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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_842_Библиотеки_им_академика_М_И_Перельмана.pdf
312
A. Krishna et al.
29
29.1 Introduction
LeBlanc and Booth in 1993 [1] rst reported laparoscopic repair of a ventral and incisional hernia
(LIVHR). With the development of newer prosthetic devices and xation devices, laparoscopic
repair has found its applicability not only in primary ventral and incisional hernia repair but also
in parastomal and parapubic hernias. According
to the recent IEHS guidelines, laparoscopic repair
is considered the standard of care for management of patients with ventral and incisional
hernia [2]. LIVHR is a very safe procedure and
provides patients all the benets of laparoscopic
surgery like early return to activity and shorter
hospital stay. However, unlike other laparoscopic
procedures, although pain is less in laparoscopic
repair as compared to open repair, still it is associated with considerable pain in the postoperative period because of the use of mesh xation
devices like tackers. LIVHR is associated with
certain intraoperative and postoperative complications which are important to be diagnosed and
managed [2].
recognition during laparoscopic repair is more
dicult, and the injury may be missed which
has got a worst prognosis. Comparison of bowel
injury in open and laparoscopic repair has been
reported in six RCTs, and pooled data from
these six RCTs shows a bowel injury incidence
of 0.1–4% vs 0.1–0.63% in laparoscopic repair
compared to open repair [9, 12–16]. According
to these studies, aer laparoscopic procedures,
the risk for an injury of the bowel seems to be
increased; however, the dierence is low (Rohr/
Lang in [2]).
Injuries to the bowel during laparoscopic sur-
gery can be divided broadly into three categories
(Timoney, Rim, Ferzli in [2]):
1. Iatrogenic injuries recognized immediately
by either from trocar insertion or during
adhesiolysis
2. Missed injuries which are recognized in the
early postoperative period (12–24h)
3. Delayed injuries which are thermal injuries
due to dissection with monopolar cautery
or ultrasonic dissection which present aer
5–7days [17–19]
29.2 Bowel Injury
e incidence of bowel injury during LIVHR has
been reported to vary from 6% to 14.3% [3, 4].
ese bowel injuries may result in mortality also
which has been reported to range from 0.05% to
3.4% [3, 5–7]. However, in patients in whom the
enterotomy is missed, the mortality rises signicantly and ranges from 7.7% to 100% [3, 5–7]. In a
recent review, several risk factors that increase the
chances of enterotomy have been identied which
include extensive adhesiolysis taking longer than
3 h, chronic obstruction, inamed bowel, and
mesh incorporation into bowel (acc. to Timoney,
Rim, Ferzli in [2]).
LeBlanc etal. reported an iatrogenic enterotomy incidence of 1.78% with LIVHR and an
overall mortality rate of 2.8% [5]. In the subset
of patients whose injury was missed during
the initial operation (18%), the mortality rate
reached 7.7%. Predictably, the small bowel was
injured in 92% of the reported cases. A recent
Cochrane review showed an iatrogenic enterotomy rate of 1.5% with LIVHR versus 0.63%
with the open approach [5, 8–11]. e risk of
bowel injury exists with open repair also, but its
Avoiding bowel injury is of utmost importance
during LIVHR.During access the pneumoperitoneum can be created either via an open or closed
technique. Special techniques like optical trocars
(VISI PORT) can also be used. However, there is
level 1 evidence stating that there is no dierence
in the incidence of visceral injury following any
of these techniques and surgeons’ experience and
preference is the key to choosing the method of
access. Palmer’s point (LUQ) is the preferred site
for initial access for midline hernias as this has
the minimum adhesions and the abdominal wall
is thinnest here. One has to ensure that the stomach is completely deated and there is no splenomegaly before using the Palmer’s point. Sharp
dissection should always be used in areas of dense
adhesions (
. Fig.29.1). Again, the use of energy
sources close to bowel may cause delayed injuries,
with signicantly increased morbidity and mortality. Dividing the peritoneum avoids injury to
the bowel [17].
