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38. Chronic Seroma
Prevention
Prevention of seroma formation may be achieved by placing suction
drains under the skin or in any potential dead space created. Premature
removal of drains frequently results in large seromas that require
aspiration under sterile conditions, followed by placement of a pressure
dressing. Abdominal binders worn by patients for up to 6 weeks after the
hernia repair have been advocated by surgeons as they believe the extra
pressure applied across the abdominal wall may increase fl uid movement
and decrease the incidence of seroma formation [ 17 ] .
The effects of electrocautery on tissues are an acknowledged risk
factor for seroma formation. Two prospective clinical trials were
conducted where randomized breast cancer patients underwent surgery
with electrocautery and scalpel, respectively; they con fi rmed a lower
incidence of seroma formation with the latter technique. However, few
surgeons are willing to relinquish the convenience and improved
hemostasis associated with electrocautery dissection [ 4 ] .
In cases of hernia surgery, it has been suggested that cauterization of
the hernia sac together with a central full-thickness suture to reduce dead
space seems to prevent seroma formation [ 18 ] .
There have been attempts to prevent or decrease seroma formation as
the application of tetracycline and/or bovine thrombin as sclerosing
agents, but they have not worked well. Fibrin glues, patches, and sealants
appear promising, but they too have proven to not be useful for the
prevention of seromas. Additional strategies promoted especially for
open-component separation techniques include quilting sutures to fi x the
skin fl aps to the abdominal wall and minimize dead space and the use of
aerosolized talc to induce tissue adherence of skin fl aps to the abdominal
wall musculofascial in the early postoperative period.
Treatment
A seroma that reaccumulates after several aspirations can be evacuated
by opening the incision and packing the wound with saline-moistened
gauze to allow healing by secondary intention. In the presence of
synthetic mesh, the best option may be open drainage in the operating
room with the incision closed to avoid exposure and infection of the
mesh; closed suction drains are generally placed. An infected seroma is
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M. Franklin Jr. et al.
also treated by open drainage, typically without skin closure. However,
the presence of synthetic mesh in these cases may prevent the wound
from healing. Management of the mesh depends on the severity and
extent of infection. In the absence of severe sepsis, spreading cellulitis,
or the presence of localized infection, the mesh can be left in situ and
removed at a later date when the acute infectious process has resolved.
Granulation tissue may grow into and over the mesh. This is especially
true for the less dense, wider pore types of mesh and least likely for
PTFE mesh. If the mesh does not integrate well into the tissue and signs
of infection are not resolving, the mesh will most likely need to be
removed and the wound managed with open wound care [ 1 ] .
References
1. Surgical complications. In: Townsend CM (eds) Sabiston textbook of surgery, 18th ed.
Saunders. 2008; (15) .
2. Kuroi K, Shimozuma K, Taguchi T, Imai H, Yamashiro H, Ohsumi S, Saito S.
Pathophysiology of seroma in breast cancer. Breast Cancer. 2005;12(2):288–93.
3. Bryant M, Baum M. Postoperative seroma following mastectomy and axillary
dissection. Br J Surg. 1987;74:1187.
4. Porter KA, O’Connor S, Rimm E, Lopez M. Electrocautery as a factor in seroma
formation following mastectomy. Am J Surg. 1998;176:8–11.
5. Burak WE, Goodman PS, Young SC, Farrar WB. Seroma formation following axillary
dissection for breast cancer: risk factors and lack of in fl uence of bovine thrombin. J
Surg Oncol. 1997;64:27–31.
6. Tejler G, Aspegren K. Complications and hospital stay after surgery for breast cancer:
a prospective study of 385 patients. Br J Surg. 1985;72:542–4.
7. Puttawibul P, Sangthong B, Maipang T, Sampao S, Uttamakul P, Apakupaul N.
Mastectomy without drain at pectoral area: a randomized controlled trial. J Med Assoc
Thai. 2003;86:325–31.
8. Souba WW. Laparoscopic hernia repair. In: ACS surgery principles practice. WebMD
Professional Publishing, Inc.
9. Bullocks J, Basu B, Hsu P, Singer R. Prevention of hematomas and seromas. Semin
Plast Surg. 2006;20(4):233–40.
10. Mc Caul JA, Aslaam A, Spooner RJ, Louden I, Cavanagh T, Purushotham AD.
Aetiology of seroma formation in patients undergoing surgery for breast cancer.
Breast. 2000;9:144–8.
11. Bernatchez SF, Parks PJ, Gibbons DF. Interaction of macrophages with fi brous
materials in vitro. Biomaterials. 1996;17:2077–86.
