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SeromainLaparoscopicVentralHernioplasty

ARTICLEinSURGICALLAPAROSCOPY,ENDOSCOPY&PERCUTANEOUSTECHNIQUES·NOVEMBER2001

ImpactFactor:1.14·DOI:10.1097/00129689-200110000-00006·Source:PubMed

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EvangelosTsimoyiannis

"G.Hatzikosta"GeneralHospital,Ioannina,…

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GeorgiosKGlantzounis

UniversityofIoannina

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P.Mavridou

GeneralHospitalofIoannina"G.Hatzikosta"

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Availablefrom:EvangelosTsimoyiannis

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Surgical Laparoscopy, Endoscopy & Percutaneous TechniquesVol . 11, No. 5,pp.317-321O 2001 Lippincott Williams & Wilkins, Inc., Philadelphia

Expanded polytetrafluoroethylene mesh is the mostapprcpriate material for the laparoscopic intraperitonealonlay technique in the management of ventral hernias(1-3), but seroma is a frequent complication of this ex-cellent technique (3-6).

Most of these seromas resolve without any interven-tion within 30 days (3). However, some seromas, be-cause of their size, become painful or infected and must

Received January 19, 2001; revision received July 6, 2001; acceptedJuIy 20,2001.

From the Departments of Surgery (ECT, PS, GG, SK), Anesthesia(PM), and Radiology (KIG), G. Hatzikosta General Hospital, Ioannina,Greece.

Address correspondence and repdnt requests to Dr. Evangelos C.Tsimoyiannis, Hippocratus 3, Stavraki 453 32 Ioannina, Greece. Ad-dress electronic mail to: etsimogi@acropolis.net

be aspirated. Aspiration of this serum has the risk ofintroducing bacteria into the serum (3), resulting in theinfection of serum and the reculrence of the hernia.

To avoid the production of serum into the hernia sac,

because the excision of the sac is not feasible in most

cases, we designed a technique of destruction of the sac

with monopolar electrocautery or ultrasonically activatedshears. To study the results of this technique, we de-

signed a prospective, randomized study in which the con-

trol group is the standard intraperitoneal onlay mesh re-pair of the ventral hernia (5).

MATERIALS AND METHODS

The study was approved by the Scientific Committeeon Human Rights in Research of the G. Hatzikosta

Seroma n Laparc scopic Ventral Hernioplasty

Evangelos C. Tsimoyiannis, MD, FACS, FABI, Philipos Siakas, MD, George Glantzounis, MD,

Spyros Koulas, MD, Paraskevi Mavridou, MD, and Konstantinos I. Gossios, MD

Summary: Seroma is a frequent complication of laparoscopic or open repair of ventralhernias using expanded polytetrafluoroethylene mesh. Aspiration of this seroma hasthe risk of introducing bacteria, resulting in infection and the recurrence of the hernia.Between May 1996 and December 2000, 51 patents who underwent 53 laparoscopicventral hernioplasties (44 incisional, 5 large epigastric, and 4 large umbilical) wererandomized to participate in a trial comparing the intraperitoneal onlay mesh repairwith or without cauterization of the hernia sac. Group A (26 patients; 28 hemias)patients were operated on by using an expanded iolyGi6fluoroethylene Dual Meshpatch (Gore and Associates, Flagstaff, AZ, U.S.A.) inserted intraperitoneally and se-

cured by full-thickness stitches and endoscopic clips to cover the hernia defect, whilethe sac was left intact. Grggp--B (25 patients, 25 hernias) patients were operated onaccording to the same teEfrnique as those in group A, but the hernia sac was cauterizedby monopolar cautery (5 cases) or harmonic scalpel (20 cases). After surgery, clinicalexamination and computed tomography scans were used to confirm or test the exis-tence of seroma and recuttence. In group A, four clinically evident seromas werefound. Two of them were resolved with no interrrention. In the remaining two cases,multiple aspirations were needed for 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 observed on computed tomography scans). In group B, subclinical seroma (only

observed in computed tomography scan) resolved in a few days, and one recurrencewithout seroma was observed. Although only a small number of patients were studied,our findings suggest that the cauterization of the hernia sac prevents setomas andreduces recurences in laparoscopic repair of ventral hernias. Key Words: Expandedpolytetrafluoroethylene-Laparoscopy-Incisional hernia-Epigastric hernia-Umbilical hernia-Prosthetic material.

