|Year : 2018 | Volume
| Issue : 2 | Page : 55-59
Prevention of seroma formation after laparoscopic inguinoscrotal indirect hernia repair by a new surgical technique: A preliminary report
Junsheng Li, Zhenling Ji, Xiangyu Shao
Department of General Surgery, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
|Date of Submission||21-Jun-2018|
|Date of Acceptance||19-Jul-2018|
|Date of Web Publication||16-Aug-2018|
Dr. Junsheng Li
Department of General Surgery, Affiliated Zhongda Hospital, Southeast University, Nanjing 210009
Source of Support: None, Conflict of Interest: None
BACKGROUND: Seroma formation is a frequent complication of laparoscopic inguinoscrotal hernia, and the most appropriate technique regarding the distal sac management in laparoscopic inguinoscrotal hernia is still debated. The aim of this study is to present a new technique to manage the large distal sac and to avoid the clinical significant seroma formation after laparoscopic inguinoscrotal hernia repair.
MATERIALS AND METHODS: One hundred and ninety-five consecutive elective inguinal hernias were performed in our group in 1-year period and 12 of them were inguinoscrotal indirect hernias, defined as the hernia sac descending into the scrotum. In these inguinoscrotal hernia patients, the distal hernia sacs were transected and left in place without complete dissection out of scrotum and reduction. Then, the lower edge of the distal sac was fixed to the posterior abdominal wall cranial and lateral to the internal ring with barbed suture. The patients were prospectively followed with physical examination, and in five of them, ultrasound was performed on the 1st day and 7th day after the operation. The primary postoperative outcome parameter was seroma formation; the secondary parameters included groin pain, surgical complications, and early hernia recurrence.
RESULTS: Only one patient developed clinical significant seroma by physical examination during the follow-up period. The patients complained no chronic groin pain, and there were no other surgical complications and early hernia recurrence in these series.
CONCLUSION: Seroma formation could be effectively prevented by suspension of the lower edge of the distal sac to the posterior abdominal wall is an easy, reproducible, reliable, and cost-effective method to prevent postoperative clinical significant seroma formation after laparoscopic inguinoscrotal hernia repair. Although the early results were promising, the comparative studies and randomized controlled trials are necessary for further evaluation.
Keywords: Hernia sac, inguinal hernia, inguinoscrotal, laparoscopic repair, seroma
|How to cite this article:|
Li J, Ji Z, Shao X. Prevention of seroma formation after laparoscopic inguinoscrotal indirect hernia repair by a new surgical technique: A preliminary report. Int J Abdom Wall Hernia Surg 2018;1:55-9
|How to cite this URL:|
Li J, Ji Z, Shao X. Prevention of seroma formation after laparoscopic inguinoscrotal indirect hernia repair by a new surgical technique: A preliminary report. Int J Abdom Wall Hernia Surg [serial online] 2018 [cited 2021 Apr 20];1:55-9. Available from: http://www.herniasurgeryjournal.org/text.asp?2018/1/2/55/239129
| Introduction|| |
Total extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) techniques are the two most widely adopted laparoscopic procedures for inguinal hernia repair with favorable clinical outcomes, such as shorter hospital study, minimal postoperative pain, and decreased surgical site infection. However, seroma formation is the most frequent complication after laparoscopic repair., Various seroma formation rates (0.5%–15%) have been reported in literature,,, and with no surprise, the frequency and volume of seroma increased significantly in large and scrotal inguinal hernias.,,Many reasons have been attributed to the development of seroma formation after laparoscopic inguinal hernia repair, including the dissection of preperitoneal space for mesh placement, the existence of dead space after hernia sac reduction, and the irrigation of prosthetic materials implanted in preperitoneal space. The seroma often fills the inguinal canal and previous hernia site; thus, a suspicion of recurrence would be raised by the patient, and it also often puts the surgeon in a dilemma as to whether it is a real recurrence or just a seroma. Several perioperative measures have been described in literature to minimize seroma formation, including the use of a drainage, pressure dressing, and obliteration of the dead space by suture and fibrin glue, while not all of these measures were with conclusive results.,, Furthermore, seroma is regarded as a natural course after laparoscopic inguinal repair, unless complained by the patients, since most of them would dissolve by the time and cause no adverse consequences. In addition, the optimal approach of distal sac management in laparoscopic inguinoscrotal hernia is still debated. Thus, in the present study, we present a new method to address this problem. We divided the hernia sac and fixed the lower edge of the distal hernia sac to the ipsilateral posterior abdominal with barbed suture, with the aim to decrease the incidence and volume of seroma formation following laparoscopic inguinoscrotal inguinal hernia repair. To the best of our knowledge, this is the first report of this technique; we believe this technique is a reasonable, safe, reproducible, and cost-effective method to address the problem of seroma formation in large inguinoscrotal hernia repair.
| Materials and Methods|| |
From May 2017 to May 2018, 195 consecutive elective inguinal hernias were performed with either laparoscopic technique (TAPP or TEP) or open techniques in our group. Among them, 12 consecutive primary inguinoscrotal hernias which were laparoscopic repaired were prospectively included in this study. Hernias smaller than this size, recurrent hernias, or direct inguinal hernias and patients not fit for laparoscopic repair due to other medical conditions were excluded from the study. Informed consents were obtained from all the patients.