Management of intraoperatively detected
bowel injuries is controversial (. Fig.29.2). ere
are several options in such situations depending
upon the extent of bowel injury, the part of bowel
which is injured, level of contamination, and
experience of the surgeon. Conversion to lapa-
Complications and Comparison to Open Repair
. Fig. 29.1 Dense omental adhesions in incisional hernia
. Fig. 29.2 Intraoperatively detected small bowel injury
during laparoscopic IPOM
rotomy followed by bowel repair and anatomical
closure is the safest option [11, 21]. If the contamination is minimal, a small incision can be
given and bowel repaired extracorporeally followed by closure of the incision and laparoscopic
mesh placement [11, 21]. Some studies also have
reported either open or laparoscopic repair followed by a delayed repair of the incisional hernia
aer 7–10days once the patient recovers and the
intra-abdominal infection subsides [17, 20].
In 2010, Itani etal. [9] reported a series of
73 patients who underwent conversion to an
open technique for bowel injury with minimal
313
contamination during LVHR. In three patients,
the enterotomy was repaired, and the herniorrhaphy was performed with polypropylene (PP)
mesh laparoscopically. None of the patients who
underwent conversion to laparotomy, including those in whom mesh was placed, experienced a surgical- site infection. Lederman and
Ramshaw [17] reported a series of nine patients
who sustained an iatrogenic enterotomy during
LVHR.Aer repair of the injury, the patients were
observed for an average of 3days while receiving
intravenous antibiotics. With this regimen, seven
of the nine patients had successful completion of
their LVHR [17].
Some authors prefer the use of biologic mesh
over synthetic mesh for LIVHR in the presence
of contamination. In 2004, Franklin et al. [22]
described their experience with the use of porcine-derived prosthetic mesh in 43 patients who
underwent successful LVHR in a contaminated
eld. Details of the contamination are vague but
included bowel resection, strangulation, and
prior mesh infection. One patient experienced a
wound infection and a stula. e authors report
no recurrences, but for denite assessment the
follow-up period is too short.
In the recently published “Guidelines for
laparoscopic treatment of ventral and incisional
abdominal wall hernias” of the International
Endohernia Society (IEHS) risks, management and prevention of injuries to the bowel are
described and discussed in detail [2]. Regarding
unrecognized enterotomies, Karl LeBlanc analyzed 174 papers and found a higher rate of this
kind of injury in laparoscopy, but the dierence
29
29
314
A. Krishna et al.
to the open technique was statistically not signicant [2, 8, 15, 23, 24].
Evidence-based statements and recommenda-
tions acc. to Timoney, Rim, and Ferzli in [2]:
(Only Level 1 and 2 studies as well as Grades
A (must), B (should), and C (can) recommendations are given.)