) t /

E. C. TSIMOYIANNIS ET AL,3 1 8

General Hospital, Ioannina, Greece' All patients gave

their informed consent to pafiicipate in this study'

Between May 1996 and December 2000, 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 cauterization of the hemia sac'

Patients were excluded if their abdominal wall defect

was less than 4 cm2 (six patients, because this defect is

small for mesh repair) or was more than 100 cm' (seven

patients, because the procedure is very expensive for

expanded polytetrafluoroethylene mesh repair), if the pa-

tients required an emergency procedure (four patients)'

or if conversion to open repair was required (two patients

with incisional hemias, because the dense adhesions did

not permit the laparoscopic approach)' 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

defect by at least 2.5 io 3 cm on each side' The patch was

fixed to the abdominal wall with standard four full-

thickness sutures in each of the corners and staples or

tacks between the sutures, as previously described (5)' In

some cases, especially in large patches, more sutures

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 polytetrafluo-

roethylene 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

subcutaneous tissue was enough to cover the knot of this

suture. The light of the laparoscope helps to find the thin

area of the abdominal wall easily' Group B patients (25

patients; 20 incisional, 3 epigastric, attd2 umbilical pro-

cedures) were operated on according to the same tech-

nique as group A, but the hernia sac, in the first 5 cases'

was cauterized by monopolar cautery (Fig' 2)' and' in the

remaining 20 cases, by ultrasonically activated coagulat-

ing sheais (Ethicon Endosurgery Inc', Smithfield' RI'

US.e.l. The replacement of the monopolar cautery from

the ultrasonicaliy activated coagulating shears was in all

steps of the procedure because of the better hemostasis

und th" smaller degree of danger for intraabdominal vis-

cera injury. In two patients with thin abdominal wall in

the center of the hernia defect, the suture reducing the dead

space was placed laterally to the center. as ln groun A'

All patients underwent postoperative clinical exami-

nations by the same group of surgeons during the imme-

diate posioperative period, and then every 6 months or

when the patient had any problem or question in tele-

phone communication. Also, a computed tomography

,.un *u. performed on the 1st and 15th postoperative

day. More computed tomography scans were scheduled

at the 30th or another postoperative day if seroma was

present and in cases with clinical signs of recurrence'

Statistical analysis was performed using SPSS soft-

ware. A P value less than 0.05 was considered statisti-

cally significant.

FIG. 1. The Gore-Tex Dual Mesh bio-

material (Gore and Associates' Flagstaff,

AZ, U.S.A.) fixed to the abdominal wall

with sutures and 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

SEROMA IN LAPAROSCOPrc VENTRAL HERNIOPLASTY 319

TABLE 2. Postoperative experience

- t

; t

I

Group A Group B

Mean follow-up (months)Mean hospital stay (days)Mean retum to normal activity (days)Postoperative complications

SeromaTotal no.Clinically evidentSubclinical

HematomaInfection

Recurrence

2 8 ! 1 6 2 6 t 1 13.2 + 1, .3 2.4 ! l . l2 8 1 5 5 1 3 + 5

1(257o)4( l4Vo)3 ( l IVo )

323

l (47a)x

0t1(4Va)

I0I

FIG. 2. The cauierization ol the hernia sac s ith monopolar hook cau-tery. Multiple cauterized areas app€ar as black areas.

RESTJLTS

Characteristics of the patients are shown in Table 1.The mean follow-up period was 28 months (range. 2-54months) Tor group A and 26 months (range, 2-49months) for group B. The mean hospital stay was 3.2days (range, 2-6 days) for group A and 2.4 days (range,1-5 days) for group B.

A1l patients appeared to have mild pain during the first1 to 2 postoperative days were treated with 2 to 4 sup-positories of 4-(acetyl amino)-phenol 400 mg with co-deine phosphate 20 mg plus caffeine 50 mg (Lonarid N,Boehringer Ingelheim, Germany). All patients returnedto full activity within 7 days to 3 weeks, except for twopatients of group A (Table 2). These two patients expe-rienced persistent symptomatic seromas for which mul-tiple aspirations were needed at 4 and 7 months, respec-tively. Two and 3 months, respectively, after resolutionof the seroma, a recurrence of the hernia was observed(Table 2). Two more clinically evident seromas (Fig. 3)and three small (subclinical) seromas observed only inthe computed tomography scans of group A resolvedwithout intervention within the first 30 postoperative

TABLE l, Demographic characteristics of the patients

Group A Group B

* P < 0 . Q 2 5 ( 1 ' t e s t ) .

