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423
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_37,
© Springer Science+Business Media New York 2013
37. Enterotomy During Hernia Repair
Ross F. Goldberg and C. Daniel Smith
An obvious enterotomy or bowel injury that can lead to an enterotomy
can occur during abdominal access, lysis of adhesions, or hernia reduction
during any hernia repair [ 1 ] .
Incidence
In a recent review of the literature, the enterotomy rate during ventral
hernia repair (of over 3,900 patients) was determined to be 1.78% [ 2 ] .
Eighty-two percent of these enterotomies are noticed at the time of the
operation (total of 1.5% of all patients), while the remainder go
unrecognized [ 2 ] . The overall incidence of occult enterotomies was
0.33%, resulting in the death of 2.8% of patients [ 2 ] . It was also found
that these enterotomies could occur in either a laparoscopic or open
hernia repair, and some are missed even during an open repair [ 2 ] .
Diagnosis
Recognized enterotomies are, by namesake, apparent during the
operation. Spillage of the intestinal contents is sometimes evident,
indicating that there is a perforation of the bowel wall. However,
sometimes an enterotomy can be made without spillage, and therefore
high index of suspicion is paramount. Whether operating with the
laparoscope or open techniques, if there is a chance an enterotomy was
made, the surgeon should do everything to ensure it was treated.
Occult enterotomies are more dif fi cult to diagnose. As the name
would suggest, these injuries are not recognized during the operation and
424
R.F. Goldberg and C.D. Smith
are found postoperatively. If a patient develops fever, tachycardia, pain,
or abdominal distention in the immediate postoperative setting, bowel
injury with possible intestinal spillage needs to be seriously considered.
This concern increases if the patient has a concurrent leukocytosis. If a
patient develops these symptoms, especially within the fi rst few days
after the hernia repair, radiographic imaging, such as CT scans, usually
does not provide de fi nitive diagnosis of bowel injury. If there is a concern
for a bowel injury, the best approach for diagnosis is early reoperation,
either through a laparoscopic or open approach. A CT scan failing to
demonstrate extravasation of contrast does not rule out a bowel
enterotomy, and this fact cannot be overstated enough. If there is a chance
that a patient is decompensating because of an enterotomy, and there is
no other feasible explanation for the current symptoms, then the patient
should be explored.
Management
There are a variety of approaches to repairing an enterotomy, which
is dependent on several situational factors including whether the injury is
found at the time of the primary operation or in the postoperative period.
Factors that help decide the appropriate course of action include the
patient’s medical condition, the type of bowel injured (the majority being
small bowel), the presence and amount of gross spillage, the extent of the
lysis of adhesions, and the size of the hernia defect [ 1 ] . The approach to
the repair is also dependent on the surgeon’s comfort level and experience,
requiring the surgeon to use their best judgment in any given situation.
Enterotomy/Bowel Injury at the Time of Primary
Operation
In the case of a bowel injury recognized at the time of the primary
surgery, one option to consider is immediate conversion from a
laparoscopic to an open operation, allowing for either a primary repair of
the injured bowel or a bowel resection with primary anastomosis. This
would then allow for completion of the adhesiolysis. Depending on the
nature and severity of the injury, along with the surgeon’s experience, the
425
37. Enterotomy During Hernia Repair
injury can also be repaired laparoscopically. Regardless of the approach
to repairing the bowel, it is imperative that the rest of the bowel be
examined to rule out other potential injuries.
The hernia itself could then be repaired from a few approaches. First,
there is the primary repair, using suture material only with no mesh
implantation. If this approach is feasible, it removes the possibility of
foreign material becoming infected due to possible contamination from
the bowel. But this approach still leaves the patient at risk for recurrence,
especially if the hernia defect is large in size and under tension when
repaired. The patient can also be followed for several months, and once
they are healed from their enterotomy repair, they could be offered
another operation at which the permanent mesh can be placed.
Another approach would be to use a temporary mesh, either a biologic
or a mesh made of an absorbable material. This approach allows for a
hernia repair while reducing the risk of a mesh infection. Even the
timeline to insert such a mesh in the face of an enterotomy is up for
debate in the literature. One approach is to place the mesh in the same
operative setting, immediately after the enterotomy is repaired. Another
approach is to repair the enterotomy, temporarily close the incision by
just suturing skin closed and place the patient on antibiotics anywhere
from 3 days to 1 week, then returning the patient to the operating room
to place a permanent mesh prior to the formation of any dense intestinal
adhesions. The purpose of this delayed approach is to further reduce the
risk of infection in the setting of the hernia repair. While the risk is less,
there is still a chance for mesh infection, requiring further interventions
including possible mesh removal and wound debridement.
