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Seroma in Laparoscopic Ventral Hernioplasty Article in Surgical laparoscopy, endoscopy & percutaneous techniques · November 2001 DOI: 10.1097/00129689-200110000-00006 · Source: PubMed
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6 authors, including: Evangelos Tsimoyiannis
Georgios K Glantzounis
"G.Hatzikosta" General Hospital, Ioannina, G…
University of Ioannina
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Techniques Endoscopy& Percutaneous SurgicalLaparoscopy, V o l . 1 1 ,N o . 5 , p p . 3 1 7 - 3 2 1 O 2001LippincottWilliams & Wilkins, Inc., Philadelphia
Seroman Laparcscopic Ventral Hernioplasty EvangelosC. Tsimoyiannis,MD, FACS, FABI, Philipos Siakas,MD, GeorgeGlantzounis,MD, SpyrosKoulas,MD, ParaskeviMavridou, MD, and KonstantinosI. Gossios,MD
Summary: Seromais a frequent complication of laparoscopicor open repair of ventral hernias using expanded polytetrafluoroethylene mesh. Aspiration of this seroma has the risk of introducing bacteria, resulting in infection and the recurrenceof the hernia. Between May 1996 and December 2000, 51 patents who underwent 53 laparoscopic ventral hernioplasties (44 incisional, 5 large epigastric, and 4 large umbilical) were randomized to participate in a trial comparing the intraperitoneal onlay mesh repair with or without cauterization of the hernia sac. Group A (26 patients; 28 hemias) patients were operated on by using an expanded iolyGi6fluoroethylene Dual Mesh patch (Gore and Associates,Flagstaff, AZ, U.S.A.) inserted intraperitoneally and secured by full-thickness stitches and endoscopic clips to cover the hernia defect, while the sac was left intact. Grggp--B (25 patients, 25 hernias) patients were operated on according to the sameteEfrniqueas those in group A, but the hernia sac was cauterized by monopolar cautery (5 cases)or harmonic scalpel (20 cases).After surgery, clinical examination and computed tomography scans were used to confirm or test the existence of seroma and recuttence. In group A, four clinically evident seromas were found. Two of them were resolved with no interrrention. In the remaining two cases, multiple aspirationswere neededfor 4 and 7 months, respectively, but 2 and 3 months, respectively, after resolution of the seroma, a recurrence of the hernia was observed' There was one more recurence without seroma and three with subclinical seromas (only observedon computed tomography scans).In group B, subclinical seroma (only observed in computed tomography scan) resolved in a few days, and one recurrence without seromawas observed.Although only a small number of patients were studied, our findings suggest that the cauterization of the hernia sac prevents setomas and reduces recurences in laparoscopic repair of ventral hernias. Key Words: Expanded hernia-Epigastric herniapolytetrafluoroethylene-Laparoscopy-Incisional Umbilical hernia-Prosthetic material.
be aspirated. Aspiration of this serum has the risk of introducing bacteria into the serum (3), resulting in the infection of serum and the reculrence of the hernia. To avoid the production of serum into the hernia sac, becausethe excision of the sac is not feasible in most cases,we designed a technique of destruction of the sac with monopolar electrocauteryor ultrasonically activated shears. To study the results of this technique, we designed a prospective,randomized study in which the control group is the standardintraperitoneal onlay mesh repair of the ventral hernia (5).