I P < 0.05 (12 test).

days. One more reculrence of group A without seroma(total, 3 recurrences or 10.77o) was observed. In group B,one small subclinical seroma (Fig. a), observed only inthe computed tomography scan, resolved in a few dayswithout intervention, and one recunence (4%) withoutseroma were observed.

A11 recurrences were operated on laparoscopically bythe same group of surgeons. A transposition of the patch,which became wrinkled in the side of the recurrence, wasfound. The fixation with sutures and tacks, lengthwisethis side, was completely broken (Figs. 5, 6). The cau-Ierized hernia sac in the recurrence of group B waswrinkled and adhered to the patch. In two recuffences ofgroup A (one with seroma and one without seroma), andin the one recuffence of group B, during the first lapa-

FIG. 3. Computed tomography scan of the anterior abdominal wall.There is a seroma into the dead space measuring 2 x 8 cm, and theexpanded polyteffafluoroethylene patch is intact. This seroma was evi-dent clinically with inspection and palpation.

Sex (male/female)Age (years)Type of hernia

IncisionalEpigastricUmbilical

Defect size (cm2)Patch size (cm2)Operating time (minutes)

1,U156 2 t 9

a / *

22

4 8 t 1 3104 t4440t12

10/55 9 t 1 0

2032

52t11118 t 4246t16

* Two patients in group A had two incisional hernias each

Surg Laparosc Endosc Percutan Tech 2001, 11:5

E. C. TSIMOYIANNIS ET AL.320

FIG. 4. Computed tomography scan of the anterior abdominai wall in

which a subclinical seroma measuring 2 x 4 cm is observed' This

,"ro.u*urnotrevealedwithinspectionandpalpationandcompletelyresolved 15 days later.

roscopic procedure, the expanded polytetrafluoroethyl-

ene p;tchdid not cover all the length of the old incision'

but this was sized to overlap the margin of the defect at

a distance of approximately 2.5 to 3 cm, as in the other

healthy sides. Except for the total of four recurrences in

both groups (1.57o), which developed during the first 10

postoperative months' the healing of the space and the

int"giity of the patch were confirmed clinically and with

computed tomography images (Fig' 7)'

Three hematomas in group A and one in group B

resolved uneventfully. These four hematomas were cre-

ated in the abdominal wall around the pass of a whole-

FIG. 5. Laparoscopic view of recurrence in a patient with symptom-

uti. ,".o.u urpiratld for 7 months after surgery The fixation of the

patch is complLtely broken lengthwise at the side of the recurrence'

Surg Laparosc Endosc Percutan Tech 2001, I 1:5

FIG.6, Computed tomography scan of a patlent who underwent repeat

rrrg"tv ftp".6*opiculylrur recurrence of laparoscopic repair of in-

cis[nal hirnia. The two patches are observed' The anow shows the

f i rst patch. uhich is wr inkled.

thickness suture used to fix the patch' In one patient in

group A, an infection of a full-thickness suture was pre-

sented. This suture was removed 2 months later' and the

infection healed after local wound care and antibiotic

therapy.

DISCUSSION

The laparoscopic intraperitoneal onlay technique in-

volves placing prosthetic mesh on the parietal perito-

n"uro, *h"." it is in direct contact with the abdominal

viscera. Expanded polytetrafluoroethylene mesh and es-

oeciallv the newer Gore-Tex Dual Mesh (Gore and As-

FIG. 7. Computed tomography scan of the anterior^abdominal wall at

thi"u"r,ttt postoperative month (examination for follow-up of oper-

ated colon cincet-2 years ago)' The expanded polytetrafluoroethylene

;;h lt-iil, the pulling-in the cenier of the patch from the full-

ihi.ko.r, suture is obvious' and the healing of the dead space 1s com-

plete.

sociates) biomaterial are the most appropriate materialsfor this procedure because they evoke minimal inflam-mation and little foreign-body response and adhesionformation, while allowing good tissue ingrowth (1-5).

