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| REVIEW ARTICLES |
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| Year : 2023 | Volume
: 6
| Issue : 1 | Page : 14-22 |
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Seroma-prevention strategies in minimally invasive inguinal hernia repair: A systematic review and meta-analysis
Trina Priscilla Ng1, Brandon Yong Kiat Loo1, Clement Luck Khng Chia2
1 Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
2 Department of General Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| Date of Submission | 20-Jan-2023 |
| Date of Decision | 01-Feb-2023 |
| Date of Acceptance | 10-Feb-2023 |
| Date of Web Publication | 30-Mar-2023 |
Correspondence Address:
Clement Luck Khng Chia
Department of General Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768826
Singapore
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijawhs.ijawhs_5_23
BACKGROUND: The rise of minimally invasive inguinal hernia repair has seen both the laparoscopic and robotic approaches increase in popularity in recent years. Despite this, seroma formation remains a common complication, and the aim of this study is to evaluate the current evidence on seroma-prevention strategies in minimally invasive inguinal hernia repair. MATERIALS AND METHODS: Four databases (PubMed, Scopus, Embase, and Cochrane Library) were searched from inception to November 15, 2021. All studies describing the use of intraoperative adjuncts to reduce postoperative seroma formation in patients undergoing laparoscopic or robotic inguinal and inguinoscrotal hernia repair were included. Meta-analyses were performed using Review Manager (Version 5.4). RESULTS: 2,382 articles were identified in the initial database search, and 40 articles were included in the final analysis. In this analysis, there was a significantly lower incidence of seroma formation in the drain group when compared to the no-drain group (P < 0.00001). Other strategies aimed at reducing the dead space involving the transversalis fascia (TF) and hernia sac such as TF inversion with tacking, Endoloop closure of TF, barbed suture closure of TF, distal sac fixation, and complete dissection of the sac have shown promising results as well. CONCLUSIONS: While there is currently insufficient evidence to recommend the routine use of any one of the interventions analyzed, the use of drains, the management of the TF, and the hernia sac have showed potential in reducing seroma formation. Keywords: Hernia, inguinal hernia repair, laparoscopic, prevention, robotic, seroma
How to cite this article:
Ng TP, Loo BY, Chia CL. Seroma-prevention strategies in minimally invasive inguinal hernia repair: A systematic review and meta-analysis. Int J Abdom Wall Hernia Surg 2023;6:14-22 |
How to cite this URL:
Ng TP, Loo BY, Chia CL. Seroma-prevention strategies in minimally invasive inguinal hernia repair: A systematic review and meta-analysis. Int J Abdom Wall Hernia Surg [serial online] 2023 [cited 2023 Jun 9];6:14-22. Available from: http://www.herniasurgeryjournal.org/text.asp?2023/6/1/14/372937 |
| Introduction | |  |
Inguinal hernias are prevalent and associated with a high lifetime risk of 27% and 3% among men and women, respectively,[1] with more than 20 million patients undergoing groin hernia repair annually. Hernia repair surgeries are tailored according to the needs and priorities of each patient, but mesh placement, either through an open or laparo-endoscopic approach, is often adopted.[2]
The laparoscopic approach for inguinal hernia repair has been gaining popularity in recent years with reported benefits of a reduction in hospital stay and recovery time, lesser perioperative complications, and a reduction in acute or chronic pain as compared to open surgery.[3],[4] More recently, the robotic-assisted approach has gained traction.
Seroma formation remains a common postoperative complication of laparoscopic inguinal hernia repair with reported frequencies ranging from 1.9% to 11.7%.[5] A seroma is a localized subcutaneous collection of clear fluid because of tissue injury, detected through clinical or radiological assessment. Not all seromas are significant, especially those that are diagnosed by imaging alone. Seromas are largely self-limiting and tend to resolve spontaneously within two months, with the majority resolving by the third month.[5],[6] However, it has the potential to impede a patient’s quality of life as it can cause pain, discomfort, and an increased risk of infection.[7] Early detection of seromas is useful because a seroma could cause patient discomfort and anxiety and allay concerns about an early hernia recurrence, which could result in higher costs due to the need for additional investigations and procedures. Hence, it is crucial to assess strategies to reduce seroma formation and the potential burden that it can have on patients who have undergone minimally invasive inguinal hernia repair.