“Statements”
5 Level 1: The incidence of iatrogenic
enterotomy during laparoscopic ventral
hernia is 1.78%. The mortality rate for
these patients is 2.8%
In most cases (92%), the small bowel
is injured
The most frequent causes are rough
adhesiolysis and the use of energized
dissection close to the adherent bowel
“Recommendations”
5 Grade C: Adhesiolysis should be per-
formed close to the abdominal wall and
not near the bowel
Sharp dissection techniques should
be preferred, and the use of energized
dissection near the bowel should be
avoided
Conversion to laparotomy is advisable if the surgeon is not proficient with
laparoscopic bowel repair techniques
A primary open repair is advisable in
the presence of gross spillage. An open
prosthetic repair may be undertaken if
conditions remain sterile
A small laparotomy away from the
hernia defect may be used to repair a
bowel injury and may be followed by
continuation of LIVHR
If a bowel injury is repaired laparoscopically, LIVHR may be performed
after an observation period of 3–7days
on parenteral antibiotic therapy if no
evidence of infection is observed
An LIVHR may be performed in the
event of bowel injury repaired immediately with minimal spillage, but this
option requires experience with laparoscopic repair of bowel injury
“Statements” regarding intraoperatively
unrecognized bowel injuries acc. to
LeBlanc and Rohr in [2]
5 Level 2A: Among patients in whom the
enterotomy is missed, the mortality rises
signicantly and ranges from 7.7%
to 100%
Reoperation will be necessary
The safest approach is open repair,
resection of the injured bowel segment,
mesh explantation, and primary repair of
the fascial defect
“Recommendations” regarding intraoperatively unrecognized bowel injuries
acc. to LeBlanc and Rohr in [2]
5 Grade B: Surgeons may use either open
or laparoscopic approach to re-explore if
there is a suspicion of a missed iatrogenic
enterotomy or to repair the injury
Resect the injured segment or create
a stoma depending on the injured organ
and the clinical situation
5 Grade C: Mesh explantation should be
performed
According to the current evidence
after mesh explantation, hernia should be
repaired primarily if feasible
29.3 Infection
e infections following incisional and ventral
hernia repair range from supercial surgicalsite infections (SSI) (. Fig.29.3) to mesh infections and deep organ infections (. Fig.29.4). e
presence of SSI signicantly increases morbidity
and mortality of an incisional and ventral hernia
repair [25]. e supercial surgical-site infection
usually manifests as pain, erythema, and tender
swelling. ey are managed with adequate drainage, dressing, and oral antibiotics. e overall
incidence of infections following incisional hernia repair is 10–12% with higher rates following
repair for recurrent hernias. e risk factors that
predispose to infections can be broadly classied
into patient-related and surgery- related factors.
Complications and Comparison to Open Repair
. Fig. 29.3 Marginal skin necrosis following open
component separation repair of large incisional hernia
315
immunosuppressant and steroids also have a
greater risk of contracting infection.
e risk of infection increases vefold for
smokers and by 9% for patients receiving steroids
[32]. Current smoking was 1.5 times more prevalent in subjects with postoperative wound infections than those without infections. Based on
these ndings, at least temporary smoking cessation prior to elective hernia repair should be considered, especially in complex hernia procedures.
Diabetes and malnutrition also are signicant
risk factors for infection [34]. Obesity decreases
the blood circulation in fat tissue and increases
the risk of infection [35]. Other factors such as
history of infection, high ASA grades, hypoxia,
hypothermia, radiation, and peripheral vascular
disease also contribute to an increased risk of SSI
[36–39] in patients undergoing incisional and
ventral hernia repair.
29
. Fig. 29.4 Wound infection with exposed mesh
following open repair of incisional hernia
29.3.1 Patient-Related Risk Factors
ese include:
1. Age
2. Comorbidities like CAD (coronary artery
disease), diabetes, and COPD
3. Malnutrition and immunosuppressed states
4. Obesity
5. Smoking
6. Steroid use
Gender and SSI are not correlated, but wound
infection in 15- to 24-year-old patients averages
10% and increases signicantly in patients older
than 65years [31, 32]. Dunne etal. [33] reported
CAD, COPD, and low preoperative serum albumin as independent predictors for infection in
elderly patients. Smokers and patients receiving
29.3.2 Surgery-Related Risk Factors
ese include:
1. Technique of part preparation
2. Operation time
3. Requirement for blood transfusions
4. Bowel injuries
5. Mesh-related fac tors
e preoperative factors increasing the risk of
infection include shaving of the surgical site,
short duration of scrubbing, antiseptic use, and
blood transfusion. e SSI rate was 5.6% for
patients who had hair removed by razor compared with 0.6% for patients who either had their
hair removed by depilatory agents or had no
hair removal [40]. Blood transfusion increases
the risk twofold [41]. Long operating time also
predisposes to the risk of infection. Procedures
longer than 3–4 h increase the risk [36]. Also,
blood loss during surgery is a signicant risk factor. Postsurgery complications such as seroma,
thromboembolism, pulmonary embolism, postprocedure pneumonia, and anemia make the
patient more susceptible to infection [46].
