Repair of large incisional hernias. To drain or not to drain. Randomized clinical trial 1 1 Research performed at Hospital Universitário do Oeste do Paraná (HUOP), Universidade Estadual do Oeste do Paraná (UNIOESTE), Cascavel-PR, Brazil. Part of Master degree thesis, Postgraduate Program in Interdisciplinary Surgical Science, Universidade Federal de São Paulo (UNIFESP). Tutor: Gaspar de Jesus Lopes Filho.

André Pereira Westphalen Allan Cézar Faria Araújo Patrícia Zacharias Eduardo Silva Rodrigues Geanine Baggio Fracaro Gaspar de Jesus Lopes FilhoAbout the authors

ABSTRACT

PURPOSE:

To evaluate the occurrence of seroma and surgical wound infection after surgery.

METHODS:

A total of 42 individuals with large incisional hernias were subjected toonlay mesh repair. Following the mesh placement, the participants were randomly allocated to two groups. In group 1, closed-suction drains were placed in the subcutaneous tissue, while progressive tension sutures were performed in group 2. The participants were subjected to clinical and ultrasound assessment to detect seroma and surgical wound infection at three time-points after surgery.

RESULTS:

The occurrence of seroma at the early, intermediate or late assessments was respectively 19.0%, 47.6%, 52.4% in group 1 and 28.6%, 57.1%, 42.9% in group 2 and was not significantly different between groups (p 0.469; 0.631; 0.619). Surgical wound infection occurred 19% in group 1 and 23.8% in group 2, without a significant difference between the groups (p>0.999).

CONCLUSION:

The frequency of seroma and infection did not exhibit significant differences between individuals subjected to onlay mesh repair of large incisional hernias with drains or progressive tension sutures without drainage.

Key words:
Hernia; Ventral. Seroma; Drainage; Suture Techniques; Herniorrhaphy

Introduction

In three to 26% of the patients subjected to surgical opening and closure of the abdominal wall, closure might fail, followed by late separation of the muscular-aponeurotic layers, which is known as incisional hernia11. Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg. 1985 Jan;72(1):70-1. PMID: 3155634.. Most incisional hernias require surgical repair, which is associated with a high incidence of complications, among which seroma formation and infection stand out22. den Hartog D, Dur AH, Tuinebreijer WE, Kreis RW. Open surgical procedures for incisional hernias. Cochrane Database Syst Rev. 2008 (3):CD006438. PMID: 18646155.. Although drains are placed at the end of surgery as an attempt to prevent such complications, there is no concrete evidence in the literature demonstrating their actual benefits or whether they might actually increase the incidence of infection33. White TJ, Santos MC, Thompson JS. Factors affecting wound complications in repair of ventral hernias. Am Surg. 1998 Mar;64(3):276-80. PMID: 9520825.

4. Kaafarani HM, Hur K, Hirter A, Kim LT, Thomas A, Berger DH, Reda D, Itani KM. Seroma in ventral incisional herniorrhaphy: incidence, predictors and outcome. Am J Surg. 2009 Nov;198(5):639-44. PMID: 19887192.
-55. Kaafarani HM, Kaufman D, Reda D, Itani KM. Predictors of surgical site infection in laparoscopic and open ventral incisional herniorrhaphy. J Surg Res. 2010 Oct;163(2):229-34. PMID: 20605590.. Other techniques are also used to prevent seroma formation, including progressive tension sutures, which are recommended by some authors for abdominoplasty66. Baroudi R, Ferreira CA. Seroma: how to avoid it and how to treat it. Aesthet Surg J. 1998 Nov-Dec;18(6):439-41. PMID: 19328174.

7. Pollock H, Pollock T. Progressive tension sutures: a technique to reduce local complications in abdominoplasty. Plast Reconstr Surg. 2000 Jun;105(7):2583-6; discussion 7-8. PMID: 10845315.
-88. Pollock TA, Pollock H. Progressive tension sutures in abdominoplasty: a review of 597 consecutive cases. Aesthet Surg J.2012 Aug;32(6):729-42. PMID: 22751080.. A Cochrane systematic review on the prophylactic use of drains following incisional herniorrhaphy did not locate any study demonstrating their usefulness99. Gurusamy KS, Allen VB, Samraj K. Wound drains after incisional hernia repair. Cochrane Database Syst Rev.2012;2:CD005570. PMID: 22336814.. We conducted a randomised clinical trial to compare the incidence of seroma and surgical wound infection between patients subjected to large incisional hernia repair by means of the onlay technique, with one group being subjected to the placement of drains, while progressive tension sutures without drains were used in a second group.

