Fade or fate

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Surg Endosc (2006) 20: 325–328 DOI: 10.1007/s00464-005-0052-6 Ó Springer Science+Business Media, Inc. 2005

Fade or fate Seroma in laparoscopic inguinal hernia repair A. Cihan,1 H. Ozdemir,2 B. H. Uc¸an,1 Z. Acun,1 M. Comert,1 O. Tascilar,1 A. Cesur,1 G. K. C¸akmak,1 S. Gundogdu2 1 2

Department of Surgery, Medical Faculty of the Zonguldak Karaelmas University, 67500 Turkey Department of Radiodiagnostics, Medical Faculty of the Zonguldak Karaelmas University, 67500 Turkey

Received: 3 February 2005/Accepted: 21 May 2005/Online publication: 5 December 2005

Abstract Background: Postoperative fluid collection in the space left behind the dissected hernia sac in laparoscopic herniorraphy puts the surgeon in a dilemma as to whether it is a recurrence or a seroma, and it is not always easily judged only by physical examination (PE). Another important issue is what kind of seroma can be accepted as a complication of surgery. Methods: Thirty patients with unilateral inguinal hernia who had a hernia sac of >4 cm were operated on with transabdominal preperitoneal hernia repair (TAPP) technique and the collection at the hernia site was followed by PE and superficial ultrasonography (USG) postoperatively on the first day, first week, first month, and third month. Results: USG detected seroma in 20 patients, while 17 could be noticed by PE on the first postoperative day. At the end of the third month, seromas resolved by 90%, and could only be detected by USG in two patients. Pain or complication rates attributable to seroma in patients were not determined (p > 0.05) in the statistical analyses between the groups. Conclusions: Superficial USG is a beneficial tool in differentiating early recurrence or seroma in patients. It should not be intervened with as a complication until the patient has complaints attributable to seroma. Key words: Laparoscopy — Inguinal hernia — Seroma — Complication — Ultrasonography

The healing of dissected soft tissue spaces in laparoscopic hernia repair may be delayed as a result of seroma formation. Additionally, prosthetic materials implanted in these spaces create exagerated seromas as a result of irritation and following serum leakage [3]. Especially in incisional hernia, seroma and prolonged Correspondence to: A. Cihan

drainage are frequently reported [10, 19]. In inguinal hernia repair, a potential tissue space left behind the dissected area that was created by the hernia mass naturally occurs. Occurrence of fluid collection in this pouch puts the surgeon in a dilemma about whether it is a complication or a natural process of the healing [1, 11, 19]. The character of this postoperative mass in the previous hernia region connot be discriminated with physical examination (PE) alone. In this prospective study, ultrasonograpy (USG) was used to detect and follow the nature of this fluid collection in the hernia site. Patient discomfort and the resorption time are also reported.

Materials and methods In this prospective study, 30 male patients with a unilateral inguinal hernia mass, whose sac diameter measured 4 cm or more in the most expanded area with the Valsalva maneuver after substraction of cutaneous and subcutaneous tissue thickness, were included. Hernias smaller than this size were eliminated. A history of hernia surgery or additional disease causing increased intra-abdominal pressure was excluded in this study. Standard transabdominal preperitoneal (TAPP) laparoscopic hernia repair with polypropylene mesh (Surgipro, Autosuture, Norwalk, CT, USA) and tacker (Protack, Autosuture, Norwalk, CT, USA) fixation was used as an operative procedure. All of the operations were performed by the same surgical team with meticulous hemostasis. In all of the patients except four, inguinoscrotal hernia sacs were easily dissected; the others were transected and the distal sac left in place. The USG evaluations were done by the same radiologist, who was aware of the operative procedure, the regional anatomy, and the features to be searched. All of the patients underwent PE and inguinoscrotal USG at the end of the postoperative first day, first week, first month, and third month. Seroma formation, size, and content as pure cystic, solid, irregular echogenic, increased echogenity were recorded. Patients with seroma detected by USG on the first postoperative day were divided as Group 1 (n = 20) and the others as Group 2 (n = 10). Patient demographics, hospitalization period, time of operation, time to return to normal physical activity, visual analog scale (VAS) for pain at postoperative hours 0, 2, 4, 8, 24, and 48, and any other complaints attributable to the surgery, were recorded and compared.

326 Table 1. Characteristics of patients in Groups 1 and 2a

Age (yr) Follow-up (mo) Operation time (min) Hospitalization time (d) Return to normal activity (d) VAS 2nd hour VAS 8th hour VAS 24th hour a

Group 1 (n = 20) Seroma (+)

Group 2 (n = 10) Seroma ())

p value

46.8 25.7 53.2 2.6 4.8 2.8 0.3 0.05

56.2 19.3 48.0 2.1 4.2 3.4 0.2 0.0

0.100 0.183 0.373 0.267 0.350 0.650 0.588 0.846

± ± ± ± ± ± ± ±

3.5 2.0 3.8 0.2 0.4 0.5 0.1 0.05

± ± ± ± ± ± ± ±

1.9 3.8 6.3 0.2 0.5 0.5 0.2 0.0

VAS = visual analog scale for pain

Table 2. The number and size of seroma by PE and USG evaluation (n = 30)

Time

Number of seromas by PE (%)

Number of seromas by USG (%)

Size of seromas by USG (cm3 ± SEM)

1st day 1st week 1st month 3rd month

17 7 5 2

20 16 10 2

25.9 10.3 7.0 1.1

(56.7) (23.3) (16.7) (6.7)

All results were analyzed with computer software (SPSS for Windows), and calculated as mean ± SEM. Mann-Whitney U-test was used for statistical analyses of the groups and p values
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