Several intraoperative adjunctive strategies have been implemented to reduce seroma formation after laparoscopic repair of an inguinal hernia. These strategies were reviewed and evaluated in a systematic review performed by Li et al.[8] However, to our knowledge, a review of seroma prevention strategies in robot-assisted inguinal hernia repair has not been undertaken before, owing to its recent rise in popularity. The primary aim of this systematic review is to provide an updated comprehensive evaluation of intraoperative adjunct strategies to reduce seroma formation in both laparoscopic and robot-assisted inguinal hernia repairs.
| Materials and Methods | | |
This systematic review and meta-analysis were conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A study protocol had been registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42022296468).
Search strategy and study selection
A systematic literature search was conducted on electronic databases (PubMed, Scopus, Embase, and Cochrane Library) from inception to November 15, 2021. A medical librarian (Medical Library, National University of Singapore) was consulted in the development of the search strategy. Keywords and thesaurus terms related to “robotic surgical procedures,” “laparoscopic surgery,” “inguinal hernia,” “seroma,” “hernioplasty,” and relevant intraoperative techniques to reduce seroma formation were used in our search. Search results retrieved from the search were imported into EndNote X9 (Clarivate, Philadelphia, PA) to remove duplicates.
Inclusion and exclusion criteria
After the removal of duplicates, two reviewers (TPN, BYKL) independently screened abstracts according to the inclusion and exclusion criteria. The full texts of the studies were accessed, and reasons for exclusion were recorded. Discrepancies at any stage of the screening were resolved with the senior author (CLKC).
The inclusion criteria were (1) articles with patients undergoing laparoscopic or robotic inguinal and inguinoscrotal hernia repair, with intraoperative adjuncts used to reduce postoperative seroma formation and (2) randomized controlled trial (RCT), cohort studies, and prospective studies. Exclusion criteria were (1) non-English language papers, (2) unpublished or unfinished studies, (3) duplicate studies, (4) conference abstracts, (5) case reports, and (6) commentaries.
Data extraction and outcomes
Data regarding year of publication, relevant demographics (number of patients, number of cases, age, and female percentage), and outcomes were extracted from the studies using a case record form by two independent authors (TPN, BYKL). The data extraction process was blinded, and discrepancies were resolved through discussion and consensus with a senior author (CLKC). Seroma formation was taken as the primary endpoint for this study, with secondary endpoints including recurrence and postoperative pain. Seroma formation was counted if there was clinical or ultrasonographic evidence of fluid deposition in the subcutaneous space. Hernia recurrence was any recurrence found during the follow-up period. Chronic pain was taken as pain persisting beyond six months. Where applicable, odds ratios were calculated using 2 × 2 contingency tables for binary variables of interest.
Statistical analysis
Quantitative analysis was done using Review Manager (Version 5.4)[9] according to approaches from the Cochrane Handbook. Inverse variance was utilized in deriving combined was presented as I2 and τ2 statistics. Two-sided P-values of <0.05 indicated statistical significance. Only RCTs and prospective cohort studies were included in the meta-analysis.
