Avoid common mistakes on your manuscript.
Dear Editors
We read with great interest the recent article by Beckers Perletti et al. [1], published in Hernia. The authors reported that higher incidence of seroma was associated with the onlay ventral hernia repair procedure as compared to the sublay technique, and there is no significant difference between laparoscopic and open surgical procedure.
This is an important publication regarding ventral/incisional hernia repair, and several findings from the study stand out, therefore, we have some points for further discussions.
First, A variety of open or laparoscopic techniques were used for ventral/incisional hernia repair, however, which is not devoid of postoperative complications, especially in large hernias, failure of hernia repair is also common, with reoperations for recurrent hernia occurring at a rate of 12.3% after 5 years and 23.1% at 13 years [2]. As to the other complications, most of them are mesh-related complications, and some were serious, such as bowel perforation, enterocutaneous fistulas, chronic surgical site infection, late intraabdominal abscess, nonhealing wounds, hematomas, and bowel obstruction, most of these complications required reoperation [3]. Among these complications, seroma formation appeared to be a benign and less dreadful complication to both the surgeons and patients. Therefore, although seroma formation incidence was remarkable higher in one technique (onlay) over another one (sublay) [1], clinical recommendation and approach selection of ventral/incisional hernia repair usually be determined and individualized on many factors, including patients’ factors, technique factors, and social factors, other than seroma incidence. One example is the laparoscopic inguinal hernia repair, which was associated higher incidence of postoperative seroma as compared to the corresponding open Lichtenstein technique [4,5,6], and both laparoscopic technique and Lichtenstein are recommended procedures for inguinal hernia repair.
Second, the seroma formation in ventral/incisional hernia was mainly related to two factors, the hernia cavity and the position of mesh placement. The larger area of tissue dissection, the larger volume of the defect cavity, the more superficial position of the mesh locates, the more frequent of the seroma formation is. As observed in endoscopic-assisted linea alba reconstruction, although the procedure was carried out with endoscopic approach, still higher seroma formation rate was observed [7], therefore, seroma after ventral/incisional hernia seems a marker of the superficial layer the mesh is implanted, despite open or laparoscopic approach was taken.
Third, despite the evidence that sublay mesh placement is associated with the lowest risk of surgical site infection, recurrence, and less seroma formation [8], however, the onlay technique has some unique advantages over sublay and endoscopic intraperitoneal onlay mesh approach (IPOM), for example, the mesh in onlay repair is placed in a quite superficial position, which is not only technical easy, but also the mesh-related complication is less severe, and which could be easily managed in case of mesh infection.
Fourth, if the onlay technique is performed, the seroma-preventing procedure should be performed concomitantly, the most often used method was closed suction drainage. In my practice, especially in complicated cases, the prophylactic use of vacuum assisted closure (VAC) was applied, which has the efficacy to prevent surgical site infection (SSI), hernia recurrence and other wound complications following closed laparotomy incisions following ventral hernia repair [9], and excellent results was observed.
Even though we felt the need to discuss these few points, we congratulate Beckers Perletti et al. for their work, and we hope that their contribution, in addition to this discussion, will be useful to surgeons involved in the treatment of ventral hernia repair.
References
Beckers Perletti L, Spoelders F, Berrevoet F (2021) Association between surgical hernia repair techniques and the incidence of seroma: a systematic review and meta-analysis of randomized controlled trials. Hernia. https://doi.org/10.1007/s10029-021-02531-4 (Epub ahead of print. PMID: 34773524)
Flum DR, Horvath K, Koepsell T (2003) Have outcomes of incisional hernia repair improved with time? A population-based analysis. Ann Surg 237(1):129–135
Itani KM (2016) New findings in ventral incisional hernia repair. JAMA 316(15):1551–1552
Li J, Ji Z, Shao X (2018) Prevention of seroma formation after laparoscopic inguinoscrotal indirect hernia repair by a new surgical technique: a preliminary report. Int J Abdom Wall Hernia Surg 1:55–59
Li J, Bao P, Shao X, Cheng T (2021) The management of indirect inguinal hernia sac in laparoscopic inguinal hernia repair: a systemic review of literature. Surg Laparosc Endosc Percutan Tech 31(5):645–653
Li J, Gong W, Liu Q (2019) Intraoperative adjunctive techniques to reduce seroma formation in laparoscopic inguinal hernioplasty: a systematic review. Hernia 23(4):723–731
Kler A, Wilson P (2020) Total endoscopic-assisted linea alba reconstruction (TESLAR) for treatment of umbilical/paraumbilical hernia and rectus abdominus diastasis is associated with unacceptable persistent seroma formation: a single centre experience. Hernia 24(6):1379–1385. https://doi.org/10.1007/s10029-020-02266-8
Henriksen NA, Montgomery A, Kaufmann R, Berrevoet F, East B, Fischer J et al (2020) Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. Br J Surg 107:171–190
Guo C, Cheng T, Li J (2022) Prophylactic negative pressure wound therapy for closed laparotomy incisions after ventral hernia repair: a systematic review and meta-analysis. Int J Surg 97:106216. https://doi.org/10.1016/j.ijsu.2021.106216 (Epub 2022 Jan 4 PMID: 34990831)
Funding
None.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
No conflict of interest to be declared by the authors.
Ethical approval
This article did not require ethical approval of any kind.
Human and animal rights
This article does not contain any studies with human participants or animals performed by any of the authors.
Informed consent
This article does not include patients, and therefore informed consent was not applicable.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Li, J. Comment on: association between surgical hernia repair techniques and the incidence of seroma. Hernia 26, 1215–1216 (2022). https://doi.org/10.1007/s10029-022-02592-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10029-022-02592-z