used scatterplots and Pearson’s correlation coefficient
(r) to assess the agreement between SA and Vol. measure-
ments and estimates as well as inter-rater agreement. We
also calculated 95% confidence intervals for correlations as
an estimate of precision. Statistical analysis was conducted
using Stata v15.1 (StataCorp, LP, College Station, Texas).
tively) (Table 3).
The agreement between SA and Vol. measurements and
estimates was good for DSA (rater #1 r = 0.81, rater #2
r = 0.71). Agreement between SA and Vol. measurements
and estimates for HSV, ACV, and HSV/ACV was excellent
(r >  = 0.88, for both raters) (Fig. 4).
Table 2  Patient and hernia characteristics
n = 108

Age (SD), year 57.3 (11.3)

Results Female, n (%) 53 (49.1)
Body mass index (SD), Kg/m2
A total of 149 subjects were initially identified; however,
  < 30 37 (34.3)
after exclusions (24 had no CT scan or incomplete CT scan,
 30–34.9 41 (38.0)
13 did not undergo component separation, 3 had operative
 35 +  30 (27.8)
indications irrelevant to our study, and 1 had a non-midline
Defect width (SD), ­cma 11.4 (3.9)
hernia) 108 patients were eligible for analysis. The mean
DSA (SD), ­cm2b 150.0 (94.5)
age was 57 ± 11 years, 53 (49%) were female, and 83 (77%)
Prior hernia repairs, n (%)
were non-Hispanic white. A total of 71 (66%) were obese
 0 66 (61.1)
(body mass index ≥ 30) and most patients had an American
 1 23 (21.3)
Society of Anesthesiology physical status class II (41%) or
 2 +  19 (17.6)
III (58%) (Table 2).
Prior mesh repair, n (%) 35 (32.4)
In addition, a total of 42 (39%) patients had a recurrent
Current stoma, n (%) 10 (9.3)
hernia. The most common European Hernia Society class
Parastomal hernia, n (%) 2 (1.9)
was M3 in 69 (64%). The most common abdominal wall
History of abdominal wall infection, n (%) 21 (19.4)
reconstruction technique was endoscopic component separa-
History of mesh infection, n (%) 7 (6.5)
tion (endoscopic release of external oblique muscles com-
History of enterocutaneous fistula, n (%) 9 (8.3)
bined with midline laparotomy) in 74 (69%). Mesh was used
History of fascial dehiscence, n (%) 11 (10.2)
in all cases with the most common placement being in the
History of open abdomen, n (%) 9 (8.3)
retrorectus plane in 83 (77%). A concurrent procedure was
History of abdominal-based flap, n (%) 2 (1.9)
performed in 70 (65%) patients. Mean length of stay was six
European Hernia Society class
(range 2–18) days.
 M1 20 (18.7)
The mean defect width was 11 ± 4 cm (as measured by
 M2 2 (1.9)
lead rater). The mean DSA, HSV, ACV, and HSV/ACV
 M3 69 (63.9)
ratio was 150 ± 95 ­cm2, 736 ± 755 ­cm3, 10692 ± 2934 ­cm3,
 M5 16 (15.0)
and 0.07 ± 0.08, respectively, as measured after 3D CT
reconstruction. The inter-rater agreement for defect width SD standard deviation
and length was fair (r = 0.74 and 0.72, respectively). For a
 Lead rater value
hernia sac dimensions it varied from (r = 0.75–0.91) and b
 Measurement obtained after 3D reconstruction

13
Surgical Endoscopy

Table 3  Inter-rater agreement Rater #1 Rater #2 r (95%CI)

of linear variables and SA and
volumetric estimates Linear measurements (SD), cm
 Hernia sac width 14.2 (5.3) 13.5 (5.5) 0.77 (0.68–0.84)
 Hernia sac length 17.1 (5.8) 15.2 (5.8) 0.75 (0.65–0.82)
 Hernia sac height 4.8 (2.3) 5.1 (2.5) 0.91 (0.87–0.94)
 Defect width 11.4 (3.9) 11.6 (4.4) 0.74 (0.64–0.82)
 Defect length 14.9 (5.8) 14.5 (6.0) 0.72 (0.61–0.80)
 Abdominal cavity width 29.0 (3.8) 28.0 (4.2) 0.90 (0.85–0.93)
 Abdominal cavity l­engtha 37.0 (3.7) 32.9 (4.0) 0.85 (0.79–0.89)
 Abdominal cavity depth 17.5 (3.1) 15.5 (3.2) 0.91 (0.88–0.94)
SA and vol. estimates (SD)
 DSA ­cm2 142.1 (90.7) 143.0 (94.6) 0.80 (0.72–0.86)
 HSV ­cm3 778.0 (783.5) 735.2 (798.2) 0.90 (0.89–0.93)
 ACV ­cm3a 10041 (3153) 7632 (2652) 0.92 (0.88–0.94)
 HSV/ACVa 0.08 (0.08) 0.10 (0.12) 0.84 (0.77–0.89)

r Pearson correlation coefficient, CI confidence interval, SD standard deviation, DSA defect surface area,
HSV hernia sac volume, ACV abdominal cavity volume
a
 Missing data n = 1