e reported incidence of infection is 10% for
open procedures and 1.1% for laparoscopic procedures [26]. Many single-site studies have reported
lower infection rate following laparoscopic repair
29
316
A. Krishna et al.
as compared to open repair. Laparoscopic procedures lower the risk of infection by reducing
wound size, hospital stay, operative time, and the
probability of bacteria entering the subcutaneous space [27–30]. Sauerland et al. [8] in a metaanalysis reported lower local wound infection
rate following laparoscopic repair as compared to
open repair (3.1 versus 13.4%, p = 0.00001). In a
pooled data analysis by Pierce etal. [47], wound
infections were found in 1.3% of cases aer laparoscopic repair, whereas aer open operation, the
wound infection rate was 10.9% (p = 0.0001).
To prevent infection, management of these
risk factors is important. e risk factors that
can be modied should be addressed and managed by adherence to established guidelines
and protocols. Cessation of smoking before the
surgery reduces the risk of postoperative SSI in
addition to other cardiovascular and respiratory
benets. Strict preoperative glycemic control
with maintenance of intraoperative normothermia is necessary. Remote infection, especially when mesh is being implanted, should
be treated and resolved completely before the
surgery. Preoperative hair removal should be
avoided, and clipping should be performed
instead. Prophylaxis with broad spectrum antibiotics at induction and second dose repeated
aer six hours is recommended. During surgery, careful attention to proper surgical technique and timely completion of the operation
also reduce the risk of SSI.
Evidence-based statements and recommendations acc. to Chowbey in [2]:
“Statements”
5 Level 1: Preoperative transfusion may
increase the risk of surgical-site infection
(SSI)
Laparoscopic operations lead to
a lower incidence of SSI than open
operations because the total length of
the incisions is shorter, reducing the risk
of bacteria entering the subcutaneous
space
5 Level 2: In elderly patients, chronic
obstructive pulmonary disease (COPD)
and low preoperative serum albumin
are independent predictors of wound
infections; coronary artery disease
(CAD), COPD, low preoperative serum
albumin, and steroid use are independent predictors of a longer hospital stay
Patients who undergo LIVHR with a
simultaneous bowel resection show a
higher incidence of infectious and noninfectious complications with mesh use
Wound infection is lower in laparoscopic hernia repair than in open repair
due to the decreased extent of tissue
dissection
Mesh, wherever possible, should not
be brought in contact with skin to avoid
contamination by skin flora. Polyester
meshes are associated with the highest
incidence of infection, fistualization, and
recurrence
Patients given a prophylactic antibiotic have a lower incidence of SSI
“Recommendations”
5 Grade A: Laparoscopic repair is associ-
ated with a lower risk of SSI and thus is
preferred over the open approach
Before surgery, known risk factors for
SSI must be treated if possible
The operation time and hospital stay
must be as short as possible
5 Grade B: Smoking cessation, glycemic
control, and treatment of remote infections should be done before surgery
Prosthetic mesh insertion with
simultaneous bowel resection should be
avoided
5 Grade C: Preoperative clipping of hair is
recommended
Weight loss before the operation may
be considered
29.4 Mesh Infection
Mesh infection is one of the most dreaded complications following an incisional hernia repair
which can cause a signicant morbidity and
even mortality. is can manifest not only as
subtle SSI (. Fig.29.5) but also open nonhealing wounds (. Fig.29.6). e reported incidence
of mesh infection aer laparoscopic repairs is
0–3.6% [43]. A mesh infection rate as low as
Complications and Comparison to Open Repair
. Fig. 29.5 Mesh infection presenting as chronic
discharging sinus following open mesh repair of incisional
hernia
. Fig. 29.6 SSI and mesh infection following open
mesh repair of incisonal hernia
317
0.78% aer laparoscopic repair was reported in a
systematic review by Carlson etal. [24]. Polyester
meshes and meshes positioned subcutaneously
are associated with a high incidence of infection
[43, 44]. e use of prosthetic mesh with bowel
resection or injury increases the risk of infection
manifold [45].
