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PICTORIAL REVIEW
Multidetector CT of expected findings and early postoperative
complications after current techniques for ventral hernia repair
Massimo Tonolini
1
&Sonia Ippolito
1
Received: 26 February 2016 /Revised: 31 March 2016 / Accepted: 3 May 2016
#The Author(s) 2016. This article is published with open access at Springerlink.com
Abstract
Current techniques for ventral hernia repair (VHR) rely on
prosthetic mesh implantation and are increasingly performed
laparoscopically. Potentially serious iatrogenic complications
may occur following VHR, though these are rare compared to
the vast number of procedures performed each year. This pa-
per provides an overview of contemporary open and laparo-
scopic surgical techniques and biomaterials, then reviews and
illustrates the expected postoperative imaging appearances,
and common and unusual early complications after VHR.
Emphasis is placed on multidetector computed tomography
(CT), which comprehensively visualizes the operated anterior
abdominal wall and deeper intra-abdominal structures. CT
consistently allows diagnosis of postoperative seromas, ab-
dominal wall abscesses and fistulas, haemorrhages with or
without active bleeding, bowel obstruction, peritonitis and
recurrent hernias, and thus providing a reliable basis for an
appropriate choice between conservative, interventional, or
surgical treatment. Familiarity with early post-surgical CT is
warranted to avoid misinterpretation of the expected imaging
appearance and correctly elucidate postoperative complica-
tions after VHR.
Teaching points
•Open and laparoscopic repair of ventral hernias rely on
prosthetic mesh implantation.
•Potentially serious iatrogenic complications occasionally
occur after ventral hernioplasty.
•Multidetector CT consistently evaluates the operated ab-
dominal wall and deeper structures.
•Familiarity with the expected early postoperative imaging
appearance is required.
•Complications include seroma, infections, haemorrhage,
bowel obstruction, peritonitis, and recurrence.
Keywords Ventral hernia .Hernioplasty .Prosthetic mesh .
Complications .Computed tomography (CT)
Introduction
Since the early 1990s, two major technical advances have
revolutionized the field of ventral hernia repair (VHR).
Firstly, most surgeons switched from traditional to modern
mesh-based Btension-free^techniques, thus achieving a sig-
nificant decrease in the rate of hernia recurrence [1,2].
Secondly, despite requiring greater expertise and a longer op-
eration time, the increasing use of laparoscopy in VHR has
allowed better cosmetic results and faster return to normal
activities [3,4].
Rarely, in a minority of operated patients, VHR results in
potentially serious short-term complications. Owing to the
vast number of open and laparoscopic interventions per-
formed each year at most general hospitals, radiologists may
be confronted with urgent requests to investigate suspected
iatrogenic injuries. However, the radiological reports on this
subject that are currently available are mostly focused on the
normal imaging appearance of prosthetic meshes (PMs), the
occurrence and fate of common post-surgical seromas [5,6],
the value of computed tomography (CT) for diagnosis of re-
current hernias [7], and complications secondary to laparo-
scopic access for different surgical procedures [8].
*Massimo Tonolini
mtonolini@sirm.org
1
Department of Radiology, BLuigi Sacco^University Hospital, Via
G.B. Grassi 74, 20157 Milan, Italy
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DOI 10.1007/s13244-016-0501-x
Conversely, very limited literature is available describing
the imaging appearance of common and rare postoperative
complications after VHR. This pictorial essay provides an
overview of curent open and laparoscopic surgical techniques,
then reviews and illustrates the expected postoperative appear-
ance and the imaging features of iatrogenic complications.
Most emphasis is placed on multidetector CT, which repre-
sents the mainstay modality to promptly and comprehensively
visualize the operated abdominal wall and deeper intra-
abdominal structures, thus providing a consistent basis for
appropriate choice between conservative, interventional, or
surgical treatment. Since timely recognition and management
of complications are essential in limiting iatrogenic morbidity,
the aim of this pictorial essay is to improve radiologists’fa-
miliarity with interpretation of early post-surgical CT studies.
Overview of surgical techniques
Broadly defined as Ba protrusion of tissues through a defect of
the anterior abdominal wall^, ventral hernias represent a high-
ly prevalent but heterogeneous problem in general surgery.
