Page 68 - International guidelines for groin hernia management

Hernia

significantly more seromas following TEP versus TAPP KQ18.y Is mesh migration—with the attendant risk of pain
repair. 109, 110 and severe complications—related to: mesh type, mesh
Two studies found that seroma and hematoma formation shape, repair method, wound infection, or hernia type?
incidence is lessened after TAPP and TEP repair of large

direct defects by inverting the lax fascia transversalis and Evidence in literature
closing the defect. 111, 112 A recent meta-analysis of One meta-analysis comparing endoscopic to Lichtenstein
laparoscopic IH repair comparing mesh fixation with tissue and other open mesh techniques reported 13 incidents in
glue versus tack fixation reported no difference in seroma 3640 operations (0.4%) of potentially serious operative
formation. 113 Another meta-analysis found a lower seroma complications (defined as bowel, bladder, and vascular
incidence after glue mesh fixation compared with suture injuries). 83
mesh fixation in open IH repair. 47 Another meta-analysis comparing endoscopic to Shoul-
Two studies found that drain insertion may prevent dice and other non-mesh techniques reported 4 incidents in
seroma formation especially in complicated and large 5900 operations (0.1%) of potentially serious operative
scrotal hernias. 114, 115 Two other studies demonstrated that complications. 84
drain insertion after TEP repair may also reduce the inci- A systematic review and meta-analysis of TEP versus
dence of seroma formation. 116, 117 Lichtenstein reported no inter-group differences in severe
Most seroma resolves spontaneously over 6–8 weeks. adverse events from the patient’s perspective, although
Since infections following seroma aspiration are regularly 1068 events—including chronic pain and recurrences—
described, it is our groups’ firm opinion that only symp- occurred in 5397 patients. We calculated that, if chronic
tomatic seromas be treated. pain and recurrences had been excluded, 78 (1.4%) severe
Studies of drain usage to prevent seroma formation events occurred. 76
provide conflicting results. One study of 100 patients found In one study, infrequent serious intraoperative compli-
no benefit following open repair. However, another study cations were reported to occur more frequently in endo-
involving 301 patients found fewer seromas after a 24-h scopic versus IH surgeries, although there was no overall
drainage period. 105, 114 morbidity difference. 83
Since clinically significant seroma formation following A Cochrane review of laparoscopic versus open tech-
IH repair is uncommon, our group recommends against niques found that operative complications were uncom-
routine drain insertion after primary uncomplicated repair. mon, but more frequent, in the laparoscopic group. 82
There is no evidence that binders and other compression Another Cochrane review found an increased incidence of
devices prevent hematoma and seroma formation. operative complications with the TAPP over the TEP
Infrequent complications approach. 118 The study reported that serious events were
bowel perforation, urinary bladder damage, and vascular
Key questions injuries. 82–84, 118
First trocar introduction during hernia operations has the
KQ18.w How common are serious complications during potential to cause bowel and vascular injury. A variety of
hernia surgery? techniques including: use of blunt-tipped trocars, optical
KQ18.x Are serious complications more common during access trocars, and needlescopic 3–5-mm instruments have
endoscopic hernia surgery in patients with a history of been studied, and are shown to reduce complications and
previous abdominal surgery? improve safety. 119–121

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