An important advantage of the laparoscopic
intraperitoneal onlay mesh (IPOM) technique
over open repair of incisional and ventral hernias
is the lower rate of wound and mesh infections.
is can be attributed to several factors such as
lesser mesh handling, as the mesh is introduced
via trocars hence a lesser chance of coming in
contact with the skin. Karl LeBlanc demonstrated that laparoscopic repair of incisional
and ventral hernias signicantly is attended by
fewer wound infections and less need for mesh
removal (. Fig.29.7) [20]. In the meta-analysis
by Sauerland etal. [8], a local infection requiring mesh removal was found in 0.7% of the
laparoscopic group and 3.5% of the open group
(p = 0.09). In a pooled data analysis by Pierce
etal. [47], aer laparoscopic repair, mesh infections were found in 0.9% of the cases, whereas
aer open operation, the mesh infection rate was
3.2% (p=0.0001). In a large clinical case series
and case analyses, mesh infections were detected
aer laparoscopic IPOM in 0.78% (n = 6206)
[24], 0.90% (n=4.582) [47], and 0.70% (n=850)
[11] of the patients.
In addition to the patient- and surgeryrelated factors outlined above, type of mesh is a
29
. Fig. 29.7 Mesh infection following lap IPOM presenting as discharging sinuses resulting in mesh explantation
318
A. Krishna et al.
29
signicant predictor of mesh infection. is correlates not only with mesh infection but also the
salvageability once mesh infection sets in.
In a comparative study, Hawn et al. [106]
demonstrated that in contrast to plypropylene(PP) mesh, PTFE-associated mesh infection
was rare but when it occurs it cannot be eradicated and invariably results in explantation of
the mesh. ey have reported signicantly less
need to remove a PP mesh than a PTFE mesh
because of a mesh infection (p\0.0001). Morris
and Hughes [48] published a review on the use of
intra-abdominal nonabsorbable mesh in clinical
and experimental settings and showed that polypropylene and polyester meshes were found to be
better incorporated into tissues than ePTFE which
appeared to be related to pore size. Polypropylene
showed a lower incidence of infection than ePTFE
or polyester meshes.
In a literature review, Finan et al. [42] observed
that absorbable mesh, which is likely a surrogate marker for a more complex hernia repair,
was associated with a fourfold increased rate of
wound infection, whereas permanent mesh use
was associated with an increased risk of wound
infections.
How can these mesh infections be prevented?
As outlined previously patient-related modiable factors need to be addressed preoperatively.
Remote infection should be treated and resolved
completely before the surgery. Preoperative hair
removal should be avoided, and clipping should
be performed instead. Prophylaxis with broad
spectrum antibiotics at induction and second dose
repeated aer six hours is recommended. During
surgery, careful attention to proper surgical technique and timely completion of the operation
also reduce the risk of mesh infection. e mesh
should be handled as less as possible. e surgeons should change his gloves before handling
the mesh. e mesh should not be opened at the
beginning of surgery but only when the dissention
is completed. Various authors have also advocated
dipping of mesh in bactericidal solutions like 10%
betadine and chlorhexidine solution to decrease
mesh infection. However, there have been conicting reports and lack of level I evidence advocating such maneuvers.
In the literature, case reports on the treatment
of mesh infections aer laparoscopic repair of
incisional and ventral hernias discuss both mesh
removal [49, 50] and mesh salvage [51, 52]. For
interventional and conservative treatment of a
mesh infection aer laparoscopic repair of incisional and ventral hernias, Aguila etal. [51] and
Trunzo etal. [52] advocate percutaneous drainage of accumulated pus around the mesh and
insertion of a drain through which irrigation
with gentamycin 80mg in 20ml saline solution
three times daily together with intravenous antibiotic treatment. Treatment of mesh infection
also depends on the material used. Sanchez et al.
