Post-transabdominal Preperitoneal Mesh Hernioplasty Seroma Formation and Its Management: A Case Report
Corresponding Author: Bikash Ranjan Mishra, Department of General Surgery, SCB Medical College and Hospital, Cuttack, Odisha, India, Phone: +91 8763608377, e-mail: Bikashranjanmishra100@gmail.com
How to cite this article: Biswal JK, Mohanty SK, Mishra BR. Post-transabdominal Preperitoneal Mesh Hernioplasty Seroma Formation and its Management: A Case Report. World J Lap Surg 2023;16(1):54–56.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
Received on: 18 March 2023; Accepted on: 04 June 2023; Published on: 05 September 2023
Repair of inguinal hernia is one of the commonest surgical procedures performed worldwide. Starting from Bassini’s repair proposed in 1887, numerous methods and their modifications have overwhelmed the field of inguinal hernia surgery and after the introduction of laparoscopy there has been a procedural revolution for the same. Ger documented the first laparoscopic hernia repair in 1982 by approximating the internal ring with stainless clips. Since then, transabdominal preperitoneal and total extraperitoneal hernia repair have become increasingly popular with lesser postoperative pain, postoperative complications, early return to work, and less recurrence. However, when we talk about hernia repair, there is tissue handling and this tissue manipulation gives rise to seroma formation which is one of the most common postoperative complications.
Keywords: Case report, Laparoscopic hernia repair, Open mesh repair (open), Polypropylene mesh, Scrotal mass, Seroma, Surgery, Transabdominal preperitoneal, Total extraperitoneal, Unilateral inguinoscrotal hernia.
Seroma is a mass or a lump caused by a build-up of clear fluid in a tissue, organ, or body cavity. It is often naturally resolving but in certain cases, it persists which is misinterpreted as a recurrence of hernia by the patient leading to repeated visits of the patient to outpatient as well as anxiety. Seroma usually occurs in large inguinoscrotal hernias.1–4 A remaining hernial sac during transabdominal preperitoneal (TAPP) most often than not results in seroma formation.
Also, the dissection of two layers of fascia transversalis in the initial step of TAPP may result in local inflammation, which on a later stage forms a seroma. The occurrence of seromas is common after large hernia and direct hernia repair.5 In the early phases of a learning curve in surgery, the chances of formation of a seroma is very high, but with an increasing acquaintance with the procedure, in experienced hands, the chances go significantly lower.
A 43-year-old man presented to the surgery outpatient department (OPD) with a left-sided indirect complete inguinoscrotal hernia for which TAPP was done. In the process of laparoscopic surgery, we had left the distal sac intact. The patient again presented to surgery outpatient department (SOPD) 15 days postoperative with a left-sided scrotal swelling which was globular in shape, with well-defined margins, size of approximately 6 cm × 5 cm, soft in consistency, fluctuant, and irreducible in nature. There was no pain or tenderness associated with the swelling. Getting above the swelling was positive. Testis and chord structures were palpated separately. The transillumination test was positive.
The patient was sent for ultrasonography of the bilateral inguinoscrotal region, and the report suggested of cystic swelling on the left side. All other routine serum investigations and blood parameters were within normal limits.
He was initially subjected to observation and oral antibiotics for 2 months. The swelling persisted even after 2 months postoperative. So aspiration of seromal fluid was planned and approximately 50 mL of straw-colored fluid aspirated out. After aspiration, the swelling reduced in size greatly. The patient again presented with recurrent swelling 15 days later. Repeat aspiration done for the second time. A subsequent visit after 15 days revealed a similar fluctuant, globular, discrete swelling, which was palpated separately from chord structures. Finally, putting the patient’s comfort and desire in the forefront excision of an entire sac of seroma along with its fluid content was planned, and the patient was admitted to the general surgery ward.
A left scrotal incision was given to open skin subcutaneous tissue and fascial layers.
The seroma sac was identified and separated from the left testis and cod structures (Fig. 1).
The sac was excised in toto (Fig. 2).
The testis and cord structures were repositioned back in the scrotum and all the layers along with the skin closed. The sac was then opened in a kidney tray and approximately 80 mL of hemorrhagic fluid came out. The sac was sent for histopathological study (Fig. 3).
Seroma happens to be the frequent complexity of TAPP and TEP and can easily orchestrate a dreaded mesh infection.6 Mesh infection displaces the mesh. As a result, the hernia may recur. Studies have shown that occurrence of seroma after TAPP is 7.7–17%. Susmalian et al. believed in using ultrasonography for the detection of seroma.7 However, they are mostly asymptomatic and are not clinically meaningful.
Applying pressure bandage, the application of fibrin sealant in the preperitoneal space, and placing a negative-suction or vacuum suction drain in the plain of dissection are a few of the procedures described in the literature to prevent seroma formation.8 But the drain can only be placed for a short period or else it will lead to iatrogenic infections. In the inguinoscrotal region, putting on a compression dressing is not an easy job. Some studies have also favored the complete dissection of the sac to prevent seroma formation. But with concomitantly running cord structures, most importantly the vas deference and the vessels, complete dissection can lead to unwanted complications like bleeding or transection of cord structures.
Post-dissection, the fascia transversalis becomes lax. Hence, after mesh placement in between both layers of fascia, a potential space is created which may extend into the scrotum and plays a significant role in seroma formation. Reddy et al. suggested that inversion of this lax fascia transversalis and fixing it on the pubic ramus can decrease the incidence of seroma formation during medial hernia rectification yet, these procedural approaches are not applicable for lateral hernias as there is no fascia transversalis in these hernias.9 Interestingly, Daes reported a method of pulling up the distal hernial sac out of the scrotum and fixing it to the posterior abdominal wall, which resulted in a low incidence of seroma in indirect inguinoscrotal hernia repair.10
In the case of huge inguinoscrotal hernias and sac extending deep into the scrotum, reduction and fixation of distal sac high and lateral to posterior abdominal wall are also beneficial. Certain studies also suggest cauterization of the hernia sac to avoid seromas and reduce recurrence. This is done by disrupting the serosal surface that exudes serum when infected, and second, by creating adhesion.
Repairing an inguinal hernia through a technically demanding laparoscopic procedure like TAPP only for the patient’s benefit and then making the patient suffer through mental agony and anxiety because of a mere seroma makes no sense. In our method of excision of the seroma sac with its content after 2 months of TAPP provides a lifelong solution for this complication along with patient satisfaction.
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