Preventing Postoperative Seroma formation
in Abdominal wall Hernia by Intraoperative Hypertonic Saline Irrigation, early Report
Dudai Moshe1,2* and Ittah Gilboa Karen1
1 Department of Surgery, MERAV Medical Center Bat-Yam, Israel
2 Hernia Excellence Tel-Aviv, Israel
Submission: December 03, 2018;Published: January 08, 2019
*Corresponding author: Moshe Dudai MD FACS, Department of Surgery, MERAV Medical Center Bat-Yam, Israel.
How to cite this article: Dudai M,Ittah G K. Preventing Postoperative Seroma formation in Abdominal wall Hernia by Intraoperative Hypertonic Saline
Irrigation, early Report. Open Access J Surg. 2019; 10(2): 555782. DOI: 10.19080/OAJS.2019.10.555782.
Seroma formation is a frequent post-operative complication of many operations, mainly abdominal wall Hernias and reconstructive surgeries, where extensive dissection take place. It increases overall morbidity and can be challenging to manage. Drains, aspirations and sclerotherapy are established for treating postoperative seromas and increase the risk for infections. No study has yet to describe the use of intraoperative hypertonic saline irrigation as a preventive measure for seroma formation. The purpose of this report is to describe a novel intraoperative method of hypertonic saline irrigation to abdominal wall subcutaneous surgical cavity, which prevent seroma formation and enables a shorter drainage usage due to early drain removal. Thus, reducing infections and overall morbidity, shortening hospitalization period and decreasing the annoying inconveniency of repeated aspirations and drains insertion with significant cost saving.
Our experience is preventing abdominal wall seromas formation in seven patients undergone the Extended Endoscopic Hernia & Linea Alba Reconstruction Glue surgery for Ventral Hernias and Rectus Muscles Separation. A wide endoscopic dissection of the anterior Rectus fascia is followed by mesh placing over the repaired Rectus muscles which is fused to the muscles with Fibrin Glue. A developed novel preventive method includes Intraoperative Irrigation of the cavity through two 7mm Jackson-Pratt closed system drains with 20 cc of NaCl 10%, left in place for 10 minutes. We have excellent early results of seroma prevention, reduced secretions and drain removal within 20 hours. This method can be applied in other potential seroma formation surgeries. Further follow up will be needed.
Seroma formation (SF) is a common post-operative complication of many operations . Extensive dissection area resulting in a big dead space predispose the accumulation of fluid and the formation of a postoperative seroma and is one of the greatest risk factors for its formation. The larger the surgical intervention, the more likely it is that seromas appear. Plastic and Reconstructive surgeons use techniques like extensive dissecting, development and reposition of myo/fascio/cutaneous flaps and harvesting tissues in order to reallocate them to another area in the body, often leaving a dead space behind them. Therefore, seromas are particularly common after reconstructive surgeries.
Postoperative seromas are seen after breast surgery and high seroma rates are reported. A post mastectomy seroma is reported to have an incidence of 3% to more than 90% [2-4]. Prevalence of 2%-20% was reported in implant-based breast reconstructions.
After breast reconstruction using lipofilled latissimus dorsi flap, seroma required repeated drainage occurred in 10% of cases . After breast augmentation, seroma is reported to occur in 2% of cases . Liposuction, one of the most common procedures in the United States , includes leaving a large dead space, and postoperative seromas are reported to occur in 5% of the cases .
Big subcutaneous space formed during surgery of the abdominal wall, is also one of the most common sites for postoperative seroma. After a breast reconstruction using DIEP free flap, where fat and skin with their vasculature are harvested from the lower abdomen, micro surgically connected to vessels in the chest and repositioned instead of the former breast tissue, a prevalence of 2.8%-4% is reported for seroma formation in the abdominal wall . Abdominoplasties are commonly performed by plastic surgeons as a part of body contouring surgeries after massive weight loss. The prevalence of seroma formation after
abdominoplasty is ranging from 5%-43% .
Postoperative seromas can be seen after big hernia repairs
at the Hernia location. Morales-Conde et al.  reported an
incidence of 46% of seroma formation in 3 months follow up.
Seroma can develop following laparoscopic inguinal hernia repair
by extraperitoneal (TEP) and transabdominal approach (TAPP) in
up to 37 and 18 % of cases, respectively . Wide subcutaneous
dissection for closing big abdominal wall defect and Rectus
muscles separation is also a ground for seroma formation due
to large dead space development. Susmallian et al.  reported
an incidence of 35% of seromas diagnosed clinically in patients
undergone laparoscopic repair of incisional hernia. An Ultrasound
assisted diagnosis demonstrated seroma in 100% of cases. Lund
et al. reported postoperative seroma occurred in 22% of cases
after laparoscopic ventral hernia repair . Additionally, it
has been shown that degree of lymphatic interruption, such
as axillary or inguinal lymph node dissection, increases rate of
seroma formation .
