Dear Prasad, this is a common problem. What you are seeing at this stage is seroma formation due to the mesh. I assume the fluid is generally clear and not turbid with signs of pus if there is no evidence of infection.

I think your options are the following;

1). Remove the drain - the seroma will accumulate, and will require aspiration at regular intervals until the rate of production of fluid naturally reduces, and the size of cavity above the mesh gets smaller. This may take about 12 weeks or so, and you may have to aspirate about 3 to 4 times in total during this time. I would recommend you do this under sterile technique, with a large bore spinal needle of some length, which can be attached to suction, or under ultrasound guidance.

2). Leave the drain in - but this risks introducing infection I would think, if left in indefinitely. 

I hope that helps.

Gurpreet Singh Ranger

Very difficult situation. I would keep close contact with the patient after removal of the drain, and then see 1) how big the seroma gets and 2) how much it bothers the patient. Aspiration is not, in my opinion, necessary if it does not bother the patient. Within a year seromas can regress and some may even disappear completely.

Word of caution though: Onlay repair for such a large hernia? Why not go retromuscular, then you reduce the risk of seroma and recurrence. And if you really want to avoid these problems, demand that the patient lose weight before surgery. Probably makes both patient and surgeon happy if no complications are encountered.

Hope the best for the patient -- I am very interested in what happens next!

Regards

The answer in your case with 100ml serous fluid a day is definitely a yes , Drains are placed to drain and it was exactly what it is doing . The Closed system is working well. Usually the patient's who have a heavy drain output are morbidly obese and there is lots of dissection which results in this reactionary fluid collection. However, you have not mentioned whether the patient had any comorbid situation including diabetes or ascites which is common in this part of world. Is your patient suffering from hypoproteinemia ? and why did he/she had the hernia is the first place. All factors help in determining what to do. But the information i have from your question - I would continue with the drain ON.

Do let me know what have you decided and what is the outcome.

I will manage this case by removing the drain as it is already there for 45 days and still having drain of 100mi/day.Remove drain and put her on compression dressings (compression garments for abdomen as is done after tummy tuck). Seroma will resolve gradually. You may have to aspirate if it persists. 

Thank you all for the responses. I have removed the drain 4 days back and kept the patient under close observation. There does not appear to be significant collection after drain removal warranting aspiration till now. I am planning to keep her under regular follow up for another 60 days. I also have applied Compression Garments.

Kristian Kim Jensen : I did try ask the patient to attempt weight reduction before Surgery but no significant weight loss had occured. The patient had undergone multiple surgeries in the past and creating the retrorectal plane was difficult. 

Dear Prasad,

Delighted to hear your patient is making progress.

Best wishes,

Gurpreet Singh Ranger

Dear Prasad, 

Your question induce the idea that the mesh is the principle cause of the seroma production.I prefered always to use onlay mesh rather than inlay to avoid intestinal fistula, but I haven,t seen even one case to keep the drain for longer than 1week .On the other hand I had abdominoplasty cases without mesh Which had seroma drainage for long time, especially in  those cases that the dermal flap wasn,t fixed to the underlying fascia.In this case,you have no other choice than either to maintain the drain for long time or aspirate frequently for seroma formation.

    Best wishes;

Jalaluddin Khoshnevis

Seroma formation is very common in onlay techniques, either one performs dissection and placed besides the prothesis. This is in addition, if the patient is obese, guaranteeing 100% of the same formation. We usually 7-10 days drainage, drain unless much. Once removed it, if it is seroma, we prefer to control and or puncture. If discomfort for the patient, if there is drained by puncture, assuming the risk of infection.

Onlay mesh seromas are common. We use the sublay technique in part to avoid this. Drains will stinulate some serous fluid just by their very presence so leaving very long term unlikely to become completely dry. 30mls seems a

Common number quoted but i’m not sure how much evidence there is for waiting for that number

Good discussion,when there is 100 ml drainage we all think twice to remove but ideally it should be removed 5 days to 1 wks time lest the mesh may get infected. Usually seroma gets settled unless it is infected.

Unfortunately we don’t have a right answer for this scenario. I am looking after a 110 kg female 4 weeks post laparotomy , who had adhesiolysis of small bowel, incisional hernia repair with ultrapro onlay mesh and someone removed 4 drains 2 weeks post op and now she got infected seroma 11 cm on a CT scan , drained by wound explored 5cm and vac: dressing.

I am thinking to leave suction drains until dry.