Drainage decreases the seroma incidence in laparoscopic transabdominal preperitoneal (TAPP) hernia repair for large inguinoscrotal hernias

Comparison of anatomical polyester mesh without fixation and conventional flat mesh with fixation in laparoscopic total extraperitoneal repair for inguinal hernia

PURPOSE

Laparoscopic total extraperitoneal (TEP) inguinal hernia repair is a well-established technique. In Taiwan, the National Health Insurance (NHI) covers the fees of the procedure and conventional mesh (polypropylene mesh), whereas the anatomical polyester mesh (Parietex™) requires additional self-pay. This study aimed to compare the outcomes of the conventional mesh with fixation versus the polyester mesh (without fixation) in laparoscopic TEP repair.

METHODS

We retrospectively reviewed the medical records of male patients who underwent laparoscopic TEP repair between 2017 and 2021. Patients could choose between the conventional mesh with fixation (conventional mesh group) or self-paid Parietex™ mesh without fixation (anatomical polyester mesh group). The outcomes included operation (OP) time, prolonged length of stay (LOS), and postoperative complications.

RESULTS

A total of 74 patients with 123 hernias were included, of which 36 patients (67 hernias) underwent the anatomical mesh without fixation, while 38 patients (56 hernias) underwent the conventional mesh with fixation. The mean OP time was 102.6 ± 45.6 and 88.5 ± 42.0 min in the conventional and the anatomical polyester mesh group. After adjusting for body mass index, diabetes mellitus, cardiovascular disease, and hernia type, no significant differences were observed between the two groups in OP time (p = 0.152) and the risk of acute pain (p = 0.337), chronic pain (p = 0.816), seroma (p = 0.941), hydrocele (p = 0.423), or hematoma (p = 0.347).

CONCLUSIONS

The conventional mesh demonstrates non-inferior outcomes compared to the anatomical polyester mesh. Given that the anatomical polyester mesh is not reimbursed by Taiwan's National Health Insurance (NHI), the use of the conventional mesh with fixation in TEP inguinal hernia repair may be a more cost-effective option in Taiwan.

Establishment of a Predictive Model for Seroma Formation After TAPP Repair for Unilateral Indirect Inguinal Hernia in Males

BackgroundInguinal hernia repair, particularly using TAPP, is common in males, and acclaimed for minimal invasiveness but often complicated by seromas, significantly affecting recovery and health care costs.MethodsThis retrospective study analyzed data from 266 male patients with unilateral indirect inguinal hernia who underwent transabdominal preperitoneal (TAPP) repair. We divided the patients into a training set (n = 188) and a validation set (n = 78). We employed logistic regression to identify independent risk factors for post-TAPP seroma and developed a nomogram to predict the occurrence of seromas. The model's accuracy was evaluated using receiver operating characteristic (ROC) curves, Hosmer-Lemeshow goodness-of-fit test, calibration curves, and decision curve analysis (DCA).ResultsPostoperatively, 20.3% of patients developed a seroma. Multivariate logistic regression analysis highlighted several independent risk factors for seroma formation: the use of anticoagulants, an internal ring defect ≥5 cm, scrotal hernia, incarcerated hernia, and transected hernia sac (P < 0.05). The ROC curves for the training and validation sets demonstrated areas under the curve of 0.893 (95% CI: 0.845-0.942) and 0.864 (95% CI: 0.765-0.963), respectively, indicating good model fits (P > 0.05). DCA confirmed significant clinical applicability of the model.ConclusionThe findings suggest that the use of anticoagulants, an internal ring defect ≥5 cm, scrotal hernia, incarcerated hernia, and transected hernia sac are significant independent risk factors for seroma formation after TAPP repair. Clinical consideration of these factors and proactive preventive measures are essential. Although many of these factors are non-modifiable, understanding them is crucial for preoperative risk assessment and patient management.

Effect of sac transection versus sac reduction on seroma in laparoscopic indirect hernia repair: a systematic review and meta-analysis

BACKGROUND

Seroma formation is a prevalent postoperative complication following laparoscopic inguinal hernia repair. While seromas are mostly self-absorbed, they can cause discomfort for the patient and complicate the assessment of hernia recurrence. Two primary techniques for managing the hernia sac are sac transection and complete sac reduction. This article aims to evaluate whether sac transection leads to a higher incidence of seroma compared to sac reduction and to review the main preventive strategies for seroma.

METHODS

Four databases (PubMed, MEDLINE, Embase and Cochrane Library) and ClinicalTrials.gov were comprehensively searched for relevant studies. The date of the last search was 25 March 2024. The results reported should include reliable information on seroma incidence, mean operation time, hospital stay and postoperative complications.