Complications of postoperative seroma vary from delayed
wound healing, repeated seroma aspirations with the risk of
infection, prolonged hospital stay, skin flap necrosis, patient
discomfort, repeated visits to the outpatient clinic, delay in
commencing adjuvant therapies when needed and higher surgical
expenditures [16-18]. Seromas may be challenging to manage at
times and may persist for several months or even years [19,20]
depending on the volume and duration of serous secretions.
Conservative, non-invasive ways to manage seroma include
application of pressure dressings .
Invasive procedures such as replacement of drains and
repeated percutaneous aspiration are sometimes needed in
order to achieve resolution [1,22] and are controversial .
While seromas can be a culture medium for bacteria and get
infected  and reducing its size may prevent infections and
increase resolution, the aspiration itself carried out under aseptic
conditions carries a risk of infection. If a seroma does not resolve,
it may be necessary to take the patient back to the operating
room in order to place some form of closed-suction drain into the
wound, resect the cavity lining or inject a sclerosant. However,
this usually is not necessary in non-complicated cases and
conservative management prevails .
The cost of longer hospitalization, repeated outpatient visits
and a second surgery is high for both the patient and the health
system. It has been shown that reducing the length of hospital
stay is the most expeditious way to reduce surgical costs .
It has also been proven that postoperative seroma, although
regarded by many surgeons as an inevitable nuisance rather than
a true complication, can lead to significant morbidity including
prolongation of hospital stay [27,28].
A multifactorial process is responsible for the formation
of seromas. Blood and lymphatic vessels and an inflammatory
process both contribute to accumulation of inflammatory exudate,
lymph and plasma in a space, created either by surgery or by
trauma [1,22,25,29]. Shear forces maintain the dead space thus
preventing adhesion of the tissue surfaces. These fluid collections
will form pseudocysts as the cavity becomes lined by fibrous tissue
with no proper epithelium . Preventing seromas can start by
identifying and minimizing risk factors such as large dead space,
elevated BMI, electrocautery, and time-controlled drain removal
[1,22]. However, seromas may and do continue to form. One of the
methods to treat seromas is injection of a sclerosant .
Sclerotherapy involves filling the seroma cavity with an
irritating substance, which induces a fibrotic response needed to
seal the dead space. Several sclerosants stimulate fibrous union
of the tissue surfaces by inducing an inflammatory reaction
which causes fibrosis and closure of the pseudocyst . Others
do it through destruction of mesothelial cells lining as well as
by inhibiting fibrinolysis and the induction of fibroblast growth
factors. Some sclerosants, like fibrin glue, are not based on an
inflammatory response and contains fibrinogen, factor XIII,
thrombin, and calcium to stimulate the final stage of the clotting
Different sclerotherapies were reported; Talc, which is mainly
known to address pleural effusion and obtain pleurodesis, can
be used as a sclerosant in seromas in different anatomic sites,
including abdominal wall seromas. It is applied as a dry powder,
a slurry with or without local anesthetic or as an aerosol [32-37].
Antibiotics like Tetracycline and Erythromycin were reported
as the primary sclerosants to treat seromas in the trunk and
the lower limbs [31,38-41]. Ethanol was also suggested as a
sclerosant in seroma managing, used for different durations, from
10 minutes to 6 periods of 90 minutes [30,42,43].
Additionally, Polidocanol solution or foam for sclerotherapy
was reported [29,44]. Moritz et al. treated lower extremity
seromas after varicose vein surgery by applying Polidocanol
foam to seroma cavities and compression bandaging. Fasching
and Sinzig reported in a case report the use of sclerosing agent
OK-432, a mixture of a low-virulence strain of Streptococcus
pyogenes incubated with benzylpenicillin potassium, to treat
a sacral seroma successfully . Berkoff et al. reported using
fibrin glue to treat a seroma of the knee in 2 weeks with no
complications . Finally, a combination therapy was reported
by Throckmorton et al. who treated 18 mastectomy site seromas
in 16 patients .
Sclerotherapy was performed by instilling 95% ethanol or
dilute povidone-iodine for 20 to 30 minutes, with drains placed
for postoperative management. Several patients received ethanol
with doxycycline during repeat treatments. The use of Hypertonic
Saline was only sporadically reported in the past for the treatment
of fluid collections. Hypertonic Saline irrigation was reported as a
treatment to hepatic hydatid cyst, the larval stage of the dog tape
worm Echinococcus Granuloses, as early as in 1984 by Gage and
Viviane . Hypertonic Saline was also mentioned as sclerosing
agent for reticular and telangiectatic leg veins . For the treatment of a postoperative seromas, we were able to detect in
the literature only one citation as a single experience in a letter to
the editor in 2003 by Gruver .
Preventive measures for seroma formation can be divided
to surgical and non-surgical and their purpose is to reduce the
surgically formed dead space. Non-surgical methods include
preventing movement between the layers of the dead space by
avoiding or keeping certain positions, such as semi-recumbent
in abdominoplasty. External pressure is thought to reduce the
tendency of the fluid to leak out of vessels so a pressure dressing or
an abdominal binder are used for several weeks postoperatively.
