Seroma and recurrence in laparoscopic ventral hernioplasty

Recurrence after laparoscopic ventral hernioplasty is a severe problem despite surgeons' increased experience in recent years. It is well known that the main reasons for recurrences are lack of experience, bad technique, infection, and seroma. The aim of this study was to investigate the events, what caused recurrences, and the technique to prevent recurrence in laparoscopic ventral hernioplasty.

From May 1996 through December 2005, 78 patients who underwent 80 laparoscopic ventral hernioplasties (67 incisional hernias, 8 large epigastric, 5 large umbilical) were separated into 2 groups. Group A (n=28): ePTFE dual mesh patch secured intraperitoneally by full-thickness stitches and endoscopic tacks to cover the hernia defect and to overlap healthy margins by at least 2.5 cm (n=17, subgroup A1) or 4 cm (n=11, subgroup A2). In subgroup A2, a full-thickness suture was placed in the center of the hernia defect to reduce the "dead space." Group B (n=52): The same technique as in group A, but the hernia sac was cauterized by monopolar cautery (n=5) or Harmonic scalpel (n=47). The overlapping healthy margins were at least 2.5 cm (n=16, subgroup B1) or 4 cm (n=36, subgroup B2). In subgroup B2, a full-thickness suture was placed in the center of the hernia defect to reduce the dead space. Postoperatively, CT-scans were used to confirm complications or recurrences.

In group A, 7 seromas [4 clinical (A1) and 3 subclinical (A1=1, A2=2)], 3 hematomas (A1=2, A2=1), 2 infections (A1), and 3 recurrences (10.7%) were observed (A1=2 or 11.8%, A2=1 or 9%). Two recurrences were observed in symptomatic seromas (subgroup A1) and 1 in a patient without seroma (subgroup A2). In group B, 1 subclinical seroma, 1 hematoma, and 1 recurrence (6.2%) were noted in subgroup B1. In subgroup B2, no recurrence was observed. Significantly fewer total seromas occurred in group B compared with group A (P=0.004). The total recurrence rate in group B was 1.95% (NS vs group A), but a significant difference was observed between subgroups A1 and B2 (P=0.036).

Cauterization of the hernia sac and a central full-thickness suture to reduce dead space seems to prevent seroma. This technique combined with a large patch to cover at least 4 cm of healthy margins and the surgeon's experience may be sufficient to prevent recurrences in laparoscopic ventral hernioplasty.