RESULTS

The present study included 6 studies compared the results of indirect hernia sac transection and complete sac reduction. The pooled results indicated that indirect hernia sac transection was associated increased seroma formation (OR = 1.74, 95% CI: 1.35-2.24%), and there was no statistical difference in mean operation time, hospital stay and recurrence between the sac transection (TS) and sac reduction (RS) groups. Postoperative pain was evaluated in 4 studies. There was no statistical difference between the two groups in postoperative pain reported in each of the four articles.

CONCLUSIONS

The study revealed that transection of the indirect hernia sac is associated with a higher incidence of seroma, but does not increase the occurrence of other complications.

Risk factors and clinical impact of seroma formation following laparoscopic inguinal hernia repair: a retrospective study

BACKGROUND

Although laparoscopic inguinal hernia repair (LIHR) has advantages over open surgery, postoperative seroma formation remains an issue. This study aimed to investigate the risk factors and clinical outcomes of seroma formation in patients undergoing LIHR.

METHODS

From January 2016 to March 2023, clinical data of patients who underwent LIHR were retrospectively analyzed. Patients who developed seroma and those who did not were classified into the seroma and non-seroma groups, respectively. The demographic and clinical characteristics were compared between the two groups. Univariate and multivariate logistic regression analyses were performed for variables of interest. The receiver operating characteristic curve was used to evaluate the risk factors of the binary logistic model, and the cutoff value for each risk factor was obtained.

RESULTS

Data of 128 patients were evaluated. Compared with patients in the non-seroma group, those in the seroma group had a higher body mass index (BMI) (P < 0.001), more direct hernias (P < 0.001), larger hernial orifice size (P < 0.001), more laparoscopic total extraperitoneal hernioplasty (TEP) (P < 0.001), more frequent reduction of hernial sac (P = 0.011), and lower preoperative serum albumin level (PSAL) (P < 0.001). Multivariate logistic regression analyses performed on these variables showed that high BMI (P = 0.005), large hernial orifice (P = 0.001), TEP (P = 0.033), and low PSAL (P = 0.009) were risk factors for seroma formation. Compared with the non-seroma group, the seroma group exhibited a higher numerical rating scale score for postoperative pain (P < 0.001), and longer hospital stays (P = 0.032).

CONCLUSIONS

BMI (> 24.5 kg/m2), hernial orifice size (> 2.5 cm), TEP, and PSAL (< 32.5 g/L) were independent risk factors of postoperative seroma formation in patients who underwent LIHR. Although most seromas resolve spontaneously without surgical intervention, seroma formation results in increased patient pain and prolonged hospital stay.

Endo-laparoscopic scrotal hernia surgery: which technique must we choose to reduce seroma-sac transection or complete sac reduction? A prospective study

Seroma formation is one of the important postoperative problems in inguinal hernia surgery, especially after scrotal hernia surgery. The present study aimed to present primarily the incidence of seroma after reduction and transection of the hernia sac in endo-laparoscopic scrotal hernia repair, and secondarily the results of early postoperative complications. Patients were divided into two groups TAPP and TEP. These groups were also divided into transection and reduction subgroups. In the reduction group, the hernia sac was completely dissected and pulled to the peritoneal area, while in the transection group, the neck of the hernia sac was cut by ligating, and its distal part was fixed to the posterior abdominal wall. The groups were compared, and data were analyzed. The reduction was performed in 13 (43.33%) of the 30 patients included in the study, and transection in 17 (56.67%). Seroma developed in 2 (15.38%) of the reduction group and 7 (41.18%) of the transection group. There was no statistical difference between the groups (p = 0.229). Cord and testicular complications were seen in 6 (20%) patients, 5 (38.46%) in the reduction group, and 1 (5.88%) in the transection group. No statistical difference was detected between the groups (p = 0.061). Although not statistically significant, seroma was more common in transection, while cord and testicular complications were more common in reduction. If dissection of the hernia sac is difficult, the complete reduction should not be insisted on, and the neck of the sac should be transection by ligating, and its distal part should be fixed to the posterior abdominal wall.

The Relationship Between Small Peritoneal Flap Defects and Postoperative Seroma in TAPP Repair of Inguinal Hernias

OBJECTIVE

Total abdominal preperitoneal (TAPP) is one of the most frequently used surgical treatment methods in the treatment of inguinal hernia (IH). One of the most common early postoperative complications after hernia repair is seroma/hematoma. In this study, we aimed to study the role of unclosed peritoneal flap defects on the development of postoperative seroma.