Another suggested approach is that if the injury is recognized early,
with limited spillage, then the injury can be repaired primarily and the
prosthetic repair completed at that time. While there is some data on this
approach, the number of patients treated this way is very small. The
obvious concern is that with a prosthetic mesh and potential for infection,
further operative interventions if the mesh becomes infected may be
necessary.
A recent review of the literature by LeBlanc et al. helps re fl ect the
different approaches used for recognition and repair of enterotomies and
subsequent hernia repairs, shown here in Table 37.1 [ 2 ] .
Regardless of the approach taken, it is paramount that these issues be
discussed with the patient preoperatively. It is imperative that the patient
be made aware of the possible issues that could occur and different
avenues of repair of an injury if it were to occur.
426
R.F. Goldberg and C.D. Smith
Concern for Enterotomy/Bowel Injury
at Time of Primary Operation
If there is a concern for an injury while performing the primary
operation, the bowel should be run in its entirety once more. If there is an
area of concern, or an area of serosal injury, suturing can be done to
attempt to prevent an eventual enterotomy; this can be done
laparoscopically. If there is high suspicion, and laparoscopic exploration
fails to reveal the location, then conversion to open should occur and the
bowel should be run extracorporeally. If there is no gross spillage,
according to the literature review, the surgeon may choose to proceed
with synthetic mesh implantation, but the patient needs to be closely
monitored postoperatively for any signs of sepsis, including fever,
tachycardia, leukocytosis, and abdominal pain that is out of proportion.
Should that occur, then the patient must be returned to the operating
room to have the mesh removed.
Table 37.1. Method of recognized enterotomy repair and hernia repair [ 2 ] .
Reference Conversion
Method of
enterotomy repair
Method of hernia
repair
Open Lap Open Lap
Kyzer [
3 ] 2/2 2 0 2 0
Roth [
4 ] 1/2 1 1 1 1
a
Birgisson [
5 ] 0/2 0 2 0 1, 1
a
Parker [
6 ] 1/2 1 1 0 2
a
Bageacu [
7 ] 3/3 3 0 3 0
Ben-Haim [
8 ] 4/4 4 0 4 0
Berger [
9 ] 2/3 2 1 0 2, 1
a
Gillian [
10 ] 0/3 0 3 0 3
Eid [
11 ] 1/1 1 0 1 0
Carbajo [
12 ] 1/9 1 8 1 8
LeBlanc [
13 ] 2/2 2 0 2 0
Heniford [
14 ] 2/12 2 10 1 7, 4
a
Franklin [
15 ] 0/5 0 5 0 5
Holzman [
16 ] 1/1 1 0 1 0
Ramshaw [
17 ] 0/1 0 1 0 1
Robbins [
18 ] 1/1 1 0 1 0
Wright [
19 ] 3/3 3 0 3 0
Total (%) 24/56 (43) 24/56 (43) 32/56 (57) 20/56 (36) 27/56 (48)
9/56 (16)
a
From Ref. [ 2 ] with permission
a
Delayed laparoscopic repair
427
37. Enterotomy During Hernia Repair
The only sure way to prevent a mesh infection in the setting of an
intraoperative enterotomy is to avoid any implantation of synthetic
nonabsorbable mesh. An enterotomy and the surgeon’s plan, should one
occur, should be discussed with the patient ahead of time and included in
the informed consent.
Occult Enterotomy/Bowel Injury
If there is a missed or delayed thermal injury that results in enterotomy,
the patient will present with signs and symptoms of sepsis. If there is
concern for or evidence of a bowel injury, then an emergent operation is
warranted; typically this should be done via an open approach. With the
presence of gross spillage, the mesh has to be removed regardless of any
other intervention. This is then followed by a thorough examination of
the abdominal cavity, with either direct repair of the injured bowel or,
more likely, resection of the injured segment of bowel. Depending on the
amount of intestinal spillage, a decision can be made either to anastomose
in that setting or to bring out an ostomy and plan for a delayed repair. In
the setting of gross sepsis, the hernia defect can be closed primarily or
with an absorbable product, with the plan on returning to the operating
room at a later date for a more de fi nitive repair.