Fig. 4  Agreement between SA and vol. measurements and estimates for both raters. DSA defect surface area, HSV hernia sac volume, ACV
abdominal cavity volume

13

Discussion
Our study found that SA and Vol. estimates obtained via
simple mathematical formulas as described by Tanaka et al.
showed high degree of inter-rater agreement and high degree
of correlation with SA and Vol. measurements obtained after
3D CT reconstruction [8]. Our study is among the largest in
which volumetric analysis of abdominal CT scan was per-
formed in complex incisional hernias requiring abdominal
wall reconstruction and it is the first study (to our knowl-
edge) that attempts to validate SA and Vol. estimates using
simple mathematical formulas. Our study can open the door
for other researchers and clinicians who might perceive the
need to perform 3D reconstruction of CT scan as a barrier
to conduct volumetric analysis of abdominal CT in hernia
patients.
Volumetric analysis of abdominal CT scans has been
shown to help predict operative outcomes of abdominal
wall reconstruction. Volumetric analysis has been primarily
performed after 3D CT scan reconstruction [3, 4, 7, 12].
For example, Schlosser et al. performed volumetric analysis
after 3D CT scan reconstruction of 1178 open ventral hernia
repair patients. They found that large defects and large her-
nia volume/intra-abdominal volume ratio (greater than 0.5)
significantly increases the risk of postoperative respiratory
insufficiency [5]. Sabbagh et al. performed volumetric analy-
sis using 3D CT reconstruction of 17 patients undergoing
abdominal wall reconstruction. All of these patients received
preoperative progressive pneumoperitoneum. In multivariate
analysis, only incisional hernia volume/peritoneal volume
ratio of less than 20% was predictive of tension-free fascial
closure. The authors commented that simplification of the
volumetry method is necessary [6].
A limitation of the wide adoption of volumetric analysis
after 3D CT reconstruction is that it is time-consuming and
requires special software programs and training, making
routine utilization outside of research studies impractical.
Tanaka et al. described the use of preoperative CT scan in
23 patients with large incisional hernias and loss of domain.
HSV and ACV were estimated using simple mathematical
formulas based on the presumption that the hernia sac and
abdominal cavity are ellipsoid in shape. Preoperative pro-
gressive pneumoperitoneum was implemented when HSV/
ACV was ≥ 25. The volumetric analysis helped estimate
the total volume of gas needed for preoperative progres-
sive pneumoperitoneum. Our study showed that the method
described by Tanaka produced SA and Vol. estimates with
high inter-rater agreement and high degree of correla-
tion with volumetric measurements obtained after 3D CT
reconstruction.
Our study provides evidence to validate volumetric anal-
ysis using simple mathematical formulas using the ruler
13
Surgical Endoscopy
annotation tool that is widely available in most imaging
viewing software and does not require additional software
or specialized training. Our study can help expand the use
of volumetric analysis of CT scans of ventral hernias in both
the clinical and research settings. However, there are some
inherent limitations to our study. We only included patients
in whom abdominal wall reconstruction was performed and
therefore care should be exercised when extrapolating our
results to patients who have incisional hernias that do not
require abdominal wall reconstruction (e.g., patients with
smaller hernia not requiring component separation). How-
ever, we believe that volumetric CT analysis is most valu-
able in predicting surgical outcomes and guiding the use of
preoperative adjuncts in the subset of patients undergoing
abdominal wall reconstruction as described above. Addition-
ally, it would also be beneficial to determine if the inter-rater
agreement remains high over a larger sample of raters. Our
relatively small sample size does not allow for evaluation of
certain subpopulations (e.g., patients with ostomies, those
with non-elliptical sacs and those with multiple sacs). It is
also unclear if the differences between SA and Vol. estimates
and measurements, though very small, will have any bear-
ing on clinical recommendations or guidelines. Additional
studies evaluating the use of volumetric estimates in ventral
hernias of all sizes and evaluating additional volumetric var-
