Websurg, e-Surgery 關於腹腔鏡手術

Clinical Case

VOLUMINOUS SEROMA AFTER VENTRAL HERNIA REPAIR

M Vix, MD, F Jamali, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Description

This clinical case reports on the imaging studies and surgical treatment of a voluminous seroma of the abdominal wall. This occurred as a complication of a ventral hernia repair.

2. Keywords

Parietal wall, hernia, recurrence, seroma

3. Patient

Male, 73-year-old

4. Medical history

Medical:
- coronary artery disease;
- stable angina;
- multiple coronary angioplasties;
- hypercholesterolemia;
- hypertension ;
- non-insulin-dependent diabetes mellitus.

Surgical:
- midline ventral hernia of 5 years’ duration.

5. History of present illness

The patient presents 4 years after his last surgical intervention with a voluminous mass to the right of the midline. This mass developed over a 2 week period, 10 days after starting anti-platelet therapy. The collection was aspirated and revealed a sterile serosanguinous fluid. The collection was aspirated multiple times. After the last aspiration of liquid, the patient was transferred to the surgical service due to a persistent distended abdomen without resolution of the collection with a suspicion of a recurrent ventral hernia.

6. Physical examination

The exam revealed a voluminous mass situated in the midline of the abdomen. The mass was dull to percussion, non-reducible and painless. The rest of the abdomen was supple and non-tender. There were no skin changes, in particular, non-inflamed.

7. Relevant laboratory values

- screening laboratory values are within normal limits;
- Hct: 43%.

8. CT scan

The 5 CT scan images reveal a voluminous collection extending from the hepatic region to the mid portion of the pelvis. The collection descends below the anterior and superior iliac spines. There is no passage of abdominal content at the level of this mass that is purely fluid-filled. The mass is therefore a postoperative seroma and not a recurrent ventral hernia.

Figure 8.a

Figure 8.b

Figure 8.c

Figure 8.d

Figure 8.e

9. Procedure

The patient is taken to the operating room where a diagnostic aspiration if performed.

Figure 9.a

Figure 9.b

Figure 9.c

Figure 9.d

10. Clinical progression

Three weeks later patients re-accumulates a significant collection.
He is taken to the operating room where a mature capsule is found. This capsule is resected and drains are placed. The mesh was not removed at this time.

Figure 10.a

Figure 10.b

Figure 10.c

11. Follow-up

Recovery is satisfactory with no recurrence of the collection at 6 months.

12. Discussion

Wound-related complications are common after incisional hernia repair. Seromas represent some of the most frequent complications following such repairs (incidence 0-10%), but present more often in the immediate post operative period and are usually self limited. Delayed seromas are uncommon with very few cases reported in the literature. Therefore the management of such delayed seromas is not well established. The factors responsible for the development of seromas have not been elucidated. Prophylactic antibiotic use, placement of subcutaneous drains, and technical factors such as mesh implantation reportedly influence the incidence of these complications. The use of mesh and a hernia defect >10 cm were associated with significantly more wound complications 44% vs. 26% (P <0.05) and seromas 21% vs. 7% compared to simple primary repair. It appears that surgical excision and closed suction drainage, rather than simple aspiration, are required for treatment. Prolonged postoperative drainage has been advocated to prevent recurrence. In rare cases when all treatment options fail, mesh excision may be required as a final solution.

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