Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
Department of Radiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
Hernia. 2020 Aug;24(4):821-829. doi: 10.1007/s10029-020-02136-3. Epub 2020 Feb 18.
Seroma is a commonly encountered sequela after hernia repair. Tremendous effort has been spent to investigate the effective way to prevent this "complication" including the modification of surgical technique, use of per-peritoneal drainage, etc. There were debates about the use of monopolar diathermy versus blunt dissection in laparoscopic TEP in the prevention of seroma formation. This randomized study aims to compare the effects of using 2 techniques in laparoscopic TEP on pre-peritoneal drain output and seroma formation.
From 1.9.2018 to 30.9.2019, all male and female patients presented with the first occurrence, unilateral inguinal hernia anticipated for laparoscopic TEP were enrolled into the study after informed consent. Patients were randomized into "monopolar dissection preferred" (MDP) group and "blunt dissection-preferred" (BDP) group just before commencing of operation after general anesthesia. Surgeons were instructed to use monopolar energy as main dissection method for the whole operation if possible (MDP), whereas blunt dissection is the preferred choice in BDP group, but the use of monopolar energy was allowed if needed. Total energy time was measured by a specially designed homemade device attaching to the monopolar pedals as accurate as to millisecond (ms). Pre-peritoneal drains were inserted for drainage and removed 23 h after operation. Drainage output, total operating time, energy time, clinical and ultrasonic seroma sizes at day 1, day 6, 1-month post operations, recurrence are compared between 2 groups.
A total of 103 patients where included. There was no significant difference in age, gender, co-morbidities, side of hernia, mean defect size, operating time, fixation adjuncts, or postoperative stay. The drain volume in BDP group is 71.13 ± 31.42 mL while it in MDP group is 56.36 ± 21.46 mL. The MDP group had significantly fewer drain output at 23 h post operation (p = 0.007) and lower seroma incidence on days 6 (p = 0.036). Overall incidence of seroma formation was 12% on postoperative day 1, 11% on postoperative day 7. No statistically differences in postoperative pain score or complications were observed at the first week, 1- and 3-months' post operation. There was no correlation with energy time to the drain output. No recurrence was found in subsequent follow-up.
Pre-peritoneal drainage is clinically safe in laparoscopic totally extra-peritoneal hernioplasty and can effectively reduce the size and incidence of seroma. The seroma formation can be further reduced by appropriate use of monopolar energy as preferred dissection approach in lap TEP. Due to limitation in measuring the actual energy time, the result should be further validated by randomized multi-centers trial on its potential benefit in hernia repair by a more accurate measuring device on energy used.
血清肿是疝修补术后常见的后遗症。人们花费了大量的精力来研究预防这种“并发症”的有效方法，包括手术技术的改进、使用腹膜前引流等。在腹腔镜 TEP 中，使用单极电凝与钝性解剖预防血清肿形成的效果存在争议。本随机研究旨在比较两种技术在腹腔镜 TEP 中预防腹膜前引流液流出和血清肿形成的效果。
从 2018 年 9 月 1 日至 2019 年 9 月 30 日，所有因单侧腹股沟疝初次发作而接受腹腔镜 TEP 的男性和女性患者在知情同意后纳入研究。在全身麻醉下开始手术前，将患者随机分为“单极解剖优先”（MDP）组和“钝性解剖优先”（BDP）组。如果可能，外科医生应将单极能量作为主要的解剖方法（MDP），而在 BDP 组中，钝性解剖是首选方法，但如果需要，也可以使用单极能量。通过专门设计的、附在单极脚踏板上的自制装置来测量总能量时间，精确到毫秒（ms）。术后放置腹膜前引流管引流，术后 23 小时拔除。比较两组患者的引流液量、总手术时间、能量时间、术后第 1、6、1 天的临床和超声血清肿大小、复发率。
共纳入 103 例患者。两组患者的年龄、性别、合并症、疝侧、平均缺损大小、手术时间、固定辅助物或术后住院时间均无显著差异。BDP 组引流液量为 71.13±31.42mL，MDP 组为 56.36±21.46mL。MDP 组术后 23 小时引流液量明显减少（p=0.007），术后 6 天血清肿发生率较低（p=0.036）。术后第 1 天血清肿总发生率为 12%，第 7 天为 11%。术后第 1 周、第 1 个月和第 3 个月，两组患者的术后疼痛评分和并发症均无统计学差异。引流液量与能量时间无相关性。在随后的随访中，没有发现复发。
腹腔镜完全腹膜外疝修补术中使用腹膜前引流是安全的，可有效减少血清肿的大小和发生率。在 lap TEP 中，适当使用单极能量作为首选解剖方法，可进一步减少血清肿的形成。由于测量实际能量时间的局限性，应通过使用更准确的能量测量设备，在多中心随机试验中进一步验证其在疝修补中的潜在益处。