iables such as subcutaneous fat volume and visceral fat vol-
ume are needed to expand the utility of volumetric analysis.
Conclusion
Surface area and volumetric estimates derived via simple
mathematical formulas as described by Tanaka et  al. in
patients undergoing abdominal wall reconstruction demon-
strated a high degree of correlation with surface area and
volumetric measurements obtained after 3D CT reconstruc-
tion. Although confirmatory studies should be conducted,
calculating surface area and volumetric estimates is a simple
process that can likely be used in lieu of the 3D CT recon-
struction to facilitate volumetric analysis in abdominal wall
reconstruction patients.
Funding  Study data were collected and managed using REDCap elec-
tronic data capture tools hosted at Tufts Clinical and Transitional Sci-
ence Institute (Grant No. UL1 TR001064).
Declarations 
Disclosures  In the 36 months preceding submission, Mazen R. Al-
Mansour and Jacqueline Wu have received education payments from
Intuitive Surgical, Inc. and general payments from Intuitive Surgical,
Inc. and CONMED Corporation. John Romanelli has received consul-
tation fee from Covidien LP, education payments from Intuitive Surgi-
Surgical Endoscopy
cal, Inc., and general payments from Boston Scientific Corporation,
Intuitive Surgical, Inc., Covidien LP, Ethicon US, LLC, and Olympus
America Inc. Neal E. Seymour has received general payments from
Intuitive Surgical, Inc. Greg Gagnon and Alexander Knee do not have
conflicts of interest or financial ties to disclose.
References
1. Blair LJ, Ross SW, Huntington CR et al (2015) Computed tomo-
graphic measurements predict component separation in ventral
hernia repair. J Surg Res 199:420–427. https://​doi.​org/​10.​1016/j.​
jss.​2015.​06.​033
2. Franklin BR, Patel KM, Nahabedian MY et al (2013) Predict-
ing abdominal closure after component separation for complex
ventral hernias: maximizing the use of preoperative computed
tomography. Ann Plast Surg 71:261–265. https://d​ oi.o​ rg/1​ 0.1​ 097/​
SAP.​0b013​e3182​773915
3. Winters H, Knaapen L, Buyne OR et al (2019) Pre-operative
CT scan measurements for predicting complications in patients
undergoing complex ventral hernia repair using the component
separation technique. Hernia 23:347–354. https://d​ oi.o​ rg/1​ 0.1​ 007/​
s10029-​019-​01899-8
4. Schlosser KA, Maloney SR, Prasad T et al (2019) Three-dimen-
sional hernia analysis: the impact of size on surgical outcomes.
Surg Endosc. https://​doi.​org/​10.​1007/​s00464-​019-​06931-7
5. Schlosser KA, Maloney SR, Prasad T et al (2019) Too big to
breathe: predictors of respiratory failure and insufficiency after
open ventral hernia repair. Surg Endosc. https://​doi.​org/​10.​1007/​
s00464-​019-​07181-3
6. Sabbagh C, Dumont F, Robert B et al (2011) Peritoneal volume is
predictive of tension-free fascia closure of large incisional hernias
with loss of domain: a prospective study. Hernia 15:559–565.
https://​doi.​org/​10.​1007/​s10029-​011-​0832-y
7. Martre P, Sarsam M, Tuech J-J et al (2019) New, simple and relia-
ble volumetric calculation technique in incisional hernias with loss
of domain. Hernia. https://​doi.​org/​10.​1007/​s10029-​019-​01990-0
8. Tanaka EY, Yoo JH, Rodrigues AJ et al (2010) A computer-
ized tomography scan method for calculating the hernia sac and
abdominal cavity volume in complex large incisional hernia
with loss of domain. Hernia 14:63–69. https://​doi.​org/​10.​1007/​
s10029-​009-​0560-8
9. Al-Mansour MR, Wu J, Gagnon G et al (2021) Linear versus
volumetric CT analysis in predicting tension-free fascial closure
in abdominal wall reconstruction. Hernia. https://d​ oi.o​ rg/1​ 0.1​ 007/​
s10029-​020-​02349-6
10. Harris PA, Taylor R, Thielke R et al (2009) Research electronic
data capture (REDCap)–a metadata-driven methodology and
workflow process for providing translational research informatics
support. J Biomed Inform 42:377–381. https://​doi.​org/​10.​1016/j.​
jbi.​2008.​08.​010
11. Muysoms FE, Miserez M, Berrevoet F et al (2009) Classifica-
tion of primary and incisional abdominal wall hernias. Hernia
13:407–414. https://​doi.​org/​10.​1007/​s10029-​009-​0518-x
12. Sabbagh C, Dumont F, Fuks D et al (2012) Progressive preopera-
tive pneumoperitoneum preparation (the Goni Moreno protocol)
prior to large incisional hernia surgery: volumetric, respiratory
and clinical impacts. A prospective study. Hernia 16:33–40.
https://​doi.​org/​10.​1007/​s10029-​011-​0849-2
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
13