Li J, Gong W, Liu Q
Department of General Surgery, Affiliated Zhongda Hospital, Southeast University, Nanjing, 210009, China.
Hernia. 2019 Aug;23(4):723-731. doi: 10.1007/s10029-019-01903-1. Epub 2019 Feb 8.
Seroma formation is the most common postoperative complication after laparoscopic inguinal hernia repair. Recurrence and seroma formation may be difficult to distinguish. Many adjunctive techniques with which to reduce the incidence of seroma formation after laparoscopic inguinal repair have been described in the literature; however, the evidence for using intraoperative adjunctive techniques is limited. Therefore, the present systematic review was performed to evaluate the effects and limitations of adjunctive techniques used during laparoscopic inguinal hernia repair.
Major databases (PubMed, Embase, Springer, and Cochrane Library) were searched using the terms "seroma," "laparoscopic inguinal hernia", "TAPP", "TEP", "inguinal hernia", "tack", "barbed suture", "drainage", "Endoloop technique", and "fibrin sealant". All studies involving adults undergoing laparoscopic/endoscopic inguinal hernioplasty with at least one intervention designed to reduce seroma formation were included.
Of the 965 studies identified, 8 met the inclusion criteria. Six adjunctive techniques were described in the literature. Transversalis fascia (TF) inversion with tacking: one prospective non-randomized controlled study revealed a lower incidence of postoperative seroma after TF inversion with tacking for direct inguinal hernias (4.17% vs. 14.29%, P < 0.05). Endoloop technique: one prospective study of 76 cases involving this technique revealed a low incidence of seroma formation (3.9% at 2 weeks) in direct hernias. Barbed suture closure of TF: one prospective study of 36 direct hernias reported only one clinical palpable seroma that resolved 1 month later. Surgical drains: three trials reported the results of drains, and the pooling results demonstrated significantly less seroma formation in patients with surgical drains (2.1 vs. 23.8%; odds ratio 0.12; 95% confidence interval 0.08-0.19; P < 0.0001). Fibrin sealant: one prospective clinical study of 40 patients with indirect inguinal hernias reported a lower volume (P < 0.001) and lower incidence (5% vs. 15%) of seroma formation in the fibrin group. Distal sac fixation technique: in one prospective study of six patients with large inguinoscrotal hernias, one patient developed a seroma on postoperative day 8.
Seroma formation is a natural process that cannot be completely prevented following laparoscopic inguinal hernioplasty, especially in patients with direct and large indirect inguinal hernias. Some intraoperative adjunctive techniques are effective in reducing clinically palpable seroma formation in select patients. More randomized controlled trials are needed for further evaluation.
血清肿形成是腹腔镜腹股沟疝修补术后最常见的术后并发症。复发和血清肿形成可能难以区分。文献中描述了许多用于降低腹腔镜腹股沟修补术后血清肿形成发生率的辅助技术；然而，使用术中辅助技术的证据有限。因此，进行本系统评价以评估腹腔镜腹股沟疝修补术中使用的辅助技术的效果和局限性。
使用“血清肿”、“腹腔镜腹股沟疝”、“经腹腹膜前疝修补术（TAPP）”、“全腹膜外疝修补术（TEP）”、“腹股沟疝”、“补钉”、“倒刺缝线”、“引流”、“Endoloop技术”和“纤维蛋白胶”等术语检索主要数据库（PubMed、Embase、Springer和Cochrane图书馆）。纳入所有涉及接受腹腔镜/内镜腹股沟疝修补术且至少有一项旨在减少血清肿形成的干预措施的成人研究。
在确定的965项研究中，8项符合纳入标准。文献中描述了六种辅助技术。用补钉固定腹横筋膜（TF）反转：一项前瞻性非随机对照研究显示，对于直接腹股沟疝，采用补钉固定TF反转术后血清肿发生率较低（4.17%对14.29%，P<0.05）。Endoloop技术：一项对76例涉及该技术的患者的前瞻性研究显示，直接疝血清肿形成发生率较低（2周时为3.9%）。TF的倒刺缝线缝合：一项对36例直接疝的前瞻性研究报告仅1例临床可触及的血清肿，1个月后消退。手术引流：三项试验报告了引流结果，汇总结果表明手术引流患者的血清肿形成明显较少（2.1%对23.8%；优势比0.12；95%置信区间0.08 - 0.19；P<0.0001）。纤维蛋白胶：一项对40例间接腹股沟疝患者的前瞻性临床研究报告，纤维蛋白组血清肿形成量较低（P<0.001）且发生率较低（5%对15%）。远端疝囊固定技术：在一项对6例大型腹股沟阴囊疝患者的前瞻性研究中，1例患者术后第8天出现血清肿。
血清肿形成是腹腔镜腹股沟疝修补术后无法完全预防的自然过程，尤其是在直接和大型间接腹股沟疝患者中。一些术中辅助技术在特定患者中可有效减少临床可触及的血清肿形成。需要更多的随机对照试验进行进一步评估。
