From imaging to outcomes: evaluating the predictive value of preoperative CT for intra and postoperative outcomes in ventral hernia repair – a systematic review

Introduction: Although ventral hernia repair (VHR) is one of the most commonly performed general surgery procedures worldwide, postoperative complications remain a significant concern, impacting patient outcomes and healthcare costs. Preoperative computed tomography (CT) is commonly used to assess abdominal wall anatomy and evaluate surgical risks. However, the predictive value of CT findings for postoperative complications remains unclear. This study represents a comprehensive systematic review to evaluate the role of preoperative CT in predicting postoperative complications following VHR. Methods: Following the PRISMA guidelines, an online search was conducted using PubMed, Cochrane, and Embase from inception to February 18, 2025. Studies investigating the influence of preoperative CT as a predicting tool to evaluate postoperative complications following VHR were included. The outcomes analyzed were need for component separation, fascial closure rate, surgical site infection (SSI), surgical site occurrences (SSO), and recurrence rates. Results: From 2,167 records, 24 studies were fully reviewed after screening, and 14 were included in this review, encompassing 1,707 patients. The majority of operations were performed using an open approach (1,121; 65.7%), followed by robotic (137; 8%), and laparoscopic repair (30; 1.8%). In 419 cases (24.5%), the surgical approach was not specified. Most articles evaluated the need for additional myofascial release or component separation for defect closure based on the mean hernia width/volume, varying from 7.50 to 19.08, and rectus width: defect width ratio, varying from 1.22 to 3.85, as evidenced on preoperative CT scan. Besides that, Component Separation Index (CSI), when available, is an important tool to foresee a tension-free fascial closure and highlights the need for component separation when the CSI is > 0.068. Other articles used the preoperative CT to evaluate sarcopenia or abdominal fat thickness to predict complications, including surgical site and systemic complications, recurrence rates, varying from 2.56 to 56.25% in patients with sarcopenia, and mortality, which established an association between sarcopenia and a higher mortality risk. Conclusion: Recent studies emphasize the increasing importance of preoperative CT in evaluating ventral hernias, offering objective parameters to guide surgical decision-making. Metrics such as visceral fat volume, rectus width: defect width ratio, muscle attenuation, and composite indices have demonstrated to be highly valuable in predicting the need for component separation, successful tension-free fascial closure, and postoperative complications. Additionally, clinical factors alone seem to hold less predictive value compared to specific radiologic characteristics. These findings indicate that a standardized integration of CT-based metrics into surgical planning may improve patient outcomes in VHR.