12. Wu FP, Hoekman K, Meijer S, Cuesta MA. VEGF and endostatin levels in wound fl uid
and plasma after breast surgery. Angiogenesis. 2003;6:255–7.
435
38. Chronic Seroma
13. Toi M, Matsumoto T, Bando H. Vascular endothelial growth factor: its prognostic,
predictive, and therapeutic implications. Lancet Oncol. 2001;2:667–73.
14. Folkman J. Endogenous angiogenesis inhibitors. APMIS. 2004;112:496–507.
15. Heidemann W, Jeschkeit-Schubbert S, Ruf fi eux K, Fischer JH, Jung H, Krueger G,
Wintermantel E, Gerlach KL. pH stabilization of predegraded PDLLA by an admixture
of water soluble sodium hydrogen phosphate—results of an in vitro- and in vivo-study.
Biomaterials. 2002;23:3567–74.
16. Klink CD, Binnebosel M, Lucas AH, Schachtrupp A, Klinge U, Shumpelick V, Junge
K. Do drainage liquid characteristics serve as predictors for seroma formation after
incisional hernia repair? Hernia. 2010;14:175–9.
17. Jin J, Schomisch S, Rosen M. In vitro evaluation of the permeability of prosthetic
meshes as the possible cause of postoperative seroma formation. Surg Innov.
2009;16(2):129–33.
18. Tsimoyiannis EC, Tsimogiannis KE, Pappas-Gogos G. Seroma and recurrence in
laparoscopic ventral hernioplasty. JSLS. 2008;12(1):51–7.
Part VIII
Current Debates in Ventral
and Incisional Hernia Repair
439
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_39,
© Springer Science+Business Media New York 2013
39. Bridging Versus Closing the Defect
During Laparoscopic Ventral Hernia
Repair
Yuri W. Novitsky
Bene fi ts of Laparoscopy in Ventral Hernia Repair
Hernia repair continues to be one of the most common procedures
performed by general surgeons. With the advent of laparoscopy,
minimally invasive techniques have been employed in abdominal wall
reconstructions in an effort to reduce postoperative morbidity and wound
complications. In fact, over the last decade, laparoscopic repair has been
utilized for repairs of many ventral hernia defects due to its ef fi cacy and
safety [ 1– 3 ] . Compared to open repairs, laparoscopic ventral hernia
repair (LVHR) has been shown to result in reduced wound complications,
quicker recovery of bowel function, shorter hospital stay, and improved
cosmesis [ 4– 6 ] . In addition, appropriately performed laparoscopic repair
has also been associated with low recurrence rates [ 1, 5, 7 ] . Not
surprisingly, LVHR has been proposed as the gold standard for many
ventral hernia repairs [ 7, 8 ] .
Drawbacks of Traditional LVHR
Despite a multitude of perioperative advantages, there are several
drawbacks to the use of laparoscopic techniques. Postoperative seroma is
a common complication of a traditional LVHR [ 9 ] . Reduction of the
viscera followed by mesh “patching” of the hernia defect results in a
potential space that is fi lled with serous fl uid postoperatively. Such
seromas are common and typically do not require intervention; however,
they may be a source of postoperative discomfort and wound-related
440
Y.W. Nov it sk y
morbidity. Furthermore, traditional laparoscopic repairs have been
associated with bulging at the site of the hernia repair. While laparoscopic
underlay mesh repair is a true “tension-free” technique, it leaves behind
adynamic, “bridged” areas of the abdominal wall. Lack of anatomic
reconstruction and medialization of rectus muscles, in turn, often leads
to various degrees of visceral bulging at the site of a hernia defect.
Although this fact has received little attention in the majority of LVHR
literature, practicing surgeons have long been frustrated by this
shortcoming of a traditional laparoscopic technique.
Goals of Repair
As with any other surgical procedure, there are several goals that
should be achieved during a given ventral hernia repair. First, the
operation needs to be conducted safely with minimal risks to the patient.
This is achieved via proper patient selection, careful abdominal access,
and meticulous adhesiolysis, among other are key safety principles. Next, a
surgeon should strive to minimize postoperative infectious complications
and limit other long-term adverse side effects of a herniorrhaphy.
Appropriate mesh selection is paramount, especially during laparoscopic
ventral hernia repair. Finally, an operation should be aimed at providing
a durable and lasting repair with minimal chance of recurrence. Important
principles in this regard have been reported to be complete adhesiolysis,
appropriate mesh sizing with suf fi cient overlap, as well as permanent
transabdominal fi xation. In addition to these principles, reconstruction of
an abdominal wall that resembles native anatomy has recently emerged
as another key component of a ventral hernia repair.
