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Risk factors and clinical impact of seroma formation following laparoscopic inguinal hernia repair: a retrospective study

BMC Surgery volume 24, Article number: 274 (2024) Cite this article

Abstract

Background

Although laparoscopic inguinal hernia repair (LIHR) has advantages over open surgery, postoperative seroma formation remains an issue. This study aimed to investigate the risk factors and clinical outcomes of seroma formation in patients undergoing LIHR.

Methods

From January 2016 to March 2023, clinical data of patients who underwent LIHR were retrospectively analyzed. Patients who developed seroma and those who did not were classified into the seroma and non-seroma groups, respectively. The demographic and clinical characteristics were compared between the two groups. Univariate and multivariate logistic regression analyses were performed for variables of interest. The receiver operating characteristic curve was used to evaluate the risk factors of the binary logistic model, and the cutoff value for each risk factor was obtained.

Results

Data of 128 patients were evaluated. Compared with patients in the non-seroma group, those in the seroma group had a higher body mass index (BMI) (P < 0.001), more direct hernias (P < 0.001), larger hernial orifice size (P < 0.001), more laparoscopic total extraperitoneal hernioplasty (TEP) (P < 0.001), more frequent reduction of hernial sac (P = 0.011), and lower preoperative serum albumin level (PSAL) (P < 0.001). Multivariate logistic regression analyses performed on these variables showed that high BMI (P = 0.005), large hernial orifice (P = 0.001), TEP (P = 0.033), and low PSAL (P = 0.009) were risk factors for seroma formation. Compared with the non-seroma group, the seroma group exhibited a higher numerical rating scale score for postoperative pain (P < 0.001), and longer hospital stays (P = 0.032).

Conclusions

BMI (> 24.5 kg/m2), hernial orifice size (> 2.5 cm), TEP, and PSAL (< 32.5 g/L) were independent risk factors of postoperative seroma formation in patients who underwent LIHR. Although most seromas resolve spontaneously without surgical intervention, seroma formation results in increased patient pain and prolonged hospital stay.

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Introduction

With the advent of laparoscopic surgery, laparoscopic inguinal hernia repair (LIHR) has become the preferred treatment option due to its minimally invasive nature, rapid recovery, decreased post-operative discomfort, and early return to activities [1, 2]. Postoperative seroma is a common complication after LIHR, occurring at a higher rate compared with open techniques [3, 4]. Seroma is the abnormal accumulation of serous fluid in a dead space containing lymphatic and plasma fluids. Although its etiology remains unclear, it is thought to be an accumulation of serum resulting from the disruption of lymphatic and vascular drainage due to extensive tissue dissection during surgery, as well as possible inflammatory exudation, postoperatively collected in a dead cavity [5]. Seroma formation after LHIR manifests as a mass in the hernia region, mimicking hernia recurrence, leading to patient anxiety and adversely affecting the quality of life after surgery [6]. Physical examination alone is insufficient for accurate diagnosis, necessitating the use of ultrasonography or computed tomography (CT) for confirmation [7, 8].

Despite the prevalence of seroma following LIHR, studies examining the potential causes and outcomes of this complication is scarce. Therefore, in this study, we aimed to investigate the risk factors and clinical impact of seroma formation in patients undergoing LIHR.

Methods

Case selection

Hospital records were retrospectively reviewed to identify patients who underwent LIHR between January 2016 and March 2023. The eligibility criteria included an inguinal hernia diagnosis confirmed via ultrasonography or CT, age ranging from 20 to 80 years, and follow-up record for more than 1 year with complete clinical data. The exclusion criteria included incarcerated or strangulated hernias, blood coagulation disorders, severe hepatic or renal dysfunction, and mental disorders.

The same medical team with expertise in LIHR performed all surgeries. This study was approved by the Ethics Committee of the Ningbo Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University (No. KYSL-2024-001-027). All procedures were performed in accordance with the tenets of the Declaration of Helsinki. The need for informed consent was waived due to the retrospective nature of the study.