The European Hernia Society (EHS) categorizes abdominal
wall hernias as either primary or incisional. The former group
includes midline (epigastric and umbilical) and lateral
(spigelian and lumbar) hernias, which are classified according
to their size (<2 cm, >4 cm, or intermediate). Congenital or
acquired umbilical hernias represent the most common prima-
ry hernias [9].
An incisional hernia is defined as Bany abdominal wall gap
with or without a bulge in the area of a postoperative scar
perceptible or palpable by clinical examination or imaging
from incisional hernias^. Incisional hernias develop after any
abdominal surgery, with an incidence approaching 20 %, and
are increasingly encountered because of increased life expec-
tancy and the high prevalence of risk factors such as obesity
and diabetes. Recurrences after repair of primary hernias fall
in the incisional group [9].
Indications for VHR include pain, cosmesis, and preven-
tion or treatment of complications such as bowel obstruction
and strangulation [1,2]. At our hospital, the mean case volume
approaches 110 VHR procedures each year; the vast majority
(85–90 %) are for incisional hernias.
Before the availability of modern PMs, the rate of postop-
erative hernia recurrence approached 50 %. Current tech-
niques for VHR rely on PM implantation, may be performed
during either open surgery or –increasingly –laparoscopic
surgery, and consistently achieve favourable results with min-
imal perioperative morbidity (3.7 % overall complication rate)
and limited (7.5–10 %) recurrence rate [1,3,4,10–12].
Open VHR is recommended for large (>10 cm) abdominal
wall defects. The sublay-mesh (Rives–Stoppa) procedure re-
mains the preferred open technique to treat ventral (particular-
ly incisional) hernias. Following skin incision, the surgeon
opens the hernial sac, dissects the anterior abdominal struc-
tures up to the preperitoneal space, and removes the previous
surgical scar, adhesions in the abdominal cavity and the her-
nial sac itself. The PM is then implanted extraperitoneally in
the newly formed space, interposed between the posterior rec-
tus sheath and rectus muscle. Very large hernias with lateral
displacement of the rectus abdominis muscles require open
repair with the intraperitoneal onlay-mesh (IPOM) technique:
Fig. 1 Usual imaging appearance of polypropylene (PP) prosthetic mesh
(PM) in a 72-year-old male, two weeks after uncomplicated open repair
(Rives-Stoppa technique) of a large ventral incisional hernia. On sagittal
(a)andaxial(b) post-contrast CT images, a thin structure (thin arrows)
with soft-tissue attenuation is identified at the deep aspect of the atrophic
rectus abdominis muscles (+), which corresponds to the PP PM
interposed between the parietal peritoneum and muscle sheath.
Asymptomatic adhesion of the caudalmost portion of the PM to the
urinary bladder (thick arrow in A) was incidentally noted
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after exposure and opening of the hernial sac, adhesions be-
tween the abdominal wall and intestinal loops are detached,
the hernial sac is removed, and a large PM is positioned from
the inside over the breach [10–14].
Conversely, laparoscopic VHR involves creation of pneu-
moperitoneum, introduction of instruments through the trocar
ports, and reduction of herniated bowel loops into the perito-
neal cavity. The PM is placed intraperitoneally over the defect,
without excision of the hernia sac [15].
With either approach, sutures, fixation screws or an addi-
tional second PM may be used to reinforce the repair.
Thorough yet easy-to-understand step-by-step graphical ex-
planations of the open and laparoscopic techniques described
above are freely downloadable from the dedicated www.
herniamed.de website [13–15].
Imaging techniques after ventral hernia repair
Role of ultrasonography
After VHR, the early postoperative assessment is essentially
based on physical findings. Some authors have advocated
ultrasonography as a useful adjunct to clinical evaluation.