Methods

The present randomised clinical trial was approved by the research ethics committees of School of Medicine, Universidade Federal de São Paulo (UNIFESP), Universidade Estadual do Oeste do Paraná (UNIOESTE) and Hospital Universitário do Oeste do Paraná (HUOP) in compliance with the 1964 Declaration of Helsinki and later updates.

The study design and randomisation followed the Consolidated Standards of Reporting Trials (CONSORT) version 20101010. Schulz KF, Altman DG, Moher D, Group C. CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med. 2010 Jun 1;152(11):726-32. PMID: 20335313..

The study was register in clinicaltrials.gov public site with the identifier NCT02163460.

All the participants read and signed an informed consent form during the preoperative assessment visit.

Inclusion and exclusion criteria

Individuals with primary or recurrent incisional hernia were assessed at HUOP, and those with longitudinal or transverse ventral hernia secondary to a previous surgical incision, measuring 5 to 15 cm after dissection of the hernial sac and classified as large or very large according to Chevrel's classification, were considered to be eligible1111. Chevrel JP, Rath AM. Classification of incisional hernias of the abdominal wall. Hernia. 2000;(4):7-11.. In individuals with multiple defects, the length between the cranial margin of the most cranial defect and the caudal margin of the most caudal defect was considered1212. Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, Dietz UA, Eker HH, El Nakadi I, Hauters P, Hidalgo Pascual M, Hoeferlin A, Klinge U, Montgomery A, Simmermacher RK, Simons MP, Smietański M, Sommeling C, Tollens T, Vierendeels T, Kingsnorth A. Classification of primary and incisional abdominal wall hernias.. Hernia 2009 Aug;13(4):407-14. PMID: 19495920.. Individuals subjected to emergency surgery, with infection, immunosuppressed, younger than 18 or older than 80 years old, ASA III or IV, with a serum albumin concentration lower than 3.0 g/dl or who refused participation were excluded from the study.

Surgical technique

The participants were admitted to the hospital the night before surgery to perform or update the assessment of their surgical risk according to the American Society of Anesthesiologists (ASA) criteria, as well as for measurement of the serum albumin concentration.

Incisional herniorrhaphy surgery was performed following the group's technique systematisation by a resident physician supervised by one of four surgeons professors at the medical course of UNIOESTE and who the using the onlay technique as described by Chevrel1313. Chevrel JP, Rath AM. The use of fibrin glues in the surgical treatment of incisional hernias.. Hernia 1997;1(1):9-14.,1414. Licheri S, Erdas E, Pisano G, Garau A, Ghinami E, Pomata M. Chevrel technique for midline incisional hernia: still an effective procedure.. Hernia 2008 Apr;12(2):121-6. PMID: 17972008.. Antibiotic prophylaxis was performed with a single 2g dose of cefazolin at the time of anaesthetic induction followed by a booster 1g dose when the surgery lasted more than three hours.

The aponeurosis was dissected 5 cm beyond the aponeurotic defect. After dissection, the greater thickness of subcutaneous fat was measured with sterile ruler. Recorded the longitudinal and transverse measurements of the aponeurotic defect and was calculated its area by the formula of the ellipse. Approximation of the aponeurotic margins for midline reconstruction was performed using polyglactin 910 #1 sutures. Tension was relieved by releasing incisions performed on the external oblique muscle aponeurosis, 3 cm away from the linea alba, as described by Gibson1515. Gibson CL. Operation for cure of large ventral hernia. Ann Surg. 1920 Aug;72(2):214-7. PMID: 17864331.. A macroporous polypropylene monofilament P1 mesh of 100 g/m2(Cousin Biotec) was fixed on the aponeurosis by separate 2-0 polypropylene sutures performed every 2 cm.

The participants were randomised immediately after mesh fixation by a computer-based random number generator and allocated to the two intervention groups.