Surgical methods to prevent seroma formation include techniques
like quilting sutures , meticulous control of bleeding, sealing
agents, like a collagen sponge coated with human coagulation
factors , and the most traditional method, negative pressure
using drains .
Recently, drains are falling out of favor due to evidence
that support their use is limited and conflicting .
Prolonged drain use was associated with postoperative infection
. A systematic review evaluated the association of surgical
site infection (SSI) with routine post-operative closed system
drainage have yielded conflicting results. A few studies suggested
an increased risk of SSI associated with drain placement but were
usually associated with open drainage. They recommend judicious
use and prompt, timely removal of closed system drainage .
No report in the literature was found for using intraoperative
Hypertonic Saline or other sclerosant as a preventive measure for
SF or for early drain removal.
The purpose of this report is to describe our developed novel
method of Intraoperative Hypertonic Saline Irrigation (IHSI) to
surgical cavity, which reduces SF rate, decreases drain secretions
and enables a shorter drainage time due to early drain removal.
As mention above, there is high prevalence rate in very commonly
performed surgeries for SF leading to high risk of secondary
complications like infections, annoying challenging management
and treatment and finally high cost for both patient and heath care
system due to longer hospitalization, repeated outpatient visits
and potentially another surgery. All contribute to the rational of
developing a new preventive method for postoperative SF.
Our experience is with preventing abdominal wall SF after
the Extended Endoscopic Hernia & Linea Alba Reconstruction
Glue surgery (eEHLARglue) for Ventral Hernia (VH) and Rectus
Muscles Separation (RMS) [54,55]. This surgery combines wide
Anterior Rectus Fascia dissection and therefore holds a high
risk for seroma formation. An Endoscopic dissection of the subcutaneous
fat tissue from the Anterior Rectus Fascia is performed
at the beginning of the surgery. The Endoscopic penetrating is
with tree trocars from the supra-pubic line dissecting up to the
Xiphoid, laterally 7cm away from the Rectus muscles separation
line. Any Hernia sac is dissected, and the content reduce back to
the abdominal cavity (Figures 1-3).
Relaxing Incision of the Rectus Fascia are performed longitudinally
in the lateral aspect. The Rectus Separation is closed by
two rows of V- lock suture plications: 1st plicate the loos Linea
Alba Figure 4, and 2nd plicate the Anterior Rectus Facia Figure 5; a
New Linea Alba is reconstructed Figure 6. A light Prolen Soft Mesh
30X15cn is placed over the repaired Rectus Muscles and irrigation
with 4+4 cc Fibrin Glue all over the mesh area is performed for achieving immediate homogeneous fusion of the mesh surface
to the muscles and hemostasis Figure 7. Two 7 mm Jackson-Pratt
closed system drains are inserted through the bottom 5mm trocars
skin port cut (Figure 8).
Our novel IHSI method includes: At the end of the surgery,
irrigating the developed cavity with Hypertonic 10% NaCl Figure
9. Through each of the two drains Figure 10, 10 cc of NaCl 10%
(Total 20cc) are injected and left in place for 10 minutes before
connecting the vacuum chamber Figure 11. Abdominal binders are
wrapped in the OR table and used for 3 months postoperatively.
We encountered two cases of big SF post eEHLARglue surgery.
In both cases patients were overweigh men with extensive RMS
combined with Umbilical Hernia, in one patient it was a recurrent
Umbilical Hernia. Both cases of postoperative seromas were
treated with extensive drainage and we decided to complete it
with irrigation through the inserted drain with Hypertonic Saline
10%. The results were successful, and that lead us to think one
step ahead to find a preventive method. We developed and applied
the novel preventive method of IHSI to a surgical cavity in our
eEHLARglue surgery for VH and RMS. We applied the IHSI method
on seven patients, five women and two men, treated for different
reasons (Table 1).
RMS: Rectus Muscles Separation.
We had excellent early results of seroma prevention, and in
three months follow up, no evidence of SF was found in any of the
patients. Drain secretions were clear serosanguineous and were
reduced in volume right from the very beginning, approaching
to a secretion rate of 20cc in 10 hours. Drains were removed 20-
24 hours postoperatively in all patients. IHSI reduces seroma
formation rate, decreases drain secretions and enables an early
drain removal. Postoperative seromas are common, challenging
to manage and hold a risk for further complications to repeated
aspirations and additional surgery. IHSI can thus reduce overall
morbidity and costs due to shorter hospitalization period and less
outpatient visits. There is no effective preventing method of SF in
the literature for this common complication, and a real solution is
required. This IHSI method can be the answer and can be applied
in other potential SF surgeries.
IHSI to a surgical cavity addresses the prevention of one of the
most common and annoying surgical complication, postoperative
SF. It reduces SF rate, decreases drain secretions and enables
an early drain removal as we demonstrate in our early cases of
eEHLARglue. Thus, reducing overall morbidity and hospitalization
period and saving costs and inconveniency due to repeated
outpatient visits and aspiration or additional surgery. IHSI can be
applied in other potential SF surgeries. Additionally, the majority
of SF are developed in the early postoperative period, and further
follow up will be needed.