Expanded polytetrafluoroethylene mesh is the most apprcpriate material for the laparoscopic intraperitoneal onlay technique in the management of ventral hernias (1-3), but seromais a frequentcomplicationof this excellent technique(3-6). Most of these seromasresolve without any intervention within 30 days (3). However, some seromas,because of their size, become painful or infected and must Received January 19, 2001; revision received July 6, 2001; accepted JuIy 20,2001. From the Departments of Surgery (ECT, PS, GG, SK), Anesthesia (PM), and Radiology (KIG), G. Hatzikosta General Hospital, Ioannina, Greece. Address correspondenceand repdnt requests to Dr. Evangelos C. Tsimoyiannis, Hippocratus 3, Stavraki 453 32 Ioannina, Greece. Address electronic mail to:
[email protected]
MATERIALS
AND METHODS
The study was approved by the Scientific Committee on Human Rights in Research of the G. Hatzikosta )t/
318
E. C. TSIMOYIANNISET AL,
General Hospital, Ioannina, Greece' All patients gave their informed consent to pafiicipate in this study' Between May 1996 and December2000, 51 patients with 53 ventral hernias (44 incisional, 5 large epigastric' and 4 large umbilical) were randomized to participate in a trial comparing the intraperitoneal onlay mesh repair of the hernia with or without cauterizationof the hemia sac' Patients were excluded if their abdominal wall defect was less than 4 cm2 (six patients, becausethis defect is small for mesh repair) or was more than 100 cm' (seven patients, because the procedure is very expensive for paexpandedpolytetrafluoroethylenemesh repair), if the (four patients)' procedure emergency an tients required or if conversionto open repair was required (two patients with incisionalhemias,becausethe denseadhesionsdid not permit the laparoscopicapproach)'Group A patients (26 patients, 28 hernias: 24 incisional, 2 epigastric' and 2 umbilical) were operated on using a Gore-Tex Dual Mesh biomaterial (Gore and Associates, Flagstaff' AZ' U.S.A.), which was sized to overlap the margins of the defectby at least2.5 io 3 cm on eachside' The patch was fixed to the abdominal wall with standard four fullthickness sutures in each of the corners and staples or (5)' In tacksbetweenthe sutures,as previouslydescribed sutures more patches, large in some cases,especially were placed for better fixation of the patch' The sac was left inlact. A last full-thickness suture was placed in the center of the hernia defect to reduce the "dead space" between the hernia sac and the expanded polytetrafluoroethylene patch (Fig. 1). In three patients in whom the
abdominal wall in the center of the defect was thin' this suture was placed laterally over this area' so that the subcutaneoustissue was enough to cover the knot of this suture.The light of the laparoscopehelps to find the thin (25 area of the abdominal wall easily' Group B patients propatients;20 incisional,3 epigastric,attd2 umbilical cedures) were operated on according to the same technique as group A, but the hernia sac, in the first 5 cases' was cauterizedby monopolar cautery (Fig' 2)' and' in the remaining 20 cases,by ultrasonically activated coagulating sheais (Ethicon Endosurgery Inc', Smithfield' RI' US.e.l. The replacementof the monopolarcauteryfrom all the ultrasonicaliy activated coagulating shearswas in steps of the procedure becauseof the better hemostasis und th" smaller degree of danger for intraabdominal viscera injury. In two patients with thin abdominal wall in the center of the hernia defect, the suture reducing the dead spacewas placed laterally to the center.as ln groun A' All patients underwent postoperative clinical examinations by the same group of surgeonsduring the immediate posioperative period, and then every 6 months or when the patient had any problem or question in telephone communication. Also, a computed tomography ,.un *u. performed on the 1st and 15th postoperative day. More computed tomography scanswere scheduled at the 30th or another postoperative day if seroma was present and in caseswith clinical signs of recurrence' Statistical analysis was performed using SPSS software. A P value less than 0.05 was consideredstatistically significant.
FIG. 1. The Gore-Tex Dual Mesh biomaterial (Gore and Associates' Flagstaff, AZ, U.S.A.) fixed to the abdominal wall with suturesand tacks to cover the hernia defect. The anow shows a full-thickness suture placed in the center of the defect to reduce the dead sPace.
Surg Laparosc Endosc Percutan Tech 2001, I 1:5
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SEROMAIN LAPAROSCOPrcVENTRALHERNIOPLASTY TABLE 2. Postoperative experience
Mean follow-up (months) Mean hospital stay (days) Mean retum to normal activity (days) Postoperative complications Seroma Total no. Clinically evident Subclinical Hematoma Infection Recurrence
-t
GroupA
GroupB
28!16 3.2+ 1,.3 28155
26t11 2.4! l.l 13+5
1(257o) 4( l4Vo) 3(lIVo) 3 2 3
l(47a)x
0t 1(4Va) I 0 I
*P