Interventions

In group 1, a 4.8 mm diameter continuous closed-suction tubular drain (Medsharp Ind. Com. Prod. Hosp. Ltda - Ministério da Saúde: 80267170001) was placed between the aponeurosis and the subcutaneous tissue caudally to the incision. Next, the subcutaneous tissue approximation was performed with separate absorbable 2-0 polyglactin 910 sutures.

Drains were not used in group 2, but separate absorbable 2-0 polyglactin 910 sutures were placed from the subcutaneous mesh to the aponeurosis every 2 cm by means of the progressive tension suture (or Quilting Sutures) technique, as described by Pollock et al.77. Pollock H, Pollock T. Progressive tension sutures: a technique to reduce local complications in abdominoplasty. Plast Reconstr Surg. 2000 Jun;105(7):2583-6; discussion 7-8. PMID: 10845315.,88. Pollock TA, Pollock H. Progressive tension sutures in abdominoplasty: a review of 597 consecutive cases. Aesthet Surg J.2012 Aug;32(6):729-42. PMID: 22751080.. The flap is advanced with the surgeon's nondominant hand while 2-0 polyglactin 910 sutures are placed from the subcutaneous fat to the aponeurosis. The assistant then stabilizes the flap in place while the surgeon ties the suture. The process of advancement and suture placement are initially placed in the flap lateral side edge, is repeated on lines each 2cm up to midline. This process minimize the dead space and and stabilizes the flap.

Skin closure was performed with simple separate sutures at 1 cm intervals using 4-0 nylon monofilament suture in both groups. Before closing, the skin excess and the previous scar was removed.

The participants were requested to use the support girdles provided by the surgical staff at the hospital and at home during the first 30 days after surgery.

In group 1, the drains were removed when the drained volume was less than 40 ml/24 hours.

Outcomes

All the participants were clinically assessed by the attending staff to detect postoperative complications, seroma formation and surgical site infection, especially on postoperative (PO) days one, three, five, seven, 14-16 and 29-31. The data were recorded on a pre-established form.

All the participants were subjected to abdominal wall ultrasound to assess seroma formation at three time points defined as: early (PO days four to six), intermediate (PO days 14 to 16) and late (PO days 29 to 31). The tests were performed by the radiology staff at HUOP. Seroma was defined as the collection of any volume of subcutaneous fluid without debris. All the participants remained in the hospital until the first ultrasound assessment was performed. The presence of seroma was considered as the main outcome. Clinical seroma was defined as a visible bulge or fluctuation without signs of infection, subclinical seroma was defined as the absence of detectable abnormalities on physical examination but the presence of any volume of fluid collection on abdominal wall ultrasound, and seroma was defined as all occurrences of fluid collection detected on ultrasound.

Surgical wound infection was prospectively defined according to the criteria formulated by the Centers for Disease Control and Prevention (CDC) in the Guideline for Prevention of Surgical Site Infection, 19991616. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999 Apr;20(4):250-78; quiz 79-80. PMID: 10219875..

Sample size calculation

The sample size was calculated based on significance level alpha = 5% and 80% power. A two-tailed test for the comparison of the two proportions was used to compare the occurrence of seroma between the groups with drains (50.0%) or progressive tension sutures (10.0%). These references reflect the incidence of seroma in the literature with these techniques in case series and clinical trials and that we considered clinically relevant44. Kaafarani HM, Hur K, Hirter A, Kim LT, Thomas A, Berger DH, Reda D, Itani KM. Seroma in ventral incisional herniorrhaphy: incidence, predictors and outcome. Am J Surg. 2009 Nov;198(5):639-44. PMID: 19887192.,88. Pollock TA, Pollock H. Progressive tension sutures in abdominoplasty: a review of 597 consecutive cases. Aesthet Surg J.2012 Aug;32(6):729-42. PMID: 22751080.,1717. Klink CD, Binnebosel M, Lucas AH, Schachtrupp A, Klinge U, Schumpelick V, Junge K. Do drainage liquid characteristics serve as predictors for seroma formation after incisional hernia repair?. Hernia 2010 Apr;14(2):175-9. PMID: 19998048..