[54] reported mesh infection in 8.1% of patients
aer the use of ePTFE and in 3.9% aer the use
of PP. ey further reported that infected ePTFE
mesh salvage was not possible in any patient, in
contrast to infected PP mesh which could be
salvaged in all patients. Hence, the chances of
mesh salvage aer infection are greater with PP
meshes than with ePTFE meshes, which usually
have to be explanted. If an interventional conservative attempt at treating a mesh infection
aer laparoscopic IPOM proves unsuccessful or
if from the outset the circumstances no longer
allow preservation of the mesh, various options
can be used for mesh infections aer mesh
repair of incisional and ventral hernias, including [53–56]:
5 Mesh removal and primary skin closure, with
the repair repeated aer 6–9months
5 Mesh removal, repair using the compo-
nent separation technique, with the skin
le open and vacuum-assisted wound
closure or open wound dressing applied
. Fig.29.8)
(
5 Mesh removal, repair of the defect with a
biologic mesh, leaving the skin open and
applying vacuum-assisted wound closure or
open wound dressing (
. Fig.29.9)
5 Mesh salvage, with the skin le open, and
vacuum-assisted wound closure or open
wound dressing applied
e treatment options available in the literature
relate only to individual cases or to small case
series; currently, no concrete evidence-based
recommendation can be made for the optimal
management that gives the best results. Instead,
the surgeon must decide in the individual case
which option is best for the individual patient.
Further studies are denitely required in this difcult area.
Evidence-based statements and recommenda-
tions acc. to Köckerling, Chowbey, and Misra in [2]:
Complications and Comparison to Open Repair
319
. Fig. 29.8 Mesh removal and component separation with mesh repair for recurrent incisional hernia following open
repair
29
. Fig. 29.9 Mesh infection presenting as discharging sinus following open onlay mesh repair
“Statements”
5 Level 1A: The rate of mesh infections
after laparoscopic ventral and incisional
hernia repair is low (1%)
The mesh does not need to be
removed in all cases of wound infection
after laparoscopic ventral and incisional
hernia repair
5 Level 2: Infected expanded polytetra-
fluorethylene (ePTFE) meshes require
removal significantly more often than
PP-based meshes
“Recommendations”
5 Grade B: An infected ePTFE mesh after
laparoscopic ventral and incisional
hernia repair should be removed
29.5 Seroma
Seroma is a collection of serous uid in the hernia
sac following incisional and ventral hernia repair.
e development of a seroma is so common aer
a laparoscopic incisional and ventral hernia repair
320
A. Krishna et al.
that many surgeons do not believe it to be a real
complication. However, this seroma is not only
cosmetically disguring for the patient but also
gives a feeling of recurrence or surgical failure to
the patient. Seroma as a complication is unique to
laparoscopic repair and very rare following open
repair. It is probably due to the fact that in laparoscopic IPOM repair aer the contents are reduced,
the hernia sac is le in situ which creates a potential space for blood, lymph, and reactionary uid
to accumulate and take the form of a seroma.
29.5.1 Risk Factors
29
e following risk factors have been identied for
seroma formation following incisional and ventral
hernia repairs: an irreducible hernia, an increased
number of prior abdominal incisions, a large
defect (. Fig.29.10), and obesity. e major cause
for seroma formation is most likely the large dead
space between the mesh and the abdominal wall.
e reported incidence of seroma aer
LIVHR varies widely from 3% to 100%, with a
peak presentation at 7days postoperatively and
almost complete resolution by 90days aer surgery [23, 57–61]. One study reported that the
incidence of seroma formation was 100% in all
the patients that were followed with ultrasonic
studies [59]. An overall review of the current
literature calculates this incidence of clinically
signicant seromas to an average of 4–5% of
patients aer LIVHR.According to the current
literature, up to 35% of patients with seroma
will become symptomatic with pain, pressure,
or erythema [61] and few patients will develop a
chronic seroma (. Fig.29.11).
ere is no technique/method described in
the literature which will prevent seroma formation. e transabdominal preperitoneal repair
for primary ventral and umbilical hernias may
decrease the likelihood of seroma formation
[61]. Randomized trials yield conicting results
regarding the likelihood of seroma formation with laparoscopic or open repair [23, 62].