Defect Closure
When addressing ventral hernia repair, abdominal wall mechanics/
physics is an important topic that necessitates some discussion. Pascal’s
principle states that pressure applied to a con fi ned fl uid is transmitted
throughout the fl uid and container walls by the same amount [ 10 ] .
Additionally, a hernia defect is akin to a vascular aneurysm, with respect
to a focal weakness or thinning of its wall. According to an extension of
the law of Laplace [ 11 ] , as the abdominal wall radius increases and
increased. Because a hernia defect provides an outlet for abdominal
441
39. Bridging Versus Closing the Defect During Laparoscopic
pressure, the force applied across the defect is increased substantially. As
discussed by Agarwal et al. [ 8 ] , mesh covering the defect in a traditional
“bridged” fashion bears this multiplied intra-abdominal pressure point,
possibly leading to mesh instability, excessive suture tension, and bulging
[ 8 ] . Thus, it can be hypothesized that by closure of the defect, abdominal
wall integrity is restored, leading to equalized pressure and tension across
the abdominal wall and intra-abdominally placed mesh.
Overall, it appears that the impetus for the modern trend of “anatomic”
repairs stems from surgeons’ three major frustrations associated with
traditional repairs: seromas, persistence of palpable defect, and bulging at
the site of a “bridged” defect. By closing the defect, the rectus abdominis
muscles are re-approximated, and the major insertion point of abdominal
musculature, the linea alba, is restored. Closure of the defect results in a
near total decrease of the “dead” space and thus minimizes the risks of
postoperative seromas. Although objective data are lacking, hernia repair
with defect closure also likely contributes to restoration of a functional and
dynamic abdominal wall. We recently reported our early experience with
routine defect closure during laparoscopic hernia repair [ 12 ] . Our
laparoscopic “shoelace” repair combined techniques of both primary
defect closure and mesh prosthesis placement for reinforcement. Although
we were not able to evaluate “functionality” of the abdominal wall, routine
defect closure resulted in subjective elimination of adynamic areas of the
abdominal wall and postoperative bulging at the site of the hernia defects.
Technical Considerations and Outcomes
Several techniques for defect closure have recently been described.
Palanivelu et al. have utilized continuous intracorporeal sutures for defect
closure with subsequent intraperitoneal onlay mesh repair [ 13 ] . However,
in addition to technical challenges of this approach, running closure may
not be applicable to wider defects. Agarwal et al. presented a series of
patients undergoing laparoscopic ventral hernia repair with rather
cumbersome transabdominal “double-breasted” defect closure. They
achieved fascial closure with interrupted sutures followed by mesh
reinforcement [ 14 ] . They reported no infectious complications, no visible
bulging, and no recurrences at mean follow-up of 34 months. Cheala et al.
published a series of nearly 400 patients with defect closure. They utilized
a laparoscopic “transparietal U reverse suturing technique.” In short, the
stitch is placed transabdominally along one side of the defect, and a
horizontal mattress stitch is formed intracorporeally through the
442
Y.W. Nov it sk y
contralateral side. The tail of the stitch is then retrieved through the
original skin incision utilizing a suture passer. At a mean follow-up of
28 months, they reported 2% rate of seromas, 1.8% rate of chronic pain,
and only a 1.5% recurrence rate. Importantly, they found a 1.3% incidence
of postoperative bulging at the site of the hernia defect. The authors
emphasized the importance of complete “reconstructive” defect closure to
minimize complications and recurrences [ 15 ] . As mentioned above, we
recently reported our series of 47 consecutive patients undergoing LVHR
with defect closure [ 12 ] . Our technique has several unique elements.