Avoidance
While a bowel injury can always occur during these operations, care
must be taken to decrease the risk of an injury as much as possible. When
gaining abdominal access, it is recommended to always enter the
abdomen under direct vision, especially in a patient with previous
abdominal operations. This can be done either via an open Hassan
technique, or using an optical trocar. These approaches help to reduce
the incidence of trocar injury to the underlying bowel.
When performing adhesiolysis, it is recommended to only use cold
instruments, such as laparoscopic shears. An energy source should never
be attached to the instrument performing the dissection, thereby removing
the risk of thermal injury to underlying tissue/bowel.
Finally, if there is a concern for bowel injury, or there is an area of
bowel that could be problematic in the future, the area can be buttressed
with simple serosal sutures. All of this can be performed laparoscopically.
428
R.F. Goldberg and C.D. Smith
At the end of every hernia repair, the involved or manipulated bowel
should be visualized to look for any signs of injury, and this fi nal
assessment and absence of bowel injury are documented in the operative
note. This becomes important in cases of occult injury to document
nothing at the time of surgery.
Conclusion
There is no standard approach to enterotomy management in the
setting of a hernia repair. The factors affecting the treatment path include
the severity and nature of the injured bowel, presence of gross spillage,
and surgeon’s expertise and comfort level, which results in options for
both laparoscopic and open repairs. As demonstrated in the literature,
multiple options exist, and all are reasonable choices, as long as they are
done safely, minimizing the risk to the patient.
References
1. Ramshaw B. Laparoscopic ventral hernia repair—managing and preventing
complications. Int Surg. 2005;90:S48–55.
2. LeBlanc KA, Elieson MJ, Corder 3rd JM. Enterotomy and mortality rates of
laparoscopic incisional and ventral hernia repair: a review of the literature. JSLS.
2007;11:408–14.
3. Kyzer S, Alis M, Aloni Y, Charuzi I. Laparoscopic repair of postoperation ventral
hernia. Early postoperation results. Surg Endosc. 1999;13:928–31.
4. Roth JS, Park AE, Witzke D, Mastrangelo MJ. Laparoscopic incisional/ventral
herniorraphy: a fi ve year experience. Hernia. 1999;3:209–14.
5. Birgisson G, Park AE, Mastrangelo Jr MJ, Witzke DB, Chu UB. Obesity and
laparoscopic repair of ventral hernias. Surg Endosc. 2001;15:1419–22.
6. Parker 3rd HH, Nottingham JM, Bynoe RP, Yost MJ. Laparoscopic repair of large
incisional hernias. Am Surg. 2002;68:530–3. discussion 533–4.
7. Bageacu S, Blanc P, Breton C, et al. Laparoscopic repair of incisional hernia: a
retrospective study of 159 patients. Surg Endosc. 2002;16:345–8.
8. Ben-Haim M, Kuriansky J, Tal R, et al. Pitfalls and complications with laparoscopic
intraperitoneal expanded polytetra fl uoroethylene patch repair of postoperative ventral
hernia. Surg Endosc. 2002;16:785–8.
9. Berger D, Bientzle M, Muller A. Postoperative complications after laparoscopic
incisional hernia repair. Incidence and treatment. Surg Endosc. 2002;16:1720–3.
429
37. Enterotomy During Hernia Repair
10. Gillian GK, Geis WP, Grover G. Laparoscopic incisional and ventral hernia repair
(LIVH): an evolving outpatient technique. JSLS. 2002;6:315–22.
11. Eid GM, Prince JM, Mattar SG, Hamad G, Ikrammudin S, Schauer PR. Medium-term
follow-up con fi rms the safety and durability of laparoscopic ventral hernia repair with
PTFE. Surgery. 2003;134:599–603. discussion 603–4.
12. Carbajo MA, del Olmo Martp JC, Blanco JI, et al. Laparoscopic approach to incisional
hernia. Surg Endosc. 2003;17:118–22.
13. LeBlanc KA, Whitaker JM, Bellanger DE, Rhynes VK. Laparoscopic incisional and
ventral hernioplasty: lessons learned from 200 patients. Hernia. 2003;7:118–24.
14. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic repair of ventral hernias:
nine years’ experience with 850 consecutive hernias. Ann Surg. 2003;238:391–9.
discussion 399–400.
15. Franklin Jr ME, Gonzalez Jr JJ, Glass JL, Manjarrez A. Laparoscopic ventral and
incisional hernia repair: an 11-year experience. Hernia. 2004;8:23–7.
