Medical talc and seroma formation following ventral hernia repair

Abstract

In the current issue, Parameswaran and colleagues discuss the use of medical talc, 8 g in a slurry, for seromadesis. In their retrospective review of a prospectively collected database over a 5-month period, 21 consecutive patients were treated prophylactically with talc in the subcutaneous space. They compared this with outcomes in a previous group of 116 patients who had an aerosolized fibrin sealant sprayed in the subcutaneous space. Furthermore, all patients had an onlay repair with a lightweight polypropylene mesh and the drains were placed in the subcutaneous space for a period of 14 days or until drainage was \50 mL in 24 h. They report a 76 % seroma and a 43 % wound infection rate, and 33 % of patients required an intervention for their seroma. These numbers are significantly higher than any reported previously in the literature. Consequently, they terminated the study early. Ventral hernia repair is one of the most common procedures performed by general surgeons today, with 300,000 performed annually in the United States alone. As herniorrhaphy techniques have progressed, an increasing number of patients are undergoing a component separation and/or concomitant panniculectomy, which require a wide subcutaneous dissection during their ventral hernia repair (OVHR/WSD). These procedures carry a high wound complication rate ranging from 33 to 66 % [1]. In our previously published data, postoperative seromas were the most common postoperative modifiable predictor for wound complications after OVHR. Despite multiple previous efforts to reduce seroma formation in the past, seromas were still seen in up to 50 % of surgeries involving extensive subcutaneous dissection [2, 3]. Talc is a hydrous magnesium silicate that is safe, very efficacious and most commonly used agent in the treatment of malignant or chronic pleural effusions (Cochrane review). We began spraying talc in the subcutaneous space of all OVHR/WSD in January 2009. In July 2011, we published our first study on talc in the subcutaneous space on 74 patients who underwent OVHR/WSD and compared it to 106 previous patients who met inclusion criteria [4]. All patients had dissection out to the anterior axillary line and had placement of the mesh in an underlay fashion either in the pre-peritoneal or retrorectus locations. We demonstrated a significant decrease in seroma interventions (20.8 vs. 2.7 %), cellulitis (39.6 vs. 20.6 %), drain duration (25.6 vs. 14.6 days) and even early hernia recurrence rates (8.5 vs. 0 %). In subsequent studies, we have demonstrated a decrease in pain scores at 1 month as well as renal insufficiency on days 3 and 4 post-op, which may be due to decreased third space fluid loss in the operative field. There are a several differences between the two studies; as Paramaswaran and colleagues point out in their discussion, our 2011 study had the mesh placed in an underlay fashion in 100 % of patients; whereas, the current study looked only at patients with an onlay mesh. While previously we and others have done multiple animal and human studies using talc in different spaces throughout the body, this is the first to our knowledge that adds talc to an interface that includes a prosthetic material thereby perhaps impeding the inflammatory reaction between two vascularized surfaces which may be required for seromadesis. In our original description, talc was only used in patients requiring significant subcutaneous dissection, extending to the anterior axillary line. Given that only 6 of the 21 This comment refers to the article available at doi:10.1007/s10029-013-1097-4.