Brie fl y, we achieve pneumoperitoneum using an optical trocar in the
subcostal area. The hernia sac is usually left in situ. Using a laparoscopic
suture passer, the hernia defect is closed with multiple fi gure-of-eight
stitches using a permanent mono fi lament suture. Each stitch is placed
through a stab incision in the skin (traversing the hernia sac) and
incorporates 1–2 cm of fascia on each side. Once all the stitches are
placed, the pneumoperitoneum is released, and the knots are tied in the
subcutaneous tissue. To facilitate closure, the knots are tied sequentially,
starting at the superior and inferior aspects of the defect fi rst and moving
toward the center. The mesh is then tailored to achieve at least a 5-cm
overlap above and below the defect. Importantly, the width of the mesh is
not calculated according to the original width of the defect. Instead, we
use 14–16 cm wide mesh which allows for about 7–8 cm of overlap in
each lateral direction from the newly re-created linea alba/midline. The
use of narrower meshes facilitates mesh positioning and allows us to avoid
“bisecting” the abdominal cavity with large, wide meshes. Furthermore,
smaller meshes should result in a reduction in the overall foreign body
response and fi brotic reactions to the mesh. With diminished lateral scar
tissue to the mesh, patients should experience improved mobility and
decreased long-term postoperative discomfort. Such reduction in the
width of the mesh implant is one of the major bene fi ts of our laparoscopic
“shoelacing” technique. The mesh is then secured with transabdominal
sutures and tacks. Finally, full-thickness, nonabsorbable U-stitches are
placed every 3–4 cm on each side of the midline closure. These stitches
are a key component to our technique as they transfer any tension at the
midline closure throughout the large portion of the mesh. We strongly
believe that these “buttress” stitches not only allow for “downsizing” of
the mesh width but also relieve tension in the newly re-created linea alba
and assist with creation of physiologic tension throughout the entire
abdominal wall. Not surprising, we found no instances of postoperative
seromas or bulging at the hernia site. In addition, we detected no
recurrences at a mean 10-month follow-up [ 12 ] .
443
39. Bridging Versus Closing the Defect During Laparoscopic
Defect Closure: Who Needs It?
A major goal of any ventral hernia repair should be the reconstructions
of a functional, dynamic abdominal wall. Traditional LVHR relies on
intraperitoneal “patching” of defects as an underlay. However, such
bridging technique fails to close the actual defect and may result in
adynamic areas of abdominal wall. Clinically, this may lead to bulging at
the site of hernia repair, especially in the long term. Moreover, signi fi cant
seroma accumulation may occur in the created dead space above the
mesh patch. By closing the hernia defect, medialization of the rectus
muscles occurs, clearly allowing for a better functional and cosmetic
reconstruction. Two major reasons exist against routine application of
defect closure during LVHR. First, this step adds time to the operation as
well as an additional technical challenge. Secondly, transabdominal
closure of large defects seems to cause signi fi cant additional incisional
discomfort with unclear long-term implications on chronic pain. As a
result, the pros and cons of defect closures have to be compared on an
individual patient-to-patient basis. In my view, most defects in younger,
active patients should be closed routinely. In addition, thinner patients
are more likely to notice persistent defects and bulging and would also
bene fi t from defect closure during LVHR. Older patients, on the other
hand, are unlikely to derive any bene fi ts from a “dynamic” reconstructed
abdominal wall and are likely best served by a traditional LVHR.
Similarly, morbidly obese patients are less likely to enjoy the bene fi ts of
defect closure. As defect closure gains wider implementation, the bene fi ts
and disadvantages of this approach should become clearer. A recently
initiated prospective randomized trial at out institution should add to the
knowledge base of LVHR with defect closure. This type of evidence may
help to determine the subgroup of patients who stand to bene fi t from this
modi fi cation of a traditional LVHR technique.
References
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nine years’ experience with 850 consecutive hernias. Ann Surg. 2003;238:391–9.
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4. Lomanto D, Iyer SG, Shabbir A, Cheah WK. Laparoscopic versus open ventral hernia
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8. Agarwal BB, Agarwal S, Mahajan KC. Laparoscopic ventral hernia repair: innovative
anatomical closure, mesh insertion without 10-mm transmyofascial port, and
atraumatic mesh fi xation: a preliminary experience of a new technique. Surg Endosc.
2009;23:900–5.
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of ventral hernias. Am Surg. 1998;64:276–80.
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12. Orenstein SB, Dumeer JL, Monteagudo J, Poi MJ, Novitsky YW. Outcomes of
laparoscopic ventral hernia repair with routine defect closure using “Shoelace”
technique. Surg Endosc. 2011;25:1452–7.
13. Palanivelu C, Jani KV, Senthilnathan P, Parthasarathi R, Madhankumar MV, Malladi
VK. Laparoscopic sutured closure with mesh reinforcement of incisional hernias.
Hernia. 2007;11:223–8.
14. Agarwal BB, Agarwal S, Gupta MK, Mishra A, Mahajan KC. Laparoscopic ventral
hernia meshplasty with “double-breasted” fascial closure of hernial defect: a new
technique. J Laparoendosc Adv Surg Tech A. 2008;18:222–9.
15. Cheala E, Thoma M, Tatete B, Lemye AC, Dessily M, Alle JL. The suturing concept
for laparoscopic mesh fi xation in ventral and incisional hernia repair: mid-term
analysis of 400 cases. Surg Endosc. 2007;21:391–5.