Kirshtein attempted to pierce the biomaterial with
the Veress needle but found that omitting this
step did not have any appreciable eect upon the
incidence of seromas [63]. Others have used the
DualMesh with holes (W.L. Gore & Associates,
Inc., Flagsta, AZ, USA), but this, too, is associated with a postoperative seroma rate of nearly
. Fig. 29.10 Large incisonal hernia in a 50 year old lady
with H/O open hysterectomy
. Fig. 29.11 Large seroma 2 weeks following laparo-
scopic incisional hernia repair
12% [21]. erefore, perforation of the mesh or
even the use of polypropylene oers any benet
in the prevention of seromas [62, 64, 65].
Some authors have tried to use preemptive measures, such as the application of electrocautery, or the
ultrasonic energy to the sac with the use of a single
Complications and Comparison to Open Repair
suture in the center of the hernia defect to xate the
prosthetic material [66, 67]. A small randomized
study found that if the hernia sac was cauterized by
electrocautery or ultrasonic energy, the seroma frequency was decreased from 25% to 4% [66]. Other
similar trials have reported that placing a quilting stitch or double-crown stapling to decrease the
dead space did not aect seroma formation [67, 68].
Another technique which has been used is the closure of defect with shoelace technique prior to mesh
placement. However, this is restricted to small defects
(<5cm in size). Most of the studies suer from small
numbers. Many surgeons will place an abdominal
binder or a compression dressing over the defect site
while the patient is still on the operating table. is
will be worn for at least 3–14days, depending upon
the initial size of the protruding hernia. e size
of the binder, the length of time that it is used, and
whether a bulky dressing is used have not been standardized, but these seem to decrease both the size
and duration of the seromas that are clinically signicant by as much as 50% [65]. e importance of
applying a pressure dressing has been supported by
only one study with methodologic limitations [72].
Most surgeons believe that majority of these
seromas will resolve usually within 3months [63,
66, 69, 70]. Aspiration is indicated only when
the patient remains symptomatic for longer than
6 months and the ultrasonic evidence does not
reveal any signicant resolution of the seroma.
If the patient is obviously symptomatic with a
degree of pain, this will be necessary earlier than
that time. It must be remembered that strict sterile technique is necessary, as bacteria can be introduced into the uid collection [71, 72].
It is best recommended that the patients
should be informed about the possible occurrence
of seromas and the expectation that the majority
will resolve spontaneously. Given the clinically
important consequences of mesh infection as a
possible complication of repeated seroma aspiration, this recommendation also may be considered stronger (. Fig.29.12).
Evidence-based statements and recommendations acc. to Bingener and Rohr in [2]:
321
. Fig. 29.12 Seroma being aspirated 6 weeks following
laparoscopic IPOM
“Recommendation”
5 Grade B: Patients should be informed on
the possibility of both asymptomatic and
symptomatic seroma formation
“Statements”
5 Level 2B: Trial about the incidence after
laparoscopic and open repair presents
with opposing results
5 Level 2B: Nonreducible hernia is a risk
factor
5 Level 2B: The incidence increases with
the number of prior abdominal incisions
5 Level 2B: Cauterizing of the hernia sac
may lead to less seroma formation
5 Level 2B: Placement of a quilting stitch
does not affect seroma formation
5 Level 2B: Double-crown stapling does
not decrease seroma formation
29
“Statement”
5 Level 2B: Up to 30% of patients who
experience development of seroma
become symptomatic
“Recommendations”
5 Grade C: Surgeons can attempt cau-
terization of the hernia sac to prevent
seroma formation