Quality assessment of each study was completed using the Risk of Bias 2 tool[10],[11] for randomized controlled trials, the MINORS[12] criteria for non-randomized cohort studies, and the Joanna Briggs Institute critical appraisal tool was used for case series.[13]
| Results | | |
Study selection
A total of 2,382 articles were identified, with 1,556 after the removal of duplicates. After the initial title and abstract screening, 176 articles were selected for full-text sieve. Two authors assessed the full texts independently and 40 articles were deemed eligible for inclusion in the final analysis. Of these studies, 10 were randomized controlled trials, 3 were case series, and 27 were cohort studies.[14] The PRISMA diagram is depicted in [Figure 1]. A summary of the studies included can be found in [Supplementary material: Table 1] [Supplementary material: Table 2] [Supplementary material: Table 3] [Supplementary material: Table 4] [Supplementary material: Table 5] [Supplementary material: Table 6] [Supplementary material: Table 7] [Supplementary material: Table 8] [Supplementary material: Table 9] [Supplementary material: Table 10] [Supplementary material: Table 11].  | Supplementary Material Table 11: Closure of Defect with Nonabsorbable Suture
Click here to view |
Surgical drains
Placement of closed-suction surgical drains in the preperitoneal space have been reported to reduce the rates of seroma formation. Four studies involving 440 hernias reported the use of drains as an intraoperative adjunct. A meta-analysis of the above studies as shown in [Figure 2], demonstrated significantly lower incidence of seroma formation in the drain group when compared to the no-drain groups (P < 0.00001), indicating that drains can effectively reduce postoperative seroma formation.[7],[14],[15],[16]
In terms of postoperative pain, both studies by Fang et al. and Fan et al. found no statistically significant difference in the incidence of chronic pain (P = 0.395, P = 0.632, respectively).[7],[16]
There was no statistically significant recurrence in the above studies.[7],[15],[16]
Transversalis fascia inversion with tacking
Tacking of the lax TF and closing the defect have been studied by two studies involving 1,020 hernias.
Reddy et al.[17] and Kumaralingam et al.[18] reported that inversion of the TF with tacking resulted in a significantly lower incidence of seroma formation (P = 0.043, P = 0.0153, respectively).
The incidence of chronic pain and recurrence was not reported in both studies.[17],[18]
Barbed suture closure of transversalis fascia
Barbed suture closure of the TF has been studied by five studies involving 598 hernias. Two of these studies were conducted via the robotic-assisted approach.
In terms of seroma formation, Yu et al. describe the use of a robot-assisted TEP technique in a prospective cohort study with a seroma formation incidence of 15%.[19] A robot-assisted transabdominal preperitoneal (TAPP)technique that was used by Pini et al.[20] in a retrospective cohort study reported no postoperative seromas on clinical examination. Zhu et al.[21] found that the use of barbed sutures resulted in significantly lower incidences of seroma formation. Usmani et al.[22] found a significantly higher incidence of seroma in the unrepaired group compared to the repaired group (P = 0.045) and in Li et al.,[23] seroma formation was 4%.
There was no chronic pain or recurrence reported in all the above studies, except for Usmani et al. which had a chronic pain incidence of 2.3%, and a recurrence incidence of 0.9%.
Suture closure of transversalis fascia
A single retrospective study of 53 patients by Ng et al. compared the outcomes between closure and nonclosure of the primary defect with nonabsorbable sutures, and seroma formation was found to be lower in the nonclosure group (P = 0.025).[24]
The incidence of chronic groin pain was similar in both groups (P = 0.289).
Endoloop closure of transversalis fascia
The Endoloop technique that was described in Berney et al.’s study found that 3.9% of patients developed asymptomatic seromas.[25] One patient (1.3%) developed a persistent seroma that was present three months postoperatively, which was initially mildly tender on palpation, but became asymptomatic eventually. Due to the considerable size of the defect, it required partial closure with several Endoloops.
There were no incidences of chronic groin pain and hernia recurrence reported.
Distal sac fixation for large inguinoscrotal hernia
The outcomes for distal sac fixation were explored in two separate studies for large inguinoscrotal hernias with a total of 18 patients. In the first study, a prospective cohort study by Daes, only one patient (16%) developed seroma among the 6 patients.[26] The second study, a case series by Wijerathne et al.[27] where a modified technique was employed, there were no incidences of seroma formation.
Chronic groin pain and hernia recurrence were not reported in both studies.
Dissection of sac
Two RCTs compared seroma outcomes between complete dissection and transection of the hernia sac in the repair of indirect inguinal hernia defect with a total of 229 patients. No significant difference was found in the study by Li et al.,[23] while a study by Ruze et al.[28] reported a lower recurrence of seroma formation in the dissected group (P = 0.034).
In terms of chronic pain, no patients had chronic pain in the former study, while it was unreported in the latter study. No hernia recurrences were found in both studies.