Because the hernia sac is left in situ in the laparoscopicrepair of incisional hernias, a transient seroma (sterilefluid accumulation) develops in some cases. A seroma isconsidered a complication, however, if it persists formore than 6 weeks, increases in size steadily, or pro-duces symptoms (6). The rate of seroma is approximately16%o in laparoscopic procedures (3) and approximatelyl5Vo in the open approach (4) of ventral hernia repairusing expanded polytetrafluoroethylene mesh. In the cur-rent study, 4 clinically evident seromas in 28 hemias ingroup A developed, and this incidence was 147o, whichis similar to that of previous studies (3,4). Adding thesubclinical seromas in group A to this incidence resultsin an occurrence rate of 257o, which is higher than that ofprevious studies.

Most of the seromas resolved without interventionwithin 30 days, and none of these become infected (3).Aspiration of the seroma is needed when it is large, pain-ful, or infected. If it is possible, we try to avoid aspirationbecause of the risk of introduction of bacteria into theserum and the consequent infection of the patch andsutures (3). This infection easily can cause rupture ofthepatch fixation. Two cases in the current study, with mul-tiple aspirations of the seroma, led to recurrence of thehernia, and we believe that this was a main cause ofrecurrence in this study. The other two recurrences havenot combined with clinical or subclinical seroma. Inthese cases, we hypothesize that the patch was too smallto cover enough healthy abdominal wall around the her-nia defect, because we covered approximately 2.5 to 3cm of healthy abdominal wall on each healthy side andthe same length of the margin lengthwise of the oldincision. We believe that if the patch is sized to overlapthe margins of the defect by at least 4 cm on each healthyside and to overlap the entire old incision, such recur-rences may be avoided.

The major factor in seroma development is most likelythe large dead space that is inevitable with large defects.Closed suction drainage and pressure dressings seem rea-sonable measures to reduce seroma collections but are

321

not uniformly successful (7). The decrease in the deadspace obtained by placing a full-thickness suture in thecenter of the defect may decrease the incidence of clini-cally evident seromas. In large hernia sacs, more suchsutures may be needed.

The cauterization of the hernia sac destroys the serosalsurface of the hernial subcutaneous cavity. In the currentstudy, the cauterization of the sac did not lead to theappearance of hematomas, as in resected sacs (8). Webelieve that the cauteiization of the sac protects the pro-duction of seroma, first by destroying the serosal surface,which produces serum when infected (septic or aseptic),and, second, by creating adhesions immediately into thesac that closes the dead space. The full-thickness suturein the center of the defect leads to better contact of theburned serosal surfaces, as well as of these surfaces andthe patch, supporting the adhesions into the dead space.This is a hypothesis that must be studied in the experi-mental field. The cauterization of the hernia sac seems toprevent seroma, which occurs frequently between thepatch and the hernial sac in laparoscopic onlay meshrepair of ventral hernias. More clinical studies, withlarger numbers of patients and longer follow-up periods,are needed to confirm this observation.

REFERENCES

1. Cristoforoni PM, Kim YB, Prey s Z, et al. Adhesion formation afterincisional hernia repair: a randomized porcine trial. Aru Surg 1996;62:935-8.

2. Murphy JL, Freeman JB, Dionne PG. Comparison of Marlex andGore-tex to repair abdominal wall defects in the rat. Can J Surg1989;32:244-7.

3. Toy FK, Bailey RW, Carey S, et al. Prospective, multicenter studyof laparoscopic ventral hemioplasty: preliminary results. Surg En-dosc 1998:12:955-9.

4. DeBord JR. Special comment: expanded polytetrafluoroethyleneprosthetic patches in repair of large ventral hemia. In: Nyhus LM,Condon RE, eds. Hernia, 4th ed. Philadelphia: Lippincott,1995;328-36.

5. Tsimoyiannis EC, Tassis A, Glantzounis G, et al. Laparoscopicintraperitoneal onlay mesh repair of incisional hemia. Surg Lapa-rosc Endosc 1998;8:360-2.

6. Park A, Gagner M, Pomp A. Laparoscopic repair of large inci-sional hernias. Surg Loparosc Endosc 1996;6:123-8.

7. DeBord JR, Wyffels PC, Marshall JS, et al. Repair of large ventralincisional hemias with expanded poiytetrafluoroethylene pros-thetic patches. Postgrad Gen Surg 1992;4:156-60.

8. Wantz GE. Complications of inguinal hernia repair. Surg ClinNorth Am 1984:64:287 -97 .

SEROMA IN I.4PAROSCOPIC VENTRAL HERNIOPLASTY

Surg Inparosc Endosc Percutan Tech 2001, I I :5