Statistics

The initial statistical analysis of all the data collected in the present study was descriptive. In regard to the quantitative (numerical) variables, summary measures including mean, standard deviation, median, maximum and minimum values were calculated, and one-dimensional scatterplots were constructed. The data corresponding to the qualitative (categorical) variables were assessed as absolute and relative (percent) frequencies.

Inferential analysis was performed to confirm or refute the evidence found in the descriptive analysis. For that purpose, Student's t-test for independent samples was used to compare the groups of participants.

In the inferential analysis, the significance level (α) was established as 5%. The statistical analyses were performed using software R version 2.15.2.

Results

A total of 42 individuals with large incisional hernias were subjected to incisional herniorrhaphy, by the technique standardized by Chevrel, at HUOP - UNIOESTE from May to December 2012. In the sample, 10 (23.8%) were recurrent hernias, seven of whom had one previous repair. The other three patients had three previous surgeries each. Patients with recurrent hernias had a 30% postoperative infection rate against 18.75% in the non-recurrent. The incidence of postoperative seroma was 80% in recurrent hernias and 62.5% for non-recurrent hernias. There was no significant difference between the cases recurrent or non- recurrent in the development of seroma (p=0.451) or postoperative infection (p=0.660).

The participants were randomised to receive subcutaneous drainage or progressive tension sutures. There was no loss of follow-up and all cases were analysed. No participant died or exhibited recurrence of hernia along the 30-day postoperative follow-up.

The average time elapsed from hernia diagnosis to surgery was 42 months, varying from three to 300 months.

Only five patients required relaxing incisions, two from group 1 and three from group 2.

The average body mass index (BMI) of the sample was 30.69 kg/m2, varying from 19.5 to 44.13 kg/m2.

The results of the inferential comparison show that both group 1 (drains) and group 2 (progressive tension sutures) exhibited the same profile (Table 1).

TABLE 1
Distribution of the participants' general characteristics per intervention group.

The groups did not differ as to the presence of seroma at the early, intermediate or late postoperative assessments (Table 2).

TABLE 2
Distribution of the hernia characteristics according to surgical procedure.

A total of 22 participants (52.4%) exhibited seroma at the intermediate ultrasound assessment but only two of them developed surgical wound infection, which was detected at the late assessment. Five participants exhibited symptoms that required drainage of the seromas. In 15 participants, resorption of the fluid collection occurred without any need of intervention in up to 90 days.

From the 22 seromas detected at the intermediate assessment, 14 (63.6%) were ultrasound findings, and eight (36.4%) were found on both ultrasound and clinical examination.

Five seromas were detected at the late ultrasound assessment only and were not accompanied by clinical changes. Five cases of seroma detected at the intermediate assessment exhibited resorption of fluid collection before the late assessment.

All participants of the study, regardless using or not drains, were divided according to the presence or not of seroma at early, intermediate and late assessments, and were analysed according to several variables: use of drains, gender, age, BMI classification, cardiac risk, hernia size, subcutaneous fat thickness and surgical time. No significant differences were found between participants with and without seromas, except for shorter surgical time in the participants who exhibited seroma at the intermediate assessment (p=0.011).

Nine participants (21.4%) exhibited surgical wound infection at up to 30 days after surgery. The occurrence of surgical wound infection did not exhibit a difference between the groups (Table 3).

TABLE 3
Distribution of the participants' general characteristics according to occurrence of infection until postoperative day 30.

One participant required mesh removal. The results of the univariate analysis showed that the occurrence of surgical wound infection within up to 30 days after surgery was not associated with the use of drains (p>0.999), gender (p=0.695), age (p=0.815), BMI classification (p=0.676), cardiac risk (p=0.422), hernia size (p=0.181), subcutaneous fat thickness (p>0.999), smoking (p=0.181), recurrent hernia(p=0.660) or surgical time (p=0.055) (Table 3).