Although sonographic visualization of the PM is inconsistent,
ultrasonography may rapidly detect anechoic collections of
Fig. 2 Usual imaging appearance of expanded polytetrafluorethylene
(ePTFE) PM following recent laparoscopic repair of a ventral incisional
hernia in a 70-year-old overweight male, suffering from postoperative
abdominal pain and vomiting. Axial (a), sagittal (b) contrast-enhanced
CT images and coronal maximum-intensity projection (MIP)
reconstruction (c) showed the moderately hyperattenuating PM (thin
arrows), fixed by metallic sutures, without abnormal collections. Note
distended small bowel loops (*) with intraluminal fluid consistent with
clinical diagnosis of postoperative intestinal obstruction, which required
laparotomic surgery including redo hernia repair
Fig. 3 CT assessment of a 15x9 cm Gore-Tex Dual-Mesh® PM
positioned laparoscopically 18 months earlier after previous failed
attempts to repair an epigastric hernia. The ePTFE PM (thin arrows)
secured by metallic-attenuation sutures is easily recognized on
unenhanced axial CT image (a), and well depicted in its entirety and
reticular structure by three-dimensional volume-rendering
reconstructions (b,c). Additionally, a clinically unsuspected focal
breach (arrowheads) was noted at its upper aspect, probably resulting
from excessive tension
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serous fluid and variably echogenic haematomas [16,17].
However, particularly in the early postoperative setting, phys-
ical and sonographic assessment are both frequently hampered
by obesity, thickened subcutaneous fat, the presence of med-
ications, and local tenderness at the surgical wound.
Multidetector CT: role and technique
Compared to ultrasonography, cross-sectional imaging with
multidetector CT consistently provides panoramic visualiza-
tion of normal structures and postoperative changes at the
anterior abdominal wall, and often provides additional infor-
mation that may prove crucial for identification of possible
complications [5–8,18].
Similarly to the preoperative assessment of ventral hernias,
the CT acquisition protocol should encompass the entire ab-
domen, from the diaphragm to the symphysis pubis. Strategies
for dose reduction, such as automated tube current modula-
tion, or, if available, iterative reconstruction, are recommend-
ed [19].
Unless contraindicated by allergy or renal failure,
contrast enhancement is warranted when there is con-
cern about infection, haemorrhage, or bowel complica-
tion. In most patients, we routinely obtain a portal-
venous phase acquisition, which, in our experience, pro-
vides the best delineation of seromas, fistulas, and ab-
scesses. A preliminary unenhanced scan allows identifi-
cation and measurement of the size and Hounsfield unit
(HU) attenuation of fluid or haemorrhagic collections,
but may be omitted in order to limit the dose of
ionizing radiation, particularly in patients who are youn-
ger than 45 years. When clinically suspected, an addi-
tional arterial-phase scanning is beneficial to detect ac-
tive bleeding. In addition to reviewing axial images, we
recommend routine image reconstruction and study in-
terpretation along the sagittal orientation, which pro-
vides the best visualization of the anterior abdominal
wall [5,8,18].
Biomaterials used for ventral hernia repair
A proliferation of mesh products for VHR are currently avail-
able. The most common PMs are made of polypropylene (PP)
or expanded polytetrafluoroethylene (ePTFE). Both types are
invisible on plain radiographs, and sonographically appear
hyperechoic with posterior acoustic shadowing.
Visualization of PMs by CT is highly variable, depending on
the intrinsic density, thickness, woven or nonwoven, knitted
or not-knitted structure, and surrounding inflammatory reac-
tion [20].
Monofilament, double-filament (such as Prolene; Ethicon,
Inc., Somerville NJ-USA), and multifilament (such as
Surgipro; Covidien, Minneapolis MN-USA) PP PMs are thin
and isoattenuating to muscles and, therefore, generally invis-
ible or hardly differentiated from the deeper fascia of the rec-
tus abdominis muscles and parietal peritoneum (Fig. 1).
Conversely, thicker ePTFE PMs (such as the Gore-Tex
Dual-Mesh; W.L.Gore & Associates, Inc., Flagstaff, AZ–
USA) are consistently recognized as hyperdense lines behind
Fig. 4 Common appearance of postoperative seroma detected six days
after open ventral hernia repair (VHR) in a 51-year-old female.
