Development and Validation of Image-Based Deep Learning Models to Predict Surgical Complexity and Complications in Abdominal Wall Reconstruction.

Importance: Image-based deep learning models (DLMs) have been used in other disciplines, but this method has yet to be used to predict surgical outcomes. Objective: To apply image-based deep learning to predict complexity, defined as need for component separation, and pulmonary and wound complications after abdominal wall reconstruction (AWR). Design, Setting, and Participants: This quality improvement study was performed at an 874-bed hospital and tertiary hernia referral center from September 2019 to January 2020. A prospective database was queried for patients with ventral hernias who underwent open AWR by experienced surgeons and had preoperative computed tomography images containing the entire hernia defect. An 8-layer convolutional neural network was generated to analyze image characteristics. Images were batched into training (approximately 80%) or test sets (approximately 20%) to analyze model output. Test sets were blinded from the convolutional neural network until training was completed. For the surgical complexity model, a separate validation set of computed tomography images was evaluated by a blinded panel of 6 expert AWR surgeons and the surgical complexity DLM. Analysis started February 2020. Exposures: Image-based DLM. Main Outcomes and Measures: The primary outcome was model performance as measured by area under the curve in the receiver operating curve (ROC) calculated for each model; accuracy with accompanying sensitivity and specificity were also calculated. Measures were DLM prediction of surgical complexity using need for component separation techniques as a surrogate and prediction of postoperative surgical site infection and pulmonary failure. The DLM for predicting surgical complexity was compared against the prediction of 6 expert AWR surgeons. Results: A total of 369 patients and 9303 computed tomography images were used. The mean (SD) age of patients was 57.9 (12.6) years, 232 (62.9%) were female, and 323 (87.5%) were White. The surgical complexity DLM performed well (ROC = 0.744; P < .001) and, when compared with surgeon prediction on the validation set, performed better with an accuracy of 81.3% compared with 65.0% (P < .001). Surgical site infection was predicted successfully with an ROC of 0.898 (P < .001). However, the DLM for predicting pulmonary failure was less effective with an ROC of 0.545 (P = .03). Conclusions and Relevance: Image-based DLM using routine, preoperative computed tomography images was successful in predicting surgical complexity and more accurate than expert surgeon judgment. An additional DLM accurately predicted the development of surgical site infection.

Preoperative botulinum toxin A injection in complex abdominal wall reconstruction- a propensity-scored matched study.

INTRODUCTION: Fascial closure during complex abdominal wall reconstruction (AWR) improves recurrence and wound infection rates. To facilitate fascial closure in massive ventral hernias preoperative Botulinum Toxin A (BTA) injection can be used. METHODS: 2:1 propensity-scored matching of patients undergoing AWR with and without BTA was performed based on BMI, defect width, and loss of domain using CT-volumetric analysis. RESULTS: 145 patients without BTA and 75 with BTA were comparable on hernia size (240vs251cm2, p = 0.589) and hernia volume (1405vs1672cm3, p = 0.243). Patients with BTA had higher wound class (CDC≥3 37%vs13%, p < 0.001). Patients with BTA had a higher fascial closure rate (92%vs81%, p = 0.036), received more components separation (61%vs47%, p = 0.042), lower wound infection rate (12%vs26%,p = 0.019) and comparable recurrence rates (9%vs12%, p = 0.589). Recurrences occurred more often without complete fascial closure compared to patients with (33%vs7%, p < 0.001). CONCLUSION: In patients with massive ventral hernias and severe loss of domain, preoperative BTA-injection improves fascial closure rates during AWR.