Discussion

Incisional hernia repair still poses a challenge to surgeons as a function of its high rate of complications, among which seroma and surgical wound infection stand out22. den Hartog D, Dur AH, Tuinebreijer WE, Kreis RW. Open surgical procedures for incisional hernias. Cochrane Database Syst Rev. 2008 (3):CD006438. PMID: 18646155.. Those complications occur due to the considerable amount of subcutaneous tissue that is detached in herniorrhaphy using the onlay technique and are more frequent among obese patients, which corresponded to most of the participants in the present study. Obesity represents a risk factor for hernia, as well as for repair complications1818. Lau B, Kim H, Haigh PI, Tejirian T. Obesity increases the odds of acquiring and incarcerating noninguinal abdominal wall hernias. Am Surg.2012 Oct;78(10):1118-21. PMID: 23025954.. Obesity is the main contraindication to hernia surgical repair, according to the survey of surgeons conducted by Evans in the United States, for which reason most such patients are referred for surgical treatment at reference centres1919. Evans KK, Chim H, Patel KM, Salgado CJ, Mardini S. Survey on ventral hernias: surgeon indications, contraindications, and management of large ventral hernias. Am Surg.2012 Apr;78(4):388-97. PMID: 22472393..

The most widely mentioned mechanisms for seroma formation are blood and lymphatic vessel injury during dissection, dead-space formation, shear forces among layers and the release of inflammatory mediators. In the case of incisional herniorrhaphy, the presence of a routinely used strange body, i.e., the mesh, is added to those factors2020. Klinge U, Klosterhalfen B, Muller M, Schumpelick V. Foreign body reaction to meshes used for the repair of abdominal wall hernias. Eur J Surg. 1999 Jul;165(7):665-73. PMID: 10452261.. Despite this evidence, previous surgeries fibrosis and foreign bodies (suture remains, mesh) present in patients with recurrent hernias in our sample did not correlate with the formation of postoperative seroma or infection, perhaps the sample size was not calculated for this purpose.

The most widely used procedure to prevent seroma formation consists of the placement of drains in the subcutaneous tissue; however, several studies indicated that drains not only fail to prevent seroma formation but may even increase the risk of infection33. White TJ, Santos MC, Thompson JS. Factors affecting wound complications in repair of ventral hernias. Am Surg. 1998 Mar;64(3):276-80. PMID: 9520825.,44. Kaafarani HM, Hur K, Hirter A, Kim LT, Thomas A, Berger DH, Reda D, Itani KM. Seroma in ventral incisional herniorrhaphy: incidence, predictors and outcome. Am J Surg. 2009 Nov;198(5):639-44. PMID: 19887192.. A Cochrane review on this subject did not find any evidence demonstrating a benefit of the use of drains99. Gurusamy KS, Allen VB, Samraj K. Wound drains after incisional hernia repair. Cochrane Database Syst Rev.2012;2:CD005570. PMID: 22336814..

The fixation of the subcutaneous tissue to aponeurosis, which seemingly reduces the dead space and minimises the shear forces, was originally described by Baroudi and Ferreira in 19986. Baroudi R, Ferreira CA. Seroma: how to avoid it and how to treat it. Aesthet Surg J. 1998 Nov-Dec;18(6):439-41. PMID: 19328174. for abdominoplasty without drainage66. Baroudi R, Ferreira CA. Seroma: how to avoid it and how to treat it. Aesthet Surg J. 1998 Nov-Dec;18(6):439-41. PMID: 19328174.. Further detail was added by Pollock7, and the technique was then reproduced by others21-23. In 20128. Pollock TA, Pollock H. Progressive tension sutures in abdominoplasty: a review of 597 consecutive cases. Aesthet Surg J.2012 Aug;32(6):729-42. PMID: 22751080., Janis, from the University of Texas, suggested to using the progressive tension suture technique in large incisional herniorrhaphy procedures2424. Janis JE. Use of progressive tension sutures in components separation: merging cosmetic surgery techniques with reconstructive surgery outcomes. Plast Reconstr Surg.2012 Oct;130(4):851-5. PMID: 23018696.. Some authors, such as Birolini C, highlights the importance of fixing the mesh to the aponeurosis with running sutures of absorbable polyglactin to prevent the formation of dead space and complications2525. Birolini C, de Miranda JS, Utiyama EM, Rasslan S. A retrospective review and observations over a 16-year clinical experience on the surgical treatment of chronic mesh infection. What about replacing a synthetic mesh on the infected surgical field?. Hernia 2015 Apr;19(2):239-46. PMID: 24509890..