Unenhanced (a) and post-contrast (b) axial CT images showed a small-
sized midline fluid-attenuating collection (+) containing tiny gas bubbles,
interposed between the rectus muscles, abutting the PM-reinforced
parietal peritoneum indicated by a linear structure isoattenuating to
muscles (thin arrows). In the absence of clinical and laboratory signs of
infection, thin peripheral contrast enhancement (arrows in b)was
observed. The seroma eventually resolved without any additional
treatment
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the muscles of the abdominal wall (Figs. 2and 3). Finally,
composite PMs including an ePTFE component (such as the
Bard Composix; Bard Davol Inc., Warwick RI-USA) are less
consistently recognizable. Visualization of faintly
Fig. 5 Postoperative abscess
following recent open repair of
post-laparotomic hernia in a
77-year-old female, clinically
heralded by hard-consistency and
inflamed swelling at the anterior
abdominal wall. Unenhanced (a),
post-contrast (b) axial and sagittal
(c) CT images showed a sizeable
(12x4 cm) collection (*) abutting
the anterior aspect of the PM (thin
arrows), with 16–18 Hounsfield
units (HU) internal attenuation
and thick irregular peripheral
enhancement (arrows in b,c). The
corresponding, unspecific
sonographic appearance (d)wasa
poorly demarcated hypoechoic
region (calipers) with posterior
acoustic shadowing. The abscess
resolved with percutaneous
drainage and antibiotics
Fig. 6 A 51-year-old male experienced wound dehiscence with culture-
proven Staphylococcus aureus infection following Rives-Stoppa repair of
a ventral incisional hernia. Ultrasound (a) showed an ill-defined,
inhomogeneously hypoechoic region (caliper) at the surgical site,
without fluid portions amenable to aspiration. Corresponding post-
contrast axial (b) and sagittal (c) CT images showed a band-shaped
abscess (*) of the anterior abdominal wall with enhancing periphery
(arrows), interposed between the PM and rectus muscles, which drained
externally through a fistula (thick arrows in c) (note hyperattenuating plug at
skin orifice)
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hyperattenuatingPMsmaybeimprovedbytheuseof
maximum-intensity projection (MIP) reconstructions
(Fig. 2c). When present, metallic surgical staples or
tacks used for mesh fixation are easily visible
(Figs. 2and 3). Additionally, three-dimensional vol-
ume-rendering images effectively visualize the posi-
tion, spatial configuration, and reticular structure of
the PM (Fig. 3)[5,6,8].
Fig. 7 In a 75-year-old female,
after recent open repair of post-
hysterectomy incisional hernia,
axial (a), coronal (b), and
oblique-coronal (c) multidetector
CT images depicted a crescent-
shaped abscess of the anterior
abdominal wall (*) with
enhancing periphery, connected
to the cutaneous opening by a
fistula (thick arrows). Surgical
reintervention with PM removal
and replacement was required
Fig. 8 Another case of fistulising
post surgical infection in a
41-year-old male after VHR of
recurrent incisional hernia.
Pus-yielding wound infection
corresponded on axial (a)and
sagittal (b) post-contrast CT
images to a small-sized collection
with mixed air (+) and fluid (*)
content in the typical midline site,
abutting the PM ventrally. A
characteristic tram-track fistula
(thick arrows) drained the
collection towards the skin, and
was a surrounded by extensive
inflammatory stranding of the
subcutaneous fat
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Early postoperative CT findings and seromas
In the early postoperative setting, suction drains may be
in place, and their position should be reported. Hours or
a few days after recent laparoscopic VHR, some resid-
ual intraperitoneal gas is commonly observed. Similarly,
mild to moderate subcutaneous emphysema from insuf-
flation into the abdominal wall during trocar passage
generally does not represent a complication, provided
there are no clinical or laboratory findings suggesting
peritonitis or necrotizing fasciitis [8].
Postoperative seromas develop at the operated anteri-
or abdominal wall in almost 10 % of patients. After
open VHR, serous fluid collects in the retromuscular–
prefascial space; conversely, following laparoscopic sur-
gery, seromas result from peritoneal fluid flowing
through the porous PM and accumulating within the
residual hernia sac [8,11,12,21].
At CT, serous collections may have different shapes (glob-
ular, multiloculated, or tubular). Seroma is confidently diag-
nosed when a collection shows fluid attenuation and does not
enhance. Unfortunately, in the early postoperative days, iden-
tification of air-fluid levels and thin reactive peripheral en-
hancement (Fig. 4) was not unusual. In this case, differentia-
tion from an abscess is challenging and relies on correlation
with clinical and laboratory findings. Conversely, a thick or
irregular enhancing Brim^should suggest infection rather than
seroma [5,6,8].