MATERIAL AND METHODS

The study was performed retrospectively in 2 university hospitals. All patients over the age of 18 years who underwent laparoscopic TAPP surgery in Istanbul Yeni Yüzyıl University Gaziosmanpaşa Hospital General Surgery Clinic and Van Yüzüncü Yıl University Faculty of Medicine General Surgery Clinic between January 1, 2018, and December 31, 2021, were included. Patients were divided into those with peritoneal defects (group 1) and those without (group 2). Whether there was a peritoneal defect or not was compiled from video recordings. In addition, risk factors affecting the development of seroma were determined.

RESULTS

A total of 250 patients, 16 (6.4%) women and 234 (93.6%) men, were included in the study. There were bilateral hernias in 35 (14%) patients, and a total of 320 hernias were analyzed in the study. It was determined that an American Society of Anaesthesiologists (ASA) III score increased the risk of seroma 15.97 fold (P<0.001, 95% CI, 4.94 to 51.56), direct hernia type increased risk 7.1 fold (P<0.03, 95% CI, 1.204 to 42.422), hernia descending into scrotum increased risk 22.48 fold (P<0.001, 95% CI, 6.66 to 75.84) and closure of the peritoneal flap completely without leaving any defect increased the risk of seroma 8.67 fold (P<0.001, 95% CI, 3.254 to 23.115).

CONCLUSIONS

The presence or leaving of small-diameter defects on the peritoneal flap may reduce seroma development without increasing the risk of complications. Prospective randomized studies are required to reach definitive conclusions.

Laparoscopic transabdominal preperitoneal repair for female patients with groin hernias

BACKGROUND

Laparoscopic transabdominal preperitoneal repair (TAPP) was recommended for female patients with groin hernias. Whereas, only a few studies focused on whether and how to preserve the round ligament of the uterus in TAPP.

METHODS

Clinical data of 159 female patients with 181 groin hernias who underwent TAPP at a single institution in China from January 2016 to June 2022 were retrospectively reviewed and collected.

RESULTS

All the patients underwent the operation smoothly without conversion. Division of the round ligament was performed for 33 hernias. Preservation of the round ligament was adopted for 148 hernias, 51 with the "keyhole" technique, 86 with the "longitudinal incision of peritoneum" method, and 11 with total dissection of the round ligament. The mean operative time was 55.6 ± 8.7 min for unilateral TAPP and 99.1 ± 15.8 min for bilateral TAPP. The mean estimated blood loss was 7.1 ± 4.5 mL. The postoperative complications included 6 (3.3%) cases of seroma, 1 (0.5%) case of hematoma, and 3 (1.6%) cases of mild chronic pain. The incidences of chronic pelvic pain and genital prolapse seemed to be higher in the division group than in the preservation groups (6.1% vs. 0.6% and 3.0% vs. 0%, separately). However, no statistical difference was observed (p > 0.05).

CONCLUSIONS

TAPP is feasible and effective for female patients with groin hernias, especially in preserving the round ligament of the uterus.

Clinical efficacy of laparoscopic closed hernia ring combined with a patch repair for Gilbert type III indirect inguinal hernia

Purpose

The incidence of seroma and postoperative pain after Gilbert type III inguinal hernia repair is high. To reduce postoperative complications, this study investigated the clinical efficacy of laparoscopic closed hernia ring combined with a patch repair for Gilbert type III indirect inguinal hernia.

Methods

Through a prospective randomized controlled study, a total of 193 patients with Gilbert type III indirect inguinal hernia admitted to Nanchong Central Hospital affiliated with Chuanbei Medical College from May 2020 to December 2021 were selected and randomly divided into the inner ring closed group (85 patients) and the inner ring non-closed group (95 patients). The patients in both groups underwent laparoscopic tension-free repair of their inguinal hernias. General information such as operative time, postoperative hospital stay, and hospital cost were compared between the two groups, and the patients were followed up at 1, 7, 14, 21, and 28 days and then 3, 6, and 12 months after surgery to compare complications such as incidence of seroma, volume of the seroma fluid, incidence of pain, and visual analogue scale (VAS) pain score.