In the present study, the frequency of seroma formation did not exhibit significant difference between the groups, and most seromas were detected at the intermediate assessment when all the drains had already been removed. These findings agree with the results reported by other authors, according to which the peak incidence of seroma formation occurs approximately two weeks after surgery, when prophylactic drains would be useless66. Baroudi R, Ferreira CA. Seroma: how to avoid it and how to treat it. Aesthet Surg J. 1998 Nov-Dec;18(6):439-41. PMID: 19328174.,2121. Nahas FX, Ferreira LM, Ghelfond C. Does quilting suture prevent seroma in abdominoplasty? Plast Reconstr Surg.2007 Mar;119(3):1060-4; discussion 5-6. PMID: 17312514.,2626. Borile G, Pavelecini M, Dreher R, Chem E, Chem RC. The use of suction drains in abdominal dermolipectomy: a randomized clinical trial. Plast Reconstr Surg.2008 Apr;121(4):228e-9e. PMID: 18349614.. In the present study, many seromas were detected by ultrasound only (63.4%), which was expected, as most participants were obese, which makes their physical examination more difficult, and the fluid collections were small. A similar frequency was reported by Tsimoyiannis and Klink, who also performed ultrasound assessment1717. Klink CD, Binnebosel M, Lucas AH, Schachtrupp A, Klinge U, Schumpelick V, Junge K. Do drainage liquid characteristics serve as predictors for seroma formation after incisional hernia repair?. Hernia 2010 Apr;14(2):175-9. PMID: 19998048.,2727. Tsimoyiannis EC, Siakas P, Glantzounis G, Koulas S, Mavridou P, Gossios KI. Seroma in laparoscopic ventral hernioplasty. Surg Laparosc Endosc Percutan Tech. 2001 Oct;11(5):317-21. PMID: 11668229..

The incidence of seroma at the intermediate postoperative assessment was 52.4%. The data in the literature exhibit wide variation ranging from 0% to 100% as a function of the definition of seroma, the diagnostic methods and experimental design employed in the various studies. In the present study, the vast majority of the seromas did not exhibit clinical repercussion and were resorbed within 90 days without sequelae, while only 22.7% of the cases required some intervention.

The occurrence of surgical wound infection was high in the present sample (21.4%) and did not correlate with any of the assessed variables, nor did its incidence exhibit significant difference between the groups. That lack of correlation and differences might have been due to beta error, as the sample size had not been calculated for that outcome. In the study by Memmon2828. Memon AA, Khan A, Zafar H, Murtaza G, Zaidi M. Repair of large and giant incisional hernia with onlay mesh: perspective of a tertiary care hospital of a developing country. Int J Surg. 2013;11(1):41-5. PMID: 23178155., the incidence of infection among individuals with a profile similar to that of the participants in the present study and subjected to the same surgical procedure was 21.67%. Most studies that reported on the occurrence of infection did not explain how the diagnosis was performed, and most of them are retrospective studies. For those reasons, we believe that our results exhibit less bias and are closer to the real situation in large surgical procedures performed with the onlay technique. In the study conducted by Barbaros29 in 200729. Barbaros U, Asoglu O, Seven R, Erbil Y, Dinccag A, Deveci U, Ozarmagan S, Mercan S. The comparison of laparoscopic and open ventral hernia repairs: a prospective randomized study.. Hernia 2007 Feb;11(1):51-6. PMID: 17131072., the incidence of infection was reported as 0%; however, the mesh had to be removed in 17.3% of the cases, which can only be justified by the occurrence of infection. In a prospective randomised clinical trial, Misra3030. Misra MC, Bansal VK, Kulkarni MP, Pawar DK. Comparison of laparoscopic and open repair of incisional and primary ventral hernia: results of a prospective randomized study. Surg Endosc. 2006 Dec;20(12):1839-45. PMID: 17063290. detected infection in 33% of the patients subjected to the onlay technique. In some retrospective case-series, the reported incidence of infection was 0%, which we believe not to be possible in this group of patients13. As a function of the discrepancy among the data available in the literature, we suggest that all studies employ the CDC criteria for the diagnosis of infection in a prospective manner1616. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999 Apr;20(4):250-78; quiz 79-80. PMID: 10219875..