Seromas should be managed conservatively unless they are
large, painful, or persistent after 4–6 weeks, and aspiration is
contraindicated to prevent superinfection [3,4,8,21].
The appearance of complications on multidetector
CT imaging
Although post-VHR iatrogenic complications are reported in
up to 18–25 % of patients overall, the majority of cases are
minor and do not require hospitalization or specific treatment.
The commonest specific complications include infection,
small bowel obstruction, and haemorrhage, in descending or-
der of frequency [3,4,11,12].
Fig. 9 In a 75-year-old male, six
weeks after VHR ultrasound (a)
depicted a huge (25x11x18 cm)
subacute haemorrhagic collection
with mixed anechoic fluid, thick
walls, and septa. Axial (b)and
sagittal (c) unenhanced CT
images depicted the liquefied
haematoma (*) centered in the
anterior abdominal wall, causing
dislocation and compression of
the PM indicated by the presence
of metallic fixation clips.
Repeated unenhanced CT (d)
showed the postoperative status
following drainage of two litres of
serum and old blood
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Wound and deep infections
Wound infections occur more frequently after open
VHR (9–14 % incidence) compared with laparoscopic
surgery (<2 % of patients), and generally resolve with
local wound care and washing and antibiotics. The more
serious deep PM-related infections are reported in up to
2–4 % of patients, and are often associated with specific
risk factors, including obesity, diabetes, and urgency, or
prolonged duration of surgery. Clinical manifestations
such as purulent discharge, tender swelling, fever, ab-
normal acute-phase reactants, and leukocyte count
should be investigated with bacteriological cultures and
treated aggressively. Mesh infection is of concern to
surgeons, since it cannot be treated with antibiotics
and almost invariably requires removal of the PM
[2–4,11,12].
The characteristic CT appearance of a post-surgical
septic collection after VHR is that of an abscess with
thick, irregular peripheral enhancement, which develops
ventrally to the PM-reinforced parietal peritoneum, and
may remain contained within the muscles of the abdom-
inal wall (Fig. 5), or extend to the anterior abdominal
skin through a cutaneous fistula (Figs. 6,7and 8).
Haemorrhage
After VHR, abdominal wall haematomas may occur in up to
4.7 % of patients, resulting from unrecognized intraoperative
injury to tiny vessels or to laparoscopic trocar placement. The
variable clinical manifestations include swelling, pain, and
ecchymosis. External bleeding from the trocar access port is
not unusual, particularly in delayed bleeding [3,4,11,12].
Multidetector CT reliably depicts abdominal wall
haematomas in their entire extent, as high-density col-
lections with attenuation ranging between 30 and 80
HU, depending on the duration of the bleeding
(Figs. 9,10,and11). Surgical revision and PM removal
are necessary when the haematocrit drops and CT find-
ings indicate major bleeding. Although uncommon, the
Fig. 10 Post-surgical haematoma
developed within three days after
VHR in a 44-year-old female,
with physical finding of
postoperative swelling at the
anterior abdominal wall.
Unenhanced axial (a) and sagittal
(b) images showed a demarcated
midline collection with
heterogeneous attenuation (*)
abutting the rectus muscles
externally and occupying the
subcutaneous fat. Axial (c)and
coronal (d) post-contrast CT
images showed minimal
peripheral enhancement (arrows),
without signs of active bleeding
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identification of active bleeding as contrasted with ex-
travasation isoattenuating with enhanced vessels
(Fig. 11) indicates the need for interventional or surgical
treatment [8,18].
Bowel obstruction
Whereas postoperative ileus is rather common, in patients
with clinical or radiographic signs of intestinal obstruction
Fig. 11 Active post-surgical
bleeding in an elderly 84-year-old
female with acute abdominal
pain, hard-consistency swelling,
and severe blood loss (8 g/dl nadir
haemoglobin) 24 hours after
Rives-Stoppa repair of a midline
incisional hernia. Emergency CT
depicted a 15x6x13 cm
hyperattenuating (median 55 HU)
fresh haematoma (*), extending
ventrally from the surgical site
through the rectus muscles and
subcutaneous fat. Note PM (thin
arrows) and drainage tubes
(arrows). Sagittal (c) and coronal
(d) MIP reconstructions showed
serpiginous contrast extravasation
(arrowheads) isoattenuating with
the enhanced aortic lumen within
the haematoma, consistent with
active arterial bleeding.