Results

There was no conversion to open procedures in any of the patients. The operation time of the closed group was significantly longer than that of the non-closed group (64.2 ± 12.2 vs. 55.3 ± 9.5 min, P < 0.01). The proportion of patients with postoperative pain in the two groups was 39 (46%) vs. 59 (62%), P = 0.029 on 7 days; 17 (20%) vs. 33 (35%), P = 0.028 on 14 days; and 6 (7%) vs. 22 (23%), P = 0.003 on 21 days in the postoperative closed group and was significantly lower than that in the non-closed group, while we found that the non-closed group had a higher VAS pain score than that of the closed group (2.36 ± 0.61 vs. 1.95 ± 0.71, P = 0.003 on 7 days and 2.12 ± 0.49 vs. 1.65 ± 0.49, P = 0.002 on 14 days) after surgery according to the statistical results of the VAS pain score. The incidence of postoperative seroma and the amount of seroma fluid decreased gradually in both groups, but when comparing the two groups, the proportion of cases of seroma in the closed group on 7 days [45 (53%) vs. 79 (83%), P < 0.01]; 14 days [23 (27%) vs. 43 (45%), P = 0.011]; and 21 days [10 (12%) vs. 29 (31%), P = 0.002] after the operation were significantly less than that in the non-closed group. For the comparison of the amount of seroma fluid between the groups, the seroma fluid volume in the non-closed group was greater than that in the closed group (34.48 ± 20.40 vs. 43.87 ± 16.40 ml, P = 0.006, 7 days) and (21.79 ± 8.42 vs. 30.74 ± 10.39 ml, P = 0.002, 14 days) after surgery. There were no differences in the length of stay, total hospital costs, or postoperative complications (urinary retention, intestinal obstruction, nausea, vomiting, bleeding, and infection) between the two groups, and the differences were not statistically significant (P > 0.05). The postoperative follow-up period was 3-20 months, and no chronic pain or recurrence occurred during the postoperative follow-up period in either group.

Conclusions

Closure of the hernia ring is safe and effective for laparoscopic hernia repair for Gilbert type III inguinal hernia, and it significantly reduces the incidence of postoperative seroma and further reduces the postoperative pain without increasing the risk of postoperative infection and recurrence.

Postoperative compression in preventing early complications after groin hernia repair

PURPOSE

We conducted this study to investigate the efficacy, safety, and clinical value of postoperative compression in preventing seroma formation, relieving acute pain, and improving QoL after groin hernia repair.

METHODS

This multi-center, prospective, observational real-world study was conducted from March 1, 2022, to August 31, 2022. The study was completed in 53 hospitals in 25 provinces in China. A total of 497 patients who underwent groin hernia repair were enrolled. All patients used a compression device to compress the operative region after surgery. The primary outcome was seroma incidence 1 month after surgery. Secondary outcomes included postoperative acute pain and QoL.

RESULTS

A total of 497 patients [median (IQR) age 55 (41-67) years, 456 (91.8%) male] were enrolled, of whom 454 underwent laparoscopic groin hernia repair and 43 open hernia repair. The follow-up rate was 98.4% 1 month after surgery. Seroma incidence was 7.2% (35 of 489 patients) overall, lower than reported by previous research. No significant differences were found between the two groups (P > 0.05). VAS scores after compression were significantly lower than before compression overall and in both groups (P < 0.001). The laparoscopic group showed a high level of QoL compared with the open group, but there was no significant difference between the two groups (P > 0.05). CCS score correlated positively with VAS score.

CONCLUSION

Postoperative compression, to a certain extent, can reduce seroma incidence, relieve postoperative acute pain, and improve QoL after groin hernia repair. Further large-scale randomized controlled studies are warranted to determine long-term outcomes.

Seroma-prevention strategies in minimally invasive inguinal hernia repair

BACKGROUND:

The rise of minimally invasive inguinal hernia repair has seen both the laparoscopic and robotic approaches increase in popularity in recent years. Despite this, seroma formation remains a common complication, and the aim of this study is to evaluate the current evidence on seroma-prevention strategies in minimally invasive inguinal hernia repair.

MATERIALS AND METHODS:

Four databases (PubMed, Scopus, Embase, and Cochrane Library) were searched from inception to November 15, 2021. All studies describing the use of intraoperative adjuncts to reduce postoperative seroma formation in patients undergoing laparoscopic or robotic inguinal and inguinoscrotal hernia repair were included. Meta-analyses were performed using Review Manager (Version 5.4).

RESULTS:

2,382 articles were identified in the initial database search, and 40 articles were included in the final analysis. In this analysis, there was a significantly lower incidence of seroma formation in the drain group when compared to the no-drain group (P < 0.00001). Other strategies aimed at reducing the dead space involving the transversalis fascia (TF) and hernia sac such as TF inversion with tacking, Endoloop closure of TF, barbed suture closure of TF, distal sac fixation, and complete dissection of the sac have shown promising results as well.

CONCLUSIONS:

While there is currently insufficient evidence to recommend the routine use of any one of the interventions analyzed, the use of drains, the management of the TF, and the hernia sac have showed potential in reducing seroma formation.