Surgical procedures

Laparoscopic transabdominal preperitoneal hernioplasty (TAPP)

All patients received general anesthesia and were placed in the supine position, tilted approximately 15° to the healthy side. A curved 10 mm incision was made inferior to the umbilicus, and a 10 mm trocar was punctured to establish carbon dioxide (CO2) pneumoperitoneum at a pressure of 12 mmHg. A laparoscope was used to investigate the site and size of the inguinal hernia. Two additional 5 mm incisions were made bilaterally at the edges of the abdominal rectus muscles for surgical instruments. An incision was made in the peritoneal wall, starting at the superior margin of the internal inguinal ring. The incision was extended medially to the medial ligament of the umbilicus and laterally to the anterosuperior iliac spine. The peritoneum was dissected away from the abdominal wall to isolate and reduce or transect the hernial sacs. After the spermatic cord in male patients or the round ligament of the uterus in female patients were freed from the peritoneal wall, a knitted polypropylene preformed mesh (BARD 3DMax Light Mesh; Davol, Inc., Warwick, RI, USA) 10.3 × 15.7 cm in size was placed and fixed with tissue adhesive (Borayer, Inc., Nanchang, Jiangxi, China). The peritoneal flap was closed using running absorbable barbed sutures (COVIDIEN, Inc., Mansfield, MA, USA). CO2 deflation was performed under observation. Skin incisions were closed using Vicryl sutures (Ethicon, Johnson & Johnson Medical, Cincinnati, OH, USA).

Laparoscopic total extraperitoneal hernioplasty (TEP)

All procedures were performed under general anesthesia. A 10 mm infraumbilical incision was made, and the linea alba was identified and incised. A 10 mm trocar was inserted, and a laparoscope was introduced into the preperitoneal space. Blunt separation was performed by placing the tip of the laparoscope toward the pubic symphysis. The CO2 pressure was maintained at 12 mmHg. Two 5 mm incisions were made in the midline to introduce the working ports. The preperitoneal working space was established along Cooper’s ligament with blunt dissection medial to the pubic symphysis and lateral to the anterior superior iliac spine. The hernia sac was identified, dissected, and reduced or transected. After the spermatic cord in male patients or the round ligament of the uterus in female patients were freed from the peritoneal wall, a knitted polypropylene preformed mesh (BARD 3DMax Light Mesh, Davol, Inc.) 10.3 × 15.7 cm in size was introduced from the 10 mm port and unrolled to cover the hernia site. CO2 deflation was performed under observation. Skin incisions were closed using Vicryl sutures (Ethicon, Johnson & Johnson Medical, Cincinnati, OH, USA).

Postoperative management

All patients resumed a normal diet and activity a day after surgery. Seroma was defined as fluid collection in the underlying tissue lacunae and in the lacunae formed after surgery due to aseptic inflammatory response and exudate accumulation [3]. The diagnosis of postoperative seroma formation was based on visible swelling of the inguinal canal or scrotum on physical examination and was confirmed via ultrasonography or CT. Surgical intervention for the seroma was considered if patients developed symptoms related to the seroma, such as pain, skin color change, and tenderness.

Follow-up regimen

The patients were asked to visit the clinic for examination immediately if any discomfort related to hernia repair developed. Regular follow-up was conducted via clinic visits at 1 week, 1 month, 3 months, and 6 months after surgery. Ultrasound was used for follow-up if a seroma developed, and the hospital visit was shortened every 15 days until complete resolution was achieved.

Data collection

Patients were categorized into the seroma and non-seroma formation groups based on the development of postoperative seroma. The following data were collected: age, sex, smoking, body mass index (BMI), hernia location, type of hernia, scrotal hernia, hernia orifice size, hernia sac size, comorbidity, preoperative medication, recurrent hernia, surgical procedure, operative time, intraoperative bleeding, treatment of the hernia sac, postoperative external compression, and preoperative serum albumin level (PSAL). Postoperative outcomes such as fever, surgical site infection, pain, hospital stay, cost, and recurrence were also documented. The postoperative pain was evaluated using numerical rating scale at 1 h, 12 h, 24 h, and the day of discharge. The mean of the four scores was calculated.

Statistical analysis

Kolmogorov–Smirnov test was used to test the normality of the continuous data [9]. Data are presented as frequencies or percentages for categorical variables and the mean ± standard deviation for continuous variables. Statistical comparisons of clinical data between the two groups were performed using the Student’s t-test for continuous variables and the chi-square test for categorical variables. To investigate the risk factors for seroma formation, we conducted a univariate exact logistic regression analysis for variables that may contribute. Significant variables (P < 0.10) were identified for the multivariate analyses. The receiver operating characteristic (ROC) curve was used to evaluate the risk factors of the binary logistic model, and the cutoff value for each risk factor was obtained. Statistical significance was set at values of P < 0.05. SPSS (version 17.0; SPSS, Inc., Chicago, IL, USA) was used for statistical analyses.

Results

Altogether, 22 female (17.2%) and 106 male (82.8%) patients were included in this study, with an average age of 47.1 ± 12.5 years. There were 21 and 107 patients in the seroma and non-seroma groups, respectively. The study algorithm and analysis process are shown in Fig. 1. No intra-abdominal infections were observed in any patient, and no deaths occurred.