In the present study, both TAPP and TEP were used, since they are quite comparable for inguinal hernia repair. All operations were carried out by the same surgical team with meticulous hemostasis. All patients were operated under general anesthesia. The TAPP or TEP repairs were performed using a standardized technique previously described elsewhere.,, During hernia sac dissection, we did not completely dissect the distal part of the sac; only the proximal hernia sac was dissected from the spermatic cord structures. In TEP procedure, the hernia sac was opened and the hernia content was reduced if it was not reduced before operation [Figure 1], then the proximal end of the sac was ligated [Figure 2], the distal hernia sac was transected distal to the ligation site and left in place. In TAPP technique, the distal hernia sac was divided without the need of hernia sac ligation. In both TAPP and TEP, special attention was paid not to divide the hernia sac at a too distal point; this will facilitate the sac fixation in the next step. Then, the lower edge of the divided distal sac was grasped [Figure 3] and fixed cranially and laterally to the posterior abdominal wall with barbed suture (3–0 barbed suture, V-Loc™ 180, Covidien™, USA) [Figure 4], [Figure 5], [Figure 6]; usually two repeated sutures were enough, and the fixation site was chosen at least 2 cm away from the internal ring, and there are no important nerves and vessels in this area.
|Figure 1: The indirect hernia sac was opened to expose the hernia content in total extraperitoneal procedure|
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|Figure 2: The proximal hernia sac was ligated in total extraperitoneal procedure|
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|Figure 3: The lower edge of the transected distal hernia sac was grasped|
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|Figure 4: A barbed suture was made on the posterior abdominal wall cranial and lateral to the internal ring|
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|Figure 5: The lower edge of the distal sac was sutured to the abdominal wall|
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|Figure 6: The fixation was completed and the distal hernia sac was still open|
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The proximal sac and peritoneum are dissected as proximally as possible to achieve parietalization of the cord for mesh placement. At the end of the procedure, the mesh was introduced and the peritoneum was closed with suture in TAPP. We routinely use a lightweight, macroporous, polypropylene mesh, and neither traumatic fixation was needed nor drainage was used.
Age, sex, side of hernia, laparoscopic procedure, operation time, hospital stay, and postoperative complications were prospectively documented. Since all cases were inpatient patients, patients were initially reviewed on the next day morning after operation and the next examination time point was 7 days later for skin suture removal. Patient's pain scale and seroma were recorded. Pain scales numbered from 0 (no pain) to 10 (worst pain). The ultrasonography (USG) was performed postoperatively on the 1st postoperative day or within 5–7 days after operation depending on the appointed schedule. All patients were advised to return to the clinic in case of delayed complications or any unexpected problems, especially chronic pain and groin swelling. There was no funding or sponsorship obtained from any commercial institution.
| Results|| |
Among the consecutive 195 elective inguinal hernias performed in our group, 12 of them were primary inguinoscrotal indirect hernias, defined as hernia extending into the scrotum. All patients were male, with the median age of 55 years old (range, 22–76 years); all the procedures (3 with TEP and 9 with TAPP) were successful, with no intraoperative adverse events in these series. Median operation time was 67 min (35–120 min) and median postoperative stay was 1 day (1–2 days). Only one patient developed clinical physical detectable seroma during the follow-up period by physical examination. USG was performed in five cases (before postoperative day 7, depending on the available schedule date), one case had evident clinical seroma, and an or less amount seroma or fluid collection was detected in the rest of the cases, although seroma was detectable with sonography, however, not detectable by physical examination due to the less amount in the scrotum, or due to the seroma only collected in the groin area. Moreover, patients felt only slight pain the next morning after operation (AVS ≤3), the pain became minimal 7 days later, and no chronic pain or neurological pain was recorded. All patients were discharged without complications. During the follow-up period (1–12 months), there are no pain, seroma, and recurrence.
| Discussion|| |
Various incidence of seroma formation has been reported in literature, and the increased frequency and volume of seroma formation were associated with large or inguinoscrotal hernias. Lau et al. reported a seroma rate of 5.7% in nonscrotal hernias and increased to 22.9% in scrotal hernias following TEP. Furthermore, Misra's reported seroma development rate as high as 70% in massive scrotal hernias after TEP procedure; similarly, Cihan revealed a 56.7% of seroma rate on the 1st operative day in large hernias after TEP repair on physical examination, and the rate increased to 66.7% as the USG was used.