Fibrin sealants
The use of fibrin sealants has been studied by 10 studies involving 1,300 hernias. The incidence of seroma formation was not significantly different between both groups in all the comparative studies.[29],[30],[31],[32],[33],[34]
Chronic pain was found to be not significant in the study by Chan et al.,[30] while the studies by Hirsch et al.[29] and Shah et al.[34] reported chronic pain in 5.9% and 1% of patients, respectively.
There was no recurrence reported in the above studies, other than in Hirsch et al.[29] which had a 1.5% hernia recurrence.
Four studies compared the use of tissue glue to tacking.[35],[36],[37],[38] Pooled results from the meta-analysis of the RCTs in [Figure 3] showed no significant difference in the incidence of postoperative seroma.
At 6 months, 7.01% of patients in Ferrarese et al.[36] experienced chronic pain, as well as 0.8% in Santoro et al.[38] There were no patients experiencing chronic pain in Boldo[37] Nizam et al.[35] found significantly lowered Visual Analogue Pain Scale (VAS) scores in the fibrin sealant group at 3 months.
There were no recurrences in the fibrin group for the study by Santoro et al.[38] and Nizam et al.,[35] and no significant difference in recurrence rates in the studies by Boldo[37] and Ferrarese et al.[36] experienced a recurrence.
Mesh fixation
Seven studies reported seroma outcomes for both the fixation of mesh and nonfixation of mesh. Four studies compared the outcomes between the two groups with a total of 1,148 patients. An RCT conducted by Kalidarei et al.,[39] an RCT by Garg and Ismail[40] in 2009, and a prospective study by Hatem et al.,[39] indicated that there was no statistical significance in seroma outcomes between the two groups, with P-values of 0.524, 0.56, and 0.52, respectively. However, Garg et al.[41] study in 2011 found that the seroma formation rates was significantly lower in the mesh fixation group (P = 0.0008).
Two large cohort studies with a total of 21,031 patients compared the outcomes between different methods of mesh fixation to nonfixation. A prospective study by Köckerling et al. consisting of 20,004 patients showed a significant difference (P < 0.001) in seroma formation between the tack, fixation with glue and nonfixation subgroups, respectively, favoring the latter group.[41] Similarly, a significant difference (P =0.000) was found in a retrospective study by Wang et al. demonstrating seroma formation in 15.2%, 9.6%, 22.5%, and 8.5% of the patients in the nonfixation, fixation with NBCA glue, fixation with tacks and fixation with both NBCA and tack subgroups, respectively[43] Another prospective study by Messaris et al., explored only the outcomes for nonfixation of mesh and reported seroma formation in 6.1% of patients.[44]
A significant difference in chronic pain between the study groups was reported in two of the studies. Kalidarei et al. demonstrated lower chronic pain in the nonfixation group (P = 0.002).[39] while another study by Wang et al. showed that 2.2% and 2.1% of patients in the fixation with tack and fixation with NBCA glue and tack group were found to have chronic groin pain as compared to none in the other two subgroups (P = 0.005).[43] On the contrary, Mohammad et al.[44] reported that there were no significant differences (P = 0.26) between both subgroups.
Hernia recurrence in the six studies was either not significant[39],[40],[45] or not present.[41],[43],[44]
Types of mesh
Seven studies discussed the use of different types of mesh for the repair of the inguinal hernia defect. Three studies compared the use of traditional monofilament polypropylene meshes against other types of propylene meshes. An RCT by Bittner et al.[46] showed that seroma formation was significantly higher in the traditional heavy-weight (HW) propylene meshes in the early postoperative period as compared to the titanized light-weighted (TLW) meshes (P = 0.0415). Seroma formation was not significant between both groups after 4 months. Another RCT by Bittner et al.[47] showed no differences in seroma formation between traditional HW, MW, LW, and titanized light-weight TLW meshes. Chronic pain was reported to be not significant between study groups in both studies. Another prospective study by Agarwal et al.[48] compared the outcomes between LW meshes and traditional polypropylene meshes. The differences in seroma formation and hernia recurrences (P = 0.14) were found to be insignificant. Chronic pain was not reported.