Conclusions

There was no significant difference in the incidence of seroma formation or surgical wound infection between the individuals who underwent placement of continuous suction drains in the subcutaneous tissue and those treated with the progressive tension suture technique. The incidence of both complications was high, and thus novel surgical techniques should be investigated for their prevention.

Acknowledgement

To Prof. Délcio Mattos, UNIFESP.

References

  • 1
    Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg. 1985 Jan;72(1):70-1. PMID: 3155634.
  • 2
    den Hartog D, Dur AH, Tuinebreijer WE, Kreis RW. Open surgical procedures for incisional hernias. Cochrane Database Syst Rev. 2008 (3):CD006438. PMID: 18646155.
  • 3
    White TJ, Santos MC, Thompson JS. Factors affecting wound complications in repair of ventral hernias. Am Surg. 1998 Mar;64(3):276-80. PMID: 9520825.
  • 4
    Kaafarani HM, Hur K, Hirter A, Kim LT, Thomas A, Berger DH, Reda D, Itani KM. Seroma in ventral incisional herniorrhaphy: incidence, predictors and outcome. Am J Surg. 2009 Nov;198(5):639-44. PMID: 19887192.
  • 5
    Kaafarani HM, Kaufman D, Reda D, Itani KM. Predictors of surgical site infection in laparoscopic and open ventral incisional herniorrhaphy. J Surg Res. 2010 Oct;163(2):229-34. PMID: 20605590.
  • 6
    Baroudi R, Ferreira CA. Seroma: how to avoid it and how to treat it. Aesthet Surg J. 1998 Nov-Dec;18(6):439-41. PMID: 19328174.
  • 7
    Pollock H, Pollock T. Progressive tension sutures: a technique to reduce local complications in abdominoplasty. Plast Reconstr Surg. 2000 Jun;105(7):2583-6; discussion 7-8. PMID: 10845315.
  • 8
    Pollock TA, Pollock H. Progressive tension sutures in abdominoplasty: a review of 597 consecutive cases. Aesthet Surg J.2012 Aug;32(6):729-42. PMID: 22751080.
  • 9
    Gurusamy KS, Allen VB, Samraj K. Wound drains after incisional hernia repair. Cochrane Database Syst Rev.2012;2:CD005570. PMID: 22336814.
  • 10
    Schulz KF, Altman DG, Moher D, Group C. CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med. 2010 Jun 1;152(11):726-32. PMID: 20335313.
  • 11
    Chevrel JP, Rath AM. Classification of incisional hernias of the abdominal wall. Hernia. 2000;(4):7-11.
  • 12
    Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, Dietz UA, Eker HH, El Nakadi I, Hauters P, Hidalgo Pascual M, Hoeferlin A, Klinge U, Montgomery A, Simmermacher RK, Simons MP, Smietański M, Sommeling C, Tollens T, Vierendeels T, Kingsnorth A. Classification of primary and incisional abdominal wall hernias.. Hernia 2009 Aug;13(4):407-14. PMID: 19495920.
  • 13
    Chevrel JP, Rath AM. The use of fibrin glues in the surgical treatment of incisional hernias.. Hernia 1997;1(1):9-14.
  • 14
    Licheri S, Erdas E, Pisano G, Garau A, Ghinami E, Pomata M. Chevrel technique for midline incisional hernia: still an effective procedure.. Hernia 2008 Apr;12(2):121-6. PMID: 17972008.
  • 15
    Gibson CL. Operation for cure of large ventral hernia. Ann Surg. 1920 Aug;72(2):214-7. PMID: 17864331.
  • 16
    Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999 Apr;20(4):250-78; quiz 79-80. PMID: 10219875.
  • 17
    Klink CD, Binnebosel M, Lucas AH, Schachtrupp A, Klinge U, Schumpelick V, Junge K. Do drainage liquid characteristics serve as predictors for seroma formation after incisional hernia repair?. Hernia 2010 Apr;14(2):175-9. PMID: 19998048.
  • 18
    Lau B, Kim H, Haigh PI, Tejirian T. Obesity increases the odds of acquiring and incarcerating noninguinal abdominal wall hernias. Am Surg.2012 Oct;78(10):1118-21. PMID: 23025954.