16. Holzman MD, Purut CM, Reintgen K, Eubanks S, Pappas TN. Laparoscopic ventral
and incisional hernioplasty. Surg Endosc. 1997;11:32–5.
17. Ramshaw BJ, Esartia P, Schwab J, et al. Comparison of laparoscopic and open ventral
herniorrhaphy. Am Surg. 1999;65:827–31. discussion 831–2.
18. Robbins SB, Pofahl WE, Gonzalez RP. Laparoscopic ventral hernia repair reduces
wound complications. Am Surg. 2001;67:896–900.
19. Wright BE, Niskanen BD, Peterson DJ, et al. Laparoscopic ventral hernia repair: are
there comparative advantages over traditional methods of repair? Am Surg.
2002;68:291–5. discussion 295–6.
431
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_38,
© Springer Science+Business Media New York 2013
38. Chronic Seroma
Morris Franklin Jr. , Richard Alexander , Gerardo
Lozano , and Karla Russek
De fi nition
A seroma is a collection of lique fi ed fat, serum, and lymphatic fl uid
in a closed space. The fl uid is usually clear, yellow, and somewhat
viscous and is found in the subcutaneous layer of the skin. Seromas
represent the most benign complications after an operative procedure
and are particularly likely to occur when large skin fl aps are developed in
the course of the operation, as is often seen with mastectomy, axillary
dissection, groin dissection, and large ventral hernias [ 1 ] .
There has been no consistent de fi nition of chronic seroma in the
literature, although it has been documented most frequently when it is
symptomatic, bothersome to the patient, palpable, fl uctuant, tense, and
requires at least one needle aspiration [ 2– 4 ] . In contrast, in a published
study [ 5 ] , seroma was documented only when multiple aspirations were
required, or if insertion of a new drain was necessary in persistent cases.
Similarly, other studies used the term seroma if a veri fi ed volume of
more than 5–20 ml of fl uid was obtained by puncture and aspiration [ 6 ] ,
whereas some studies have used ultrasonography to verify seroma [ 7 ] .
Seroma formation is one of the most commonly reported complications
after laparoscopic and open hernia surgery. It occurs early after operation
in virtually all patients, to some extent. Virtually all seromas resolve
spontaneously over a period of weeks to months, with fewer than 5%
persisting for more than 8 weeks. Because of this, seromas are rarely
clinically signi fi cant [ 8 ] .
432
M. Franklin Jr. et al.
Physiology
Postoperative fl uid collections represent sequelae of events that
ultimately contribute to negative soft tissue healing events [ 9 ] . It has
been demonstrated that seroma is not merely an accumulation of serum,
but exudate resulting from an acute in fl ammatory reaction, and concluded
that seroma formation re fl ects an increased intensity and prolongation of
the fi rst phase of wound repair. Mc Caul et al. [
10 ] have also demonstrated
that drainage fl uid has a composition different from that of lymph but
similar to that of in fl ammatory exudate.
Seroma formation can be seen as a consequence of the in fl ammatory
foreign body reaction with monocytes and macrophages involved at the
interface of connective tissue and implant. These cells produce a variety
of cytokines, which regulate the local immune response, wound healing,
and scar formation [ 11 ] .
On the other hand, Wu et al. [ 12 ] have reported an increase of vascular
endothelial growth factor (VEGF) and a decrease of endostatin in
drainage fl uid immediately after surgery. VEGF is a known mediator of
angiogenesis, vascular proliferation, and permeability, and endostatin is
a potent inhibitor of angiogenesis [ 13, 14 ] . Therefore, these changes may
not only re fl ect induction of angiogenesis as a physiologic response to
operative trauma but also enhanced accumulation of fl uid.
Heidemann et al. showed that stabilizing the pH value in the environment
of implants for several weeks improves the biocompatibility by reducing
adverse tissue reactions [ 15 ] . Though the risk of seroma formation
increases when mesh is used for repair, little is known about the genesis of
seroma formation. Alloplastic mesh prosthesis leads to a multitude of
tissue reactions, including the postoperative release of cytokines and the
formation of seroma sometimes persistent for months [ 16 ] .
Presentation
A seroma is usually manifested as a localized and well-circumscribed
swelling, pressure or discomfort, and occasional drainage of clear liquid
from the immature surgical wound. A study by Bernatchez et al. [ 11 ]
showed that the total drainage output within the fi rst few postoperative
days was signi fi cantly elevated in patients with subsequent seroma
formation.