Three of these studies explored the use of a self-adhesive mesh. Two prospective studies, Zhu et al.[6] and Bresnahan et al.,[49] reported seroma formation in 9.52% and 14.3% of patients, respectively. Another retrospective study conducted by Davila et al. demonstrated that seroma formation was significantly lower in the tacked group as compared to the self-adhering group (P = 0.04).[50] Chronic pain was reported in only 4.76% of patients in the study by Zhu et al., while no hernia recurrences were reported among the three studies.
A case series exploring the use of a novel 3D anatomical large pore LW mesh in bilateral inguinal hernia repair was explored by Grau et al.,[51] which demonstrated an incidence of seroma in 9% of patients, that resolved within a month. There were no reports of chronic groin pain and hernia recurrences.
Bioabsorbable hernia plugs
The use of a bioabsorbable plug (Bio-A; WL Gore, Flagstaff, AZ) was explored in a retrospective study by Osayi et al.,[52] consisting of 44 patients. Seroma was reported in 15.4% of the 39 patients, while chronic groin pain and hernia recurrences were reported in 15% and 5%, respectively, out of the 30 patients followed up long term.
| Discussion | | |
In this study, we found that surgical drain placement shows promise in preventing seroma formation. It is hypothesized that drains left in the preperitoneal space facilitate the collapse of the dead space, leading to early adhesion formation and in turn lowered seroma formation.[15] However, the use of drains can cause a risk of bacterial migration and mesh infection if left in situ for a prolonged duration.[16] Generally, drains do not need to be routinely used for small inguinal hernias due to the lower risk of seroma formation.[7] Contemporary guidelines, including the 2018 International Guidelines for Groin Hernia Management by the HerniaSurge Group, does not recommend routine drain insertion after an uncomplicated repair as the results for drain insertion for prevention of seroma formation are inconclusive.[2]
Similarly, management of the TF using techniques such as inversion with tacking, barbed and nonbarbed suture closure of TF, and the Endoloop technique may prove to be effective strategies in reducing seroma formation.[8] These interventions aim to close the defect and to obliterate the potential space that may predispose to seroma formation. However, Ng et al.[24] found higher incidences of seroma formation in the closure group. The authors have hypothesized that this was due to inconsistency in inversion of the apex of the sac, resulting in the formation of a potential space, increasing the risk of seroma formation.
Nonintervention of the hernia sac following the reduction of contents leaves behind a dead space that could potentiate the formation of seromas, with the consequence being more pronounced in larger hernia defects as in inguinoscrotal hernias.[53] Fixation of the distal sac to reduce the volume of the large dead space had promising results.[26],[27] Between complete dissection and transection of the hernia sac, the results on the effectiveness of these approaches differed in the two recent RCTs conducted by Ruze et al.[23] and Li et al.[28] The former demonstrated stronger evidence favoring dissection and the latter suggested that there is no difference. A consensus made in 2011 also suggested that complete dissection of the sac should be employed in the management of large indirect sacs.[54] While complete dissection carries a minimal risk of inflicting damages to cord structures and orchitis, these risks have the potential to impede the patient’s recovery and quality of life.[55] As such, while we do believe there is value in exploring the use of complete dissection in the management of the hernia sac as a strategy to reduce seroma formation, this intervention should be carried out at the surgeon’s discretion with due consideration given to the risk of complications.
The included studies on fibrin sealants have demonstrated that its use as an alternative to conventional methods of mesh fixation does not reduce the occurrence of seroma formation. While the use of fibrin glue reduces operating time and rates of minor bleeding,[32] the current evidence is not strong enough to suggest routine use of fibrin glue, with or without mesh fixation.