The need for extensive dissection of the preperitoneal space and the placement of a mesh, as well as the inflammatory response related to surgical applications, such as cutting and catheterization, all act together leading to the exudation of fluid and subsequent seroma formation after laparoscopic repair. Thus, in a certain degree, the seroma formation can be regarded as a normal wound healing process after laparoscopic repair of inguinal hernia, unless it causes pain or discomfort. All the seromas developed below the external ring and under the superficial soft tissue of the groin or the scrotum, where the hernia sac existed. The fluid collection in this area puts the surgeon in a dilemma about whether it is a seroma or hernia recurrence, which also dominates the main complaint of the patients. Furthermore, the fluid in the scrotum will take long time to be absorbed or need multiple needle aspirations.
Several different kinds of procedures have been described in the literature to address the problem of seroma formation, including the use external compression, the application of fibrin sealant in the preperitoneal space, and dwelling a closed-suction drain in the preperitoneal space. Although positive results were occasionally reported in literature,, conflicting results existed with the use of fibrin glue in this purpose. Furthermore, the placement of drainage is with a potential risk of iatrogenic infection and could only be placed for a short period of time. Pressure dressing is usually difficult to apply over the groin region. Nevertheless, the optimal management of the distal sac is still debated, and some support the complete dissection of the sac to avoid the seroma formation;, however, this complete dissection may be difficult in certain cases and carry the risk of injury to adjacent vasculature. Although in direct hernia repair, Reddy et al. reported a method of inversion and staple fixation of the lax fascia transversalis to Cooper's ligament, which reduced the incidence of seroma formation after laparoscopic repair of direct inguinal hernia, and we also used barbed suture technique to close the direct hernia defect by suturing the transversalis fascia. However, these approaches were not applicable to indirect hernia, since there is no lax fascia transversalis for management in indirect hernia. Interestingly, Daes et al. reported a method of pulling up the distal hernia sac out of the scrotum and fixing it to the posterior abdominal; and they reported the low incidence of clinical significant seroma in indirect inguinoscrotal hernia repair. However, in some cases of large scrotal hernia, the distal sac was difficult to be inversed or the hernia sac even adhered firmly to the ipsilateral testicle and other structures; besides, the use of Protack™ in Daes's approach also significantly increases the whole cost of the hernia repair procedure. Thus, in the our method, we did not invert the distal sac, we left the distal sac in place, the advantages of our method are that we avoid pulling out the distal sac. Since the potential space localized behind the mesh and extending into the scrotum is one of the main causes of the annoying seroma, in our technique, the lower edge of the distal sac was lifted and fixed to the posterior abdominal wall in the site lateral and cranial to the internal ring, which prevents the inflow of any exudation and fluid generated in the preperitoneal space during and after operation into the distal hernia sac in the scrotum. Furthermore, the distal hernia sac is not completely closed, since the upper edge of the sac was not sutured, thus preventing the potential fluid collection from the secretion of distal sac itself. Another advantage of this method is that leaving the distal sac undissected minimized the risks of damage to the cord structures.
In the present method, the suture fixation site is above the iliopubic tract, at least 2 cm lateral and cranial to the internal ring; thus, there is no worry about the important nerves to be trapped by the sutures. Usually, the genital nerve runs and makes an entry point within 1 cm around the internal ring. Moreover, this fixation site is also away from the entry points of iliohypogastric nerve and ilioinguinal nerve into the posterior abdominal wall, which both enter the abdominal dorsally to the anterior superior iliac spine. In our series of 12 cases of inguinoscrotal hernias performed with TAPP/TEP, only one case developed clinical significant palpable seroma, which required one time of needle aspiration and the seroma did not recur.
Although no exact criteria are given about evaluating seroma as a complication, the duration, location, size, and patient's complaints are important considerations. Since seroma is more or less a natural course after the laparoscopic surgical process, our aim was to prevent the seroma formation in the distal hernia sac, thus alleviating the signs and symptoms caused by seroma. Our results indicated that inguinoscrotal patients treated with laparoscopic repair can benefit from the present technique by suspension of the lower edge of the distal hernia sac to the posterior abdominal wall. However, the present study is a preliminary report; although the early results are promising, comparative or randomized controlled trials are necessary for further evaluation.
| Conclusion|| |
Our preliminary results indicated that suspension of the lower edge of the distal sac is a feasible and effective method to prevent seroma formation after laparoscopic inguinoscrotal hernia repair.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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