Relaparotomy confirmed
bleeding suprafascial haematoma,
which required haemostasis and
surgical drainage [Partly
reproduced with permission from
Ref. no. [18]]
Fig. 12 Surgically confirmed iatrogenic injury to the small bowel from
laparoscopic VHR in a 76-year-old male. Sagittal (a), axial (b), and
oblique coronal (c) images from contrast-enhanced early postoperative
multidetector CTshowed abundant fluid (§) and some air in the peritoneal
cul-de-sac consistent with peritonitis, in communication (thick arrows)
with a vast collection (*) with mixed content and air-fluid level (thin
arrows) at the anterior abdominal wall
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after VHR (Fig. 2), adhesions between the PM and the small
(or occasionally the large) bowel should be considered as the
most likely cause. In laparoscopic VHR, contiguity of bowel
loops and intraperitoneally placed PM may ease the formation
of adhesions. Alternatively, CT studies should be scrutinized for
small-bowel herniation in a peritoneal breach, most usually a
trocar access port. Conservative in-hospital treatment, including
decompression by nasogastric tube, may be successful in reliev-
ing low-grade obstruction. Alternatively, laparotomic surgical
revision with or without bowel resection may be required [8].
Bowel injury
Although exceptional (0.06–0.2 % incidence), catastrophic com-
plications such as iatrogenic bowel injury (IBI) occur more fre-
quently after laparoscopic VHR. When unrecognized during sur-
gery, bowel perforation manifests with fever, abdominal pain, and
peritonitis within a week after VHR. Delayed recognition usually
results in increased morbidity and mortality, with enterocutaneous
fistula formation and sepsis [3,4,8].
Moderate degrees of pneumoperitoneum are common-
ly observed during the first postoperative days after lap-
aroscopic surgery. Conversely, CT evidence of peritoni-
tis (Fig. 12) or abnormal intra-abdominal air-fluid col-
lections should suggest the possibility of an IBI.
Perforations usually require prompt surgery, including
bowel resection or Hartmann’sprocedure[8].
Hernia recurrence
Despite the considerably decreased incidence of recurrence
afforded by tension-free repair, after either open or laparo-
scopic VHR, up to 8–9 % of patients still develop recurrent
incisional hernias after a variable time interval [3,4,11,12,
Fig. 13 Failed repair of
peristomal hernia in a 71-year-old
male with a history of previous
Bricker radical cystectomy,
suffering from postoperative
vomiting, persistent abdominal
pain, and local swelling. Axial (a)
and coronal (b) contrast-enhanced
CT images showed recurrent
herniation at the urostomy site of
a dilated, fluid-filled structure
consistent with the ileal conduit
(*). Repeated surgery was
performed
Fig. 14 Failed repair of large ventral incisional hernia in a 50-year-old
obese female. Four days after surgery, urgent CT was obtained because
distended, tender abdomen revealed detachment of the PM (thin arrows)
from the anterior abdominal wall, and recurrent ventral herniation of
intra-abdominal fat (+) and of a portion of the gastric antrum (*)
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21]. In the vast majority of cases, hernia recurrence is reliably
identified using CT (Figs. 13 and 14)[7].
Conclusion
Multidetector CT allows comprehensive assessment of the
operated anterior abdominal wall and is, therefore, recom-
mended to elucidate suspected postoperative complications
after VHR. CT findings consistently allow diagnosis of ab-
dominal wall abscesses and fistulas, haematomas with or
without active bleeding, bowel obstruction, peritonitis, and
recurrent hernias. Familiarity with early post-surgical CT stud-
ies is warranted to avoid misinterpretation of the expected
postoperative appearance.
Open Access This article is distributed under the terms of the Creative
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creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
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priate credit to the original author(s) and the source, provide a link to the
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