Fig. 1
figure 1

Flowchart of the study

Full size image

Risk factors for seroma formation

The clinical characteristics and variables of the two groups are summarized and compared in Table 1. No statistically significant differences were found between the seroma and non-seroma groups in terms of age, sex, smoking status, hernia location, scrotal hernia, size of the hernia sac, comorbidities, preoperative medication, recurrent hernia, operative time, intraoperative bleeding, or postoperative external compression (P > 0.05). Univariate analysis was conducted on the preoperative variables that demonstrated statistical significance, including BMI, presence of direct hernia, size of hernia orifice, TEP, hernial sac reduction, and PSAL (Table 2). Variables with values of P < 0.10 were subjected to further multivariate logistic regression analysis. We found that high BMI > 24.5 kg/m2 [odds ratio (OR) 2.557, confidence interval (CI) 2.200-75.599, P = 0.005], size of hernia orifice > 2.5 cm (OR 2.653, CI 2.761–72.935, P = 0.001), TEP (OR 1.726, CI 1.153–27.371, P = 0.033), and PSAL < 32.5 g/L (OR 3.734, CI 2.585-676.894, P = 0.009) were confirmed as independent risk factors for seroma formation following LIHR (Table 3). ROC curves were constructed for BMI, hernial orifice size, and PSAL. The areas under the curve were 0.7392, 0.7143, and 0.7267, respectively (Fig. 2).

Table 1 Demography and clinical characteristics of patients between the two groups
Full size table
Table 2 Univariate logistic regression for risk factors for seroma formation following laparoscopic inguinal hernia repair
Full size table
Table 3 Multivariate logistic regression for risk factors for seroma formation following laparoscopic inguinal hernia repair
Full size table
Fig. 2
figure 2

ROC curves of logistic model. ROC = receiver operating characteristic. (A, body mass index; B, hernial orifice size; C, preoperative serum albumin level)

Full size image

Outcomes of seroma formation after LIHR

Both groups exhibited no significant differences in postoperative fever, wound infection, hospitalization costs, and recurrence (P > 0.05). However, the seroma group had a higher numerical rating scale of postoperative pain (2.2 ± 1.1 vs. 1.5 ± 0.6, P < 0.001) and a longer hospital stay (3.5 ± 1.4 vs. 3.0 ± 0.9, P = 0.032) than those of the non-seroma group (Table 4). In the seroma group, all patients were diagnosed within 1 week postoperatively, and seroma formation occurred 4.1 ± 1.3 days after LIHR. Four patients underwent surgical drainage due to pain, tenderness, and increased seroma size at 8.2 ± 1.5 days postoperatively. The resolution of seromas was complete at 81.0 ± 10.7 days and the resolution rate of the cohort within 3 months was 95.2%.

Table 4 Comparison of outcomes between the two groups
Full size table

Discussion

Compared with open approaches, LIHR offers advantages, including lesser postoperative pain, lesser consumption of analgesics, shorter recovery time, and earlier return to work [10, 11]. However, it is associated with higher incidence of seroma formation in LIHR, which remains challenge for surgeons [12].

Some studies have demonstrated that a high BMI is associated with postoperative complications and a prolonged length of hospital stay [13,14,15,16]. However, the relationship between high BMI and seroma formation after LIHR remained unclear. This study revealed that BMI > 24.5 kg/m2 is a risk factor for seroma. A raised BMI is associated with challenges in surgical care that occur both directly and indirectly because of the elevated BMI. These can result in significant problems in the surgical procedure including inguinal hernia repair [17]. In our experience, patients with a high BMI usually have more fat tissue in the inguinal region results in additional effort required to strip the hernia sac, thereby increasing postoperative wound exudation.

In our study, a hernial orifice > 2.5 cm was considered a risk factor for postoperative seroma formation, consistent with Morito et al.’s study [18]. Generally, large hernial orifices are associated with severe tissue adhesion and thickening. In these cases, dissection of hernial sac is difficult and prone to accidental damage to the spermatic cord blood vessels. Therefore, a large hernial defect tends to complicate and prolong LIHR, causing increased intraoperative bleeding and postoperative wound exudation. Furthermore, a large postoperative cavity is created after hernia is reduced. All these aforementioned factors contribute to the development of postoperative seromas.

