Page 67 - International guidelines for groin hernia management

Hernia

Another 2008 study, done retrospectively, compared Key questions
patients on warfarin with INRs in the 2–3 range with those
in the 3–4 range, and reported that an INR of 3–4 was KQ18.p What are the risk factors for postoperative seroma
associated with an increased risk of postoperative hema- formation?
toma formation (p = 0.03). The study authors concluded KQ18.q Is there an association between open anterior
that IH repair can safely be done in patients on warfarin repair method and postoperative seroma formation?
with an INR \ 39. 9 KQ18.r Do certain endoscopic or open preperitoneal
A 2014 retrospective review of 1839 patients, including techniques increase the risk of postoperative seroma
40 who continued warfarin perioperatively, reported no formation?
significant difference in hematoma formation between KQ18.s Can the risk of postoperative seroma formation be
these patients and those who had discontinued warfarin or a reduced surgically?
case-matched control group. 102 KQ18.t Does drain usage reduce the risk of postoperative
One 2011 study investigated clopidogrel effects in 46 seroma formation?
patients undergoing open or endoscopic hernia repair. KQ18.u Is there an association between hernia sac treat-
Patients were divided into those who had received clopi- ment modality and seroma/hematoma formation?
dogrel \ 7 days before operation and those who had KQ18.v Does the use of abdominal binders or comparable
received clopidogrel [ 7 days before operation. No sig- wound compression devices prevent seroma/hematoma
nificant differences in bleeding complications were formation?
101
reported.

Discussion Evidence in literature
Most anticoagulant-related studies on hernia patients are The reported incidence of seroma formation after IH repair
dated and were performed before day surgery was common varies between 0.5 and 12.2%. Seroma formation risk
and during an era when patients spent several days post- factors are as follows: coagulopathy, congestive liver dis-
operatively in hospital. In addition, patient activity levels eases, and cardiac insufficiency. 103, 104
between those admitted and those discharged are unclear. Several meta-analyses report that seroma formation
Stasis is a known risk factor for thromboembolic compli- incidence is significantly higher following endoscopic and
cations and patient mobilization levels are poorly described laparoscopic (TAPP/TEP) versus open hernia
82–84, 105
in most studies. In addition, operative techniques have repair. A 2013 RCT confirmed this finding,
changed over time. Therefore, the available study results although its clinical relevance is uncertain.
generally do not apply to the patient groups of interest in Another meta-analysis of mesh versus non-mesh open
the modern era. techniques across 13 RCTs found no significant difference
Seroma in seroma formation incidence. 106 Neither did a meta-
Seroma assessment in IH repair studies is hampered by the analysis of 8 RCTs with 2919 patients comparing Licht-
lack of standardized definitions for this condition. 103 No enstein with mesh-plug repair. 89 Another study found that
trials include seroma as a primary outcome. If studies are seromas were the most frequent complication after TAPP
planned that include seroma formation, it is our groups’ repair of scrotal hernias. 107 An RCT comparing TAPP
opinion that only symptomatic seromas should be consid- repair with titanized lightweight mesh versus TAPP repair
ered a postoperative complication. with heavyweight mesh found significantly fewer seromas
in the lightweight group. 108 Two recent RCTs reported

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