SJLA_2024_A18: Persistent Complex Seroma Treated by Capsulectomy and Argon Beam Coagulator

Abstract

Background: Seroma formation is one of the most common events following ventral hernia repair. When mesh is used for the repair of larger and more complex incisional hernias, the risk of seroma formation increases. The mesh onlay technique, which requires more extensive dissection, is associated with an even greater incidence of seroma formation. Treatment options for postoperative seromas include observation for spontaneous resolution, percutaneous aspiration, closed suction drainage, abdominal binders, and sclerosant. Methods: The aim of this report is to present a definitive management of a very challenging case of abdominal wall chronic complex seroma following herniorrhaphy with mesh approached by open capsulectomy and scarification of the remnant pseudocapsule. Results: Our patient is a 60 years-old male a status post low anterior resection with covering loop ileostomy for rectal cancer. His diverting stoma was taken off after completing the adjuvant chemotherapy treatment. Seven months later, the patient has developed an enlarging midline incisional hernia. This hernia was subsequently repaired by primary fascial closure with suprafascial onlay polypropylene mesh. Postoperatively, he developed a subcutaneous seroma which was initially treated with an abdominal binder without success. Over the following 3 months of observation, seroma was increasing in size. Discussion: Having recovered his acute condition, surgical intervention was planned. The patient underwent an excision and evacuation of the complex seroma and pseudocapsule. A 12-cm midline incision was made in line with the previous incision used for the hernia repair. The pseudocapsule of the seroma was encountered when the subcutaneous tissue was incised. The incision was carried superior, inferior, and laterally, and the capsule was exposed. The seroma opening sinus was expanded and fluid was evacuated. There were some fibrous dead tissues and coagulated dark blood. The anterior and lateral aspects of the pseudo capsule were excised. Furthermore, the posterior aspect was cleaned carefully using the curettage instrument without affecting the integrity of the mesh which was looking healthy and intact and without causing injury to the intraabdominal contents. Argon beam coagulator was used to scarify the remaining posterior aspect attaching to the mesh. Hemostasis was secured, and the wound was closed over a Jackson–Pratt drain. A pressure dressing and abdominal binder were applied. Conclusion: Factors leading to seroma following incisional herniorrhaphy are poorly understood. Many options are available for treating complicated abdominal wall seroms. capsulectomy and scarification of the remnant pseudocapsule were good option for the treatment of persistence complex seroma.