  • 19
    Evans KK, Chim H, Patel KM, Salgado CJ, Mardini S. Survey on ventral hernias: surgeon indications, contraindications, and management of large ventral hernias. Am Surg.2012 Apr;78(4):388-97. PMID: 22472393.
  • 20
    Klinge U, Klosterhalfen B, Muller M, Schumpelick V. Foreign body reaction to meshes used for the repair of abdominal wall hernias. Eur J Surg. 1999 Jul;165(7):665-73. PMID: 10452261.
  • 21
    Nahas FX, Ferreira LM, Ghelfond C. Does quilting suture prevent seroma in abdominoplasty? Plast Reconstr Surg.2007 Mar;119(3):1060-4; discussion 5-6. PMID: 17312514.
  • 22
    Bercial ME, Sabino Neto M, Calil JA, Rossetto LA, Ferreira LM. Suction drains, quilting sutures, and fibrin sealant in the prevention of seroma formation in abdominoplasty: which is the best strategy? Aesthetic Plast Surg. 2012 Apr;36(2):370-3. PMID: 21858593.
  • 23
    Andrades P, Prado A, Danilla S, Guerra C, Benitez S, Sepulveda S, Sciarraffia C, De Carolis V. Progressive tension sutures in the prevention of postabdominoplasty seroma: a prospective, randomized, double-blind clinical trial. Plast Reconstr Surg.2007 Sep 15;120(4):935-46; discussion 47-51. PMID: 17805122.
  • 24
    Janis JE. Use of progressive tension sutures in components separation: merging cosmetic surgery techniques with reconstructive surgery outcomes. Plast Reconstr Surg.2012 Oct;130(4):851-5. PMID: 23018696.
  • 25
    Birolini C, de Miranda JS, Utiyama EM, Rasslan S. A retrospective review and observations over a 16-year clinical experience on the surgical treatment of chronic mesh infection. What about replacing a synthetic mesh on the infected surgical field?. Hernia 2015 Apr;19(2):239-46. PMID: 24509890.
  • 26
    Borile G, Pavelecini M, Dreher R, Chem E, Chem RC. The use of suction drains in abdominal dermolipectomy: a randomized clinical trial. Plast Reconstr Surg.2008 Apr;121(4):228e-9e. PMID: 18349614.
  • 27
    Tsimoyiannis EC, Siakas P, Glantzounis G, Koulas S, Mavridou P, Gossios KI. Seroma in laparoscopic ventral hernioplasty. Surg Laparosc Endosc Percutan Tech. 2001 Oct;11(5):317-21. PMID: 11668229.
  • 28
    Memon AA, Khan A, Zafar H, Murtaza G, Zaidi M. Repair of large and giant incisional hernia with onlay mesh: perspective of a tertiary care hospital of a developing country. Int J Surg. 2013;11(1):41-5. PMID: 23178155.
  • 29
    Barbaros U, Asoglu O, Seven R, Erbil Y, Dinccag A, Deveci U, Ozarmagan S, Mercan S. The comparison of laparoscopic and open ventral hernia repairs: a prospective randomized study.. Hernia 2007 Feb;11(1):51-6. PMID: 17131072.
  • 30
    Misra MC, Bansal VK, Kulkarni MP, Pawar DK. Comparison of laparoscopic and open repair of incisional and primary ventral hernia: results of a prospective randomized study. Surg Endosc. 2006 Dec;20(12):1839-45. PMID: 17063290.

  • Financial source: CAPES
  • 1
    Research performed at Hospital Universitário do Oeste do Paraná (HUOP), Universidade Estadual do Oeste do Paraná (UNIOESTE), Cascavel-PR, Brazil. Part of Master degree thesis, Postgraduate Program in Interdisciplinary Surgical Science, Universidade Federal de São Paulo (UNIFESP). Tutor: Gaspar de Jesus Lopes Filho.

Publication Dates

  • Publication in this collection
    Dec 2015

History

  • Received
    13 Aug 2015
  • Reviewed
    15 Oct 2015
  • Accepted
    19 Nov 2015
Sociedade Brasileira para o Desenvolvimento da Pesquisa em Cirurgia Al. Rio Claro, 179/141, 01332-010 São Paulo SP Brazil, Tel./Fax: +55 11 3287-8814 - São Paulo - SP - Brazil
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