The evidence on the effect of mesh fixation and its various methods on seroma occurrences remains mixed, and several studies have even suggested that mesh fixation be forsaken completely.[39],[40],[45] Some studies suggest that adequate dissection and the use of a large-sized mesh are sufficient,[40] with mesh fixation reserved for hernia defects of more than 3 cm and for medial hernias.[42] Similarly, while there was no effect on seroma formation, another study suggests that fixation could improve postoperative outcomes such as chronic pain and hematoma formation at a lower cost.[43]
Apart from the method of mesh fixation, the types of mesh used may also influence seroma formation. Self-adhesive meshes resulted in significantly higher rate of seroma formation than tacked meshes, while reducing the duration of surgery and postoperative acute pain score.[6],[49],[50] LW meshes have not shown a significant effect on seroma formation, but has been linked to better patient-reported outcomes such as lower number of nonsteroidal anti-inflammatory drug tables consumed, and a lower number of days absent from work.[48] Bittner et al. published 2 RCTs[46],[47] comparing traditional HW versus LW mesh but only found a difference in seroma formation in one study[46] where the authors used an extremely LW mesh (16 g). Thus, amount of mesh material in gram seems to play a role where the use of extra-light-weighted meshes (ELWM) seems to lead to a lower incidence of seroma formation in the immediate postoperative period compared to traditional Prolene meshes, possibly attributed to ELWM giving rise to a less acute inflammatory foreign body reaction.[46]
It could be postulated that robotic dissection has the potential to remove the hernia sac more thoroughly: despite the study population containing solely patients with larger hernias (>2 cm) included in Yu et al.[20] study, the incidence of seroma formation was comparable to that of laparoscopic repair. With the abovementioned studies having a small sample size, and being limited to only direct hernias, its benefits to prevent seroma formation remain unclear. Furthermore, robot-assisted surgeries are two to three times more expensive and result in longer operative time possibly due to the steeper learning curve.[19]
Other measures such as the use of bioabsorbable hernia plug, as described by Osayi et al.,[52] have not showed to be an effective strategy to reduce seroma formation.
Among all interventions studied, the incidences of seroma recurrence and the number of patients experiencing chronic pain were largely unreported, or statistically insignificant.
In all, our current results suggest that the management of the TF and the hernia sac can be used to reduce seroma formation especially in the case of large hernias. Surgeons can consider complete dissection of the sac where technically feasible or fixation of the distal sac in the management of large hernias. In addition, details should also be given to how the dissection is performed by performing an abundant superficial electrocoagulation for closing all of the small lymphatic and blood vessels.[54] Excessive “pull and traction” technique should be avoided. Similarly, the management of the TF using techniques such as inversion with tacking, barbed and nonbarbed suture closure, and the Endoloop technique can reduce the risk of seroma formation through the same principle of obliterating the potential space; these interventions are reproducible with appropriate training, readily available, and inexpensive.
| Strengths and Limitations | | |
This study contributes to the literature by providing an updated review of intraoperative strategies in reducing seroma formation in minimally invasive inguinal hernia repair, incorporating articles from robot-assisted repair as well. However, the lack of standardized variables—types of mesh used, mesh placement and reporting of seroma outcomes, and the paucity of studies with seroma formation as a primary outcome across the studies—serves as a limitation of our study. Due to the low number of randomized trials powered to compare the various interventions, our results would benefit if larger observational studies and RCTs were to be conducted.
| Conclusion | | |
In conclusion, this systematic review and meta-analysis have suggested that the use of surgical drains, and interventions aimed at reducing the dead space via the management of the TF and the hernia sac have also shown promising results in reducing seroma formation. However, given the risks that these interventions may bring to the patient, there are no current interventions which can be recommended as routine for the prevention of seromas. Further RCTs, along with a more standardized reporting of seroma outcomes, are necessary before these interventions can be made as future recommendations for routine surgical practice.
Acknowledgements
The authors thank Ms Wong Suei Nee (Senior Librarian, National University of Singapore Libraries) for her input in the formulation of the search strategy.
Author contributions
All authors contributed to the conception and design of the study. Material preparation, data collection, and analysis were performed by Trina Priscilla Ng and Brandon Yong Kiat Loo. The first draft of the manuscript was written by Trina Priscilla Ng, Brandon Yong Kiat Loo, and Clement Luck Khng Chia. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript, and all the requirements for authorship has been met.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]
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