Our findings revealed a higher incidence of seromas in the TEP group than in the TAPP group. This disparity can be attributed to several factors. TEP separation requires creating a preperitoneal working space from the umbilicus to the pubic symphysis, which is more extensive than that in TAPP. TEP not only causes greater trauma and increased postoperative tissue fluid exudation but also creates a dead space through the dissection and reduction of the hernial sac after surgery. Furthermore, the closed cavity is the lowest part of the inguinal region and is prone to fluid accumulation, and drainage of exudates into other natural body cavities is impossible. In contrast, small gaps in the peritoneum after peritoneal closure in TAPP enable the drainage of preperitoneal exudation into the peritoneal cavity, remarkably decreasing the possibility of seroma formation.

In surgery, it is well established that a low PSAL is associated with a greater risk of adverse surgical outcomes such as infection, edema, and wound dehiscence [19,20,21]. PSAL is predictive of operative outcomes because it is a marker of disease and malnutrition and confers a direct protective effect through biological mechanisms [22, 23]. This study showed that patients with low PSAL had a higher occurrence of seroma formation following LIHR. A low PSAL causes a decrease in colloid osmotic pressure, which promotes fluid transfer from the intravascular to the extravascular and tissue interstitial spaces. This etiology worsens the edema of the damaged postoperative tissue, resulting in increased exudation and seroma formation.

In this study, we identified several risk factors for seroma formation following LIHR. However, the exact mechanism underlying seroma formation remains poorly understood, with several hypotheses. Some studies have demonstrated that the remaining large hernial defect space after surgery contributes to the formation of a seroma [24, 25]. In addition, an inflammatory response from surgical dissection and the presence of a polypropylene mesh have been reported to cause seromas [26]. Accordingly, various strategies have been adopted to reduce the incidence of postoperative seromas. These include drainage tubes, intraoperative hypertonic saline irrigation, and pressure dressings [4, 27,28,29,30]. Postoperative external compression facilitates dead space obliteration, avoids surgical site shearing, and promotes tissue adhesion. However, pressure bandages are difficult to apply over the groin, and it did not reduce the incidence of postoperative seromas in our study.

Seroma formation results in patient dissatisfaction and poor aesthetic outcomes [31]. Moreover, our study demonstrated that it causes increased postoperative pain and prolongs hospital stays. Expectant treatment with observation is plausible in small seromas, which are mostly absorbed within 3 months. However, several symptomatic seromas require postoperative surgical drainage.

This study has some limitations. First, it has a retrospective and single-center design. Second, the patient population is relatively small. Third, selection bias existed because not all patients routinely underwent postoperative CT or ultrasound and some asymptomatic patients with seromas may have been ignored. Therefore, a randomized, controlled, and multicenter study with a large sample size is required for further investigation.

Conclusions

The independent risk factors for postoperative seroma formation in patients who underwent LIHR were BMI (> 24.5 kg/m2), hernial orifice size (> 2.5 cm), TEP, and PSAL (< 32.5 g/L). Most seromas resolve spontaneously; however, seroma formation results in increased pain and prolonged hospital stay.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to the protection of personal privacy but are available from the corresponding author on reasonable request.

Abbreviations

LIHR:

Laparoscopic inguinal hernia repair

BMI:

Body mass index

TEP:

Laparoscopic total extraperitoneal hernioplasty

PSAL:

Preoperative serum albumin level

TAPP:

Laparoscopic transabdominal preperitoneal hernioplasty

CT:

Computed tomography

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Authors and Affiliations

  1. Department of Gastrointestinal Surgery, Ningbo Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University, Ningbo, Zhejiang, 315016, China

    Hong-yang Xie, Bin Chen, Jie Shen, Yi-ping Wang, Wei-cai Shen & Chun-shan Dai

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Contributions

H.X. contributed to selecting topics, providing financial support, and revising articles. B.C., J.S., C.D., and Y.W. provided ideas and revised article. W.S. and B.C. analyzed and interpreted the patient data. H.X. collected, analyzed, and interpreted the clinical data, was a major contributor in writing the manuscript. All authors reviewed and approved the final manuscript.

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Correspondence to Bin Chen.

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This study was conducted in accordance with the principles of the Declaration of Helsinki, and this study was approved by the Ethics Committee of the Ningbo Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University (No. KYSL-2024-001-027). The requirement for informed consent was waived by the Ethics Committee of the Ningbo Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University because of the retrospective nature of the study.

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Xie, Hy., Chen, B., Shen, J. et al. Risk factors and clinical impact of seroma formation following laparoscopic inguinal hernia repair: a retrospective study. BMC Surg 24, 274 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12893-024-02574-1

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BMC Surgery

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