Effects of intraoperative fixation of residual hernia sac on postoperative seroma in laparoscopic transabdominal preperitoneal inguinal hernia repair: a prospective randomized controlled trial

The study was aimed to evaluate a prospective randomized controlled trial (RCT) In laparoscopic transabdominal preperitoneal inguinal hernia repair (TAPP), whether fixation of the residual sac after transecting the hernia sac can reduce the severity of postoperative seroma. A total of 252 male patients with a primary unilateral indirect inguinal hernia who underwent TAPP from September 2018 to November 2022 were recruited. Patients were randomized to the control group (CG)and the experimental group (EG). In the experimental group, after the hernia sac was transected, the residual sac was fixed to the lower edge of the rectus abdominis, while it was left in the preperitoneal space in the control group. Close follow-up was arranged to observe the incidence of seroma and other postoperative complications. All 214 patients were discharged successfully. 106 patients were randomly assigned to the control group, and 108 patients were assigned to the experimental group. There was no significant difference in the incidence of postoperative fluid extraction between the experimental group and the control group (11.1% VS.10.4%, p = 0.862), but the patients with seroma after the operation had fewer repeated extraction (0% VS. 45.5%, P = 0.033). The incidences of other postoperative complications were comparable in the two groups. In the treatment of indirect inguinal hernia with TAPP, after transecting the hernia sac, suturing and fixing the residual sac to the inferior edge of the rectus abdominis can reduce the incidence of repeated aspiration.

Curative effect of different drainage methods on laparoscopic inguinal hernia repair: A meta-analysis

BACKGROUND

Laparoscopic inguinal hernia repair has developed rapidly as an important surgical method for inguinal hernia repair; however, postoperative complications, especially postoperative seroma, are becoming an important factor hindering its development. Many studies have shown that placing a negative-pressure drainage tube in the preperitoneal space can effectively reduce postoperative seromas. Accordingly, this study aimed to compare differences in postoperative seroma between surgical procedures with drainage tubes (DRG) and those without drainage tubes (nonDRG).

METHODS

PubMed/Medline, EMBASE, Cochrane Library, China National Knowledge Infrastructure, and Wanfang databases were searched from the establishment of the database to May 1, 2021. Odds ratio (OR), mean difference (MD), standardized mean difference (SMD), and 95% confidence interval (CI) were selected as the effect scale indices for the evaluation of the difference in seroma, operation time, hospital stay time, blood loss, and recovery time. All of these were compared using RevMan 5.3 Software.

RESULTS

Sixteen studies involving 4369 patients, 2856 in the DRG group and 1513 in the nonDRG group, were included. The incidence of seroma in the DRG group was lower than that in the nonDRG group (OR = 0.16, 95% CI: 0.07-0.35, P < .001). Additionally, the operation time (min) in the DRG group was longer than that in the nonDRG group (MD = 3.67, 95% CI: 2.18-5.17, P < .001). Nevertheless, no significant differences were found in hospital stay (days) (SMD = 0.22, 95% CI: -0.10-0.54, P = .17), blood loss (mL) (MD = 0.28, 95% CI: -0.14-0.69, P = .19), and recovery time (h) (SMD = 0.54, 95% CI: -0.60-1.69, P = .35) between the 2 groups.

CONCLUSION

Despite the slightly prolonged operation time, negative pressure drainage in the preperitoneal space during laparoscopic inguinal hernia repair can significantly reduce the occurrence of postoperative seroma without increasing blood loss, recovery, and hospital stay.

The use of polypropylene mesh in inguinal hernia surgery: A retrospective study

Previously, inguinal hernia surgery was based exclusively on repairing the abdominal wall defects using the patient's own tissues, which were put in contact with and tensioned to recalibrate the natural orifices. At present, inguinal hernia surgery is based almost solely on mounting an allograft, which has the role of strengthening the weakened groin region that allowed the herniation. This modern method of operation on inguinal hernia can be performed in a classic or laparoscopic manner. The mesh is made of polypropylene, which is a polymer of cyclic hydrocarbons. The aim of the present study was to evaluate the effectiveness, biocompatibility, as well as the immediate and long-term complications in textile allografts used in open surgery of inguinal hernia repair. Another aim was to demonstrate once again the superiority of low-weight meshes with large pores by decreasing the number of complications caused by the synthetic material used, but also by a decrease in the tension on the tissues to which it was fixed. The present study included 255 cases submitted to inguinal hernia surgery. Only 1.5% required immediate reintervention before discharge to evacuate hematoma. The short duration of hospitalization, the quality-price ratio, the good postoperative results, as well as the rapid socio-professional reintegration, render the use of polypropylene mesh in inguinal hernia surgery very attractive for patients.