HOW I DO IT
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Suturing the lax pseudosac to the Cooper's ligament to prevent seroma in endoscopic hernia repair: A new technique
Department of Minimal Access Surgery, Ernakulam Medical Center, Kochi, Kerala, India
|Date of Submission||12-Jul-2021|
|Date of Acceptance||23-Sep-2021|
|Date of Web Publication||09-Dec-2021|
Department of Minimal Access Surgery, Ernakulam Medical Center, Palarivattom, Kochi - 682 028, Kerala
Source of Support: None, Conflict of Interest: None
Seroma formation after laparoscopic or robotic inguinal hernia repair is a known complication, causing nuisance to the patient and embarrassment to the surgeon. A method of fixing the lax pseudosac of direct inguinal hernia to Cooper's ligament by suturing, to prevent post-operative seroma formation, is discussed in this study. Seventy-two pseudosac fixations were done in a 'figure of eight technique' using non-absorbable suture in 56 patients. These patients were followed up 2 weeks and 6 weeks post surgery. None developed a seroma. The primary obliteration of pseudosac by suturing with non-absorbable suture to Cooper's ligament is a cheap and reliable method for prevention of post-operative seroma. However, it is time-consuming and dependent on the suturing skill of the surgeon.
Keywords: Direct inguinal hernia, pseudosac, seroma, suturing
| ¤ Introduction|| |
Post-operative seroma formation after laparoscopic and robotic inguinal hernia repair occurs in 0.5%–12.5% of cases., It may be perceived by the patients as persistence or recurrence of hernia. The reason for seroma is the existence of dead space after hernia repair, extending into the scrotum. Several intraoperative measures have been described to minimise seroma. These include the use of pressure dressing, closed suction drain, fenestration of transversalis fascia and obliteration of pseudosac with endoloop or fibrin glue.,, Tacking the lax transversalis fascia to pubic ramus is another popular method to reduce the incidence of seroma., However, iatrogenic osteitis pubis can develop very rarely if metal tacks are used.
Here, I propose a method to suture the lax transversalis fascia to the Cooper's ligament with no. 1 non-absorbable monofilament suture to reduce seroma formation.
| ¤ Materials and Methods|| |
Fifty-six patients who underwent laparoscopic total extraperitonial (TEP) mesh hernioplasty for direct inguinal hernia were included. All cases were operated by a single surgeon under general anaesthesia. The surgery was performed in the supine position by 'two hand' technique. The port positions maintained the triangular orientation. This is vital for suturing. A transverse sub umbilical incision was made and the infraumbilical extraperitoneal space entered. The initial part of space creation (till placement of both working ports in the mid-clavicular line) was done by sweeping of 0° scope. The dissection was continued till the pseudosac was isolated. Once dissection was complete, fixation of the lax transversalis fascia to the Cooper's ligament was done using no. 1 non-absorbable monofilament suture, as described below.
A 7 cm long no. 1 prolene suture was introduced into the preperitonial space and a bite was taken through the Cooper's ligament first [Figure 1]. The fundus of the pseudosac was pulled in with the left-hand instrument thereby inverting it and, a second bite was taken through the transversalis fascia [Figure 2]. The third bite was then taken through the Cooper's ligament adjacent to the previous one [Figure 3] in a figure of eight configuration. The suture was then fastened fixing the pseudosac to the Cooper's ligament [Figure 4]. A 15 cm × 12 cm polypropylene mesh was deployed on both sides.
|Figure 3: Third bite through Cooper's ligament in a figure of eight fashion|
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Seventy-two pseudosac fixations were done in all. In 16 patients, fixation was done bilaterally. In four cases, multiple bites had to be taken since the hernia size was large. In all cases, it was possible to complete the suturing even though the time taken for the procedure was more. All the patients were reviewed in the OP clinic 2 and 6 weeks post surgery and presence or absence of seroma was assessed clinically. Sonographic confirmation of seroma did not form part of this study. Clinically significant seroma was not detected in any patient and none of them had chronic groin pain or hernia recurrence.
| ¤ Discussion|| |
Seroma is a known complication of endoscopic inguinal hernia repair. Even though asymptomatic, it mimics post-operative recurrence of hernia. The serous fluid trapped in the dead space between prosthetic mesh and transversalis fascia might remain there for 3 to 6 weeks. If seroma persists even after 6 weeks, aspiration can be done but with a small risk of infection. Clinical factors associated with seroma formation include old age, large defects, extension of hernial sac into the scrotum and presence of a residual distal indirect sac.
Seroma is regarded as a natural course after endoscopic inguinal hernia repair since most of them resolve spontaneously. However, in spite of adequate reassurance, a patient may not be fully convinced when a swelling develops at the exact site of hernia. Many methods have been tried to reduce the size of post-operative seroma. These include use of pressure dressing, closed suction drain, fenestration of transversalis fascia, obliteration of dead space using catgut endoloop or fibrin glue and fixing the pseudosac to the abdominal wall or Cooper's ligament using tacks.,, Every method has its own limitation. Use of closed suction drain decreases the incidence of seroma, but it has the potential of introduction of infection and has pain related to the drain. Use of fibrin glue has actually increased the incidence of seroma.
Obliteration of pseudosac by fixing the lax transversalis fascia to the nterior abdominal wall or Cooper's ligament is the best method to prevent seroma. Fixation by tacking the pseudosac to the Cooper's ligament or anterior abdominal wall is easy but may cause chronic pain and in rare situations, osteitis pubis. The proposed method of suturing with a non-absorbable monofilament suture prevents this complication. There is no published literature regarding suturing of pseudosac to Cooper's ligament or anterior abdominal wall to prevent seroma.
The port position and the suturing skill of the surgeon are important:
- Those who perform bilateral TEP repair through three midline ports can use an additional right midclavicular line port for suturing. This technique can be used both in TEP and ttransabdominal pre peritoneal mesh hernioplasty
- The presence of abnormal blood vessels (corona mortis) crossing the Cooper's ligament should be kept in mind while suturing in this area
- The suturing technique – figure of eight – is essential for fixing the sac; a simple suture might not be adequate
- The use of barbed non-absorbable suture can eliminate the burden of tying the knot
- This suturing technique can be particularly beneficial in robotic inguinal hernia repair where suturing is less technically demanding.
| ¤ Conclusion|| |
Primary prevention of seroma in laparoscopic and robotic inguinal hernia repair by fixing the lax pseudosac to the Cooper's ligament using non-absorbable suture is a cheap and reliable method which overcomes the risk of chronic groin pain associated with the use of metal tracks for fixation. However, it is time-consuming and requires good suturing skills. Further studies with a large number of subjects are required to confirm the advantage over existing methods.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]