Seromas are best managed conservatively. It is always better to inform the patient prior to surgery about its possibility - then they will be less concerned about it. We have seen that when we use a drain there is less chance of seroma formation.

I agree with Dr. Alfie. As long as the seroma is not infected, observation for at least 3 months is ideal, then we can think about aspiration.

This is usually problem in large hernias. When the hernia is large and there is a big empty space left we always do external packing of the inguinal region in order to make a compression which reduces the dead space. In a case of fluid collection we just follow them with ultrasound. The intervention is necessary in my experience only in case of infected fluid collection or organized hematoma.

Treatment should be conservative at first - just wait.

If the patient cares, we sometimes punkture and aspirate the fluid under sterile conditions, ones, sometimes till tree or four times.

If we have a big herniasack, old hernias or hernias till the skrotum, we desinfect preoperative the skrotum and place a closed vacuum drainagge through the scrotum through the preperitoneal space and sting (stab?) the punch again through the abdominal wall outside, cranial to the groin regio.

Must take care that this is made very carefull to avoid infection or lesion of vessels or nerves

If performed properly, deep infection (in proximity to the mesh) after TEP or TAPP is a (just about) non-existing adverse event, in spite of abstaining from prophylactic antibiotics.

In order to never see deep infections, the surgeon must constrain him-/herself from tampering with drains, aspirations, etc.

1. The treatment of choice is always the reassurance to the patient, that a postoperative swelling/seroma best should be left for spontaneous shrinkage/dissolution for at least 6 months. If then still remaining, the seroma will be significantly smaller, demarcated and most often not causing any discomfort. In the majority of these cases, the patient will not need or require any additional treatment at all.

2. As any chronic seroma with time will be clearly defined, most often along the spermatic cord in the scrotum and safely distant from the mesh, the seroma will then be accessible for puncture/removal without risking to inadvertently infect the mesh or its immediate surroundings.

Please inform preoperatively,and reassure in the follow up period.All of them settle down in in course of time.surgery is not recommended unless they develop a hydrocele.

I've done audit in our hospital as well as reviewed published article and found that hernia side seroma after laparoscopic (TEP) inguinal hernia repair is quiet frequent complication. Incidence is up to 7% in larger hernias. I do agree, conservative treatment is the first option and it takes up to 3-4 months to resorb.

I have only a little experience with TAPP, but I am following more than 240 laparoscopic ventral (incisional and primitive) hernia repair. The seroma formation is so frequent that someone do not consider it as a complicance but only a consequence. Most (75%) of them resolve spontaneously without intervention. After 3-4 weeks a sterile puncture should be advocated. In some cases a couple of evacuations are sufficient to resolve the collection, but a sonography-guided drainage could be of some help. In my experience, no infection was created in the abscence of any other complication (i.e: previous fiel contamination, bowel subclinical injury.

1. There's a different policy in groin hernia repair and incisional/ventral hernia repair.

2. Seroma formation in direct ing. hernia can be (nearly totally) prevented, if the transversalis fascia is sutured or tacked to the Cooper's Ligament. In indirect hernias it is not possible to obliterate the dead space after a complete reduction of the hernia sack. Therefore it is necessary (as already has been stated) to inform the patient (and maybe the reffering doctor too) that the posop swelling are not early recurrences or missed hernias, but something, that resolves by itself within weeks. Aspiration is seldom needed when symptomatic, most often it is a psychotherapy for the surgeon himself and for the patient to reassure the above stated.

3. Agree with Novik that infections in TAPP don't exist (according to my own series Close to 4000 since 1992.

4. There's no place for drains to prevent seromas in groin hernias. Incomplete Hemostasis cannot be improved by placing drains. The seroma is a result of the surgical Trauma and the foreign body reaction, which starts after you've taken your drains away. Unnecessary Drains are a vector for infection.

5. Aspiration in TAPP/TEP has got very low infection risk if any in contrary to abdominal wall repair. Seromas after IPOM are in 100% (if you really want to detect them) and Thea spontaneously resolve in over 95% of patients (Henniford et al). The risk of contamination of the serous cavity with consequences for the neighbouring mesh is real. Not exactly the same it is in IPOM Plus (closing the defect first and then adding the laparoscopic IPOM). The dead space is obliterated, no space for seromas, the mesh is behind the closed abdominal defect away from a possible seroma formation.

Lot of stuff to argue, enjoy or interfere

jfk

I think it can be prevented with proper subcutaneus suturing and leaving little dead space during surgery and bandage after surgery.

I agree with Jan that there is a major difference between TEP/TAPP and IPOM.

1) In TEP (or TAPP) the risk of significant seroma formation is marginal. TEP producedure might result in more seroma's than TAPP (Bansal, Surg endosc 2013), although seroma in TEP is also quite rare (one patient in my personal series of 1000) and should primarily be treated conservatively. There is no significant subcutaneous cavity that can or should be occluded. The seroma forms in the space between intact peritoneum and the muscular wall or between mesh and inguinal canal along the vas deferens. The peritoneum should be able to absorb the seroma sufficiently in the majority of cases. Minor seroma formation in the inguinal canal/scrotum hardy ever requires intervention.

2) in IPOM surgery, seroma formation is always present, but resolves in 95% of cases. In rare selected cases aspiration can be performed. Massive and recurrent seroma's can be treated applying talc suspension in the seroma cavity (eg under endoscopic sight, Lehr et al, JSLS 2001). Probably IPOM plus decreases the risk for seroma formation (and the risk for persistent buldging of the abdominal wall) and should be advocated in all patients where the port exceeds 5cm.

Prevention is better than cure. I rely on sharp dissection & avoiding energised dissection. In an indirect hernia, transection of sac rather than complete stripping from the chord structures. For ventral hernie i do a suture closure of the defect before splintting the sutured defect with an intraperitoneal onlay mesh (IPOM). This ensures anatomical reconstruction of the abdominal wall, functional compliance of the abdominal wall & reduction in the dead space along with disconnection of the contiguity of the hernial sac with the peritoneal cavity.

More evidence on seroma

New recommendation from International Endohernia Society : A closed-suction drain can be used to reduce the risk of seroma formation without increased risk of infection after TEP (Grade C)

Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society) Surgical Endoscopy

February 2015, Volume 29, Issue 2, pp 289-321

http://link.springer.com/article/10.1007/s00464-014-3917-8

As one of the steering comittee and working group  of the above mentioned Guidelines I'd like to comment: The paper of Ismail on closed suction is the only one! There are very few  groups which use systematically Drainage in TEP (e.g. Prof. Koeckerling, Berlin). There's another interesting approach to large indirect sacs described by Daes J in Hernia (2014) 18:119–122 DOI 10.1007/s10029-012-1030-2