The effect of TISSEEL fibrin sealant on seroma formation following complex abdominal wall hernia repair: a single institutional review and derived cost analysis

Sticking to What Matters: A Matched Comparative Study of Fibrin Glue and Mechanical Fixation for Split-Thickness Skin Grafts in the Lower Extremity

Background: Split-thickness skin grafts (STSGs) remain a valuable tool in the reconstructive surgeons' armamentarium. Staple or suture mechanical fixation (MF) serves as the gold standard of care, though fibrin glue (FG) has gained popularity as a fixation modality. We compare STSG outcomes following application of FG versus MF through a study of lower extremity wounds. Methods: A retrospective review (2016-2019) of patients who underwent a STSG was performed. Two cohorts consisting of patients undergoing a STSG with FG or MF (suture or staple) were matched according to wound size, wound location, and body mass index. Results: A total of 67 patients with 79 wounds were included (FG: n = 30, wounds = 39; MF: n = 37; wounds = 40). There was no significant difference between groups regarding time to 100% graft take (FG: 39 days, MF: 35.1 days; P < .384) or 180-day graft complications (FG: 10.3%, MF: 15%; P < .737). Adjusted operative time for FG (51.8 min) was lower than for MF cases (67.5 min) at a level that approached significance (P < .094). FG patients were significantly less likely to require a postoperative wound vacuum-assisted closure (VAC) (FG: 16.7%; MF: 76.7%; P < .001) and required a significantly lower number of 30-day postoperative visits (FG: 1.5 ± .78 visits; MF: 2.5 ± .03 visits; P < .001). The MF group had higher mean aggregate charges ($211,090) compared with the FG group (mean: $149,907), although these were not statistically significant (P > .05). Conclusion: The use of FG for STSG shows comparable clinical outcomes to MF, with a significantly decreased need for postoperative wound VAC, the number of 30-day postoperative visits, and a lower wound-adjusted operative time.

Bioglass/ceria nanoparticle hybrids for the treatment of seroma: a comparative long-term study in rats

Background: Seroma formation is a common postoperative complication. Fibrin-based glues are typically employed in an attempt to seal the cavity. Recently, the first nanoparticle (NP)-based treatment approaches have emerged. Nanoparticle dispersions can be used as tissue glues, capitalizing on a phenomenon known as 'nanobridging'. In this process, macromolecules such as proteins physically adsorb onto the NP surface, leading to macroscopic adhesion. Although significant early seroma reduction has been shown, little is known about long-term efficacy of NPs. The aim of this study was to assess the long-term effects of NPs in reducing seroma formation, and to understand their underlying mechanism. Methods: Seroma was surgically induced bilaterally in 20 Lewis rats. On postoperative day (POD) 7, seromas were aspirated on both sides. In 10 rats, one side was treated with NPs, while the contralateral side received only NP carrier solution. In the other 10 rats, one side was treated with fibrin glue, while the other was left untreated. Seroma fluid, blood and tissue samples were obtained at defined time points. Biochemical, histopathological and immunohistochemical assessments were made. Results: NP-treated sides showed no macroscopically visible seroma formation after application on POD 7, in stark contrast to the fibrin-treated sides, where 60% of the rats had seromas on POD 14, and 50% on POD 21. At the endpoint (POD 42), sides treated with nanoparticles (NPs) exhibited significant macroscopic differences compared to other groups, including the absence of a cavity, and increased fibrous adhesions. Histologically, there were more macrophage groupings and collagen type 1 (COL1) deposits in the superficial capsule on NP-treated sides. Conclusion: NPs not only significantly reduced early manifestations of seroma and demonstrated an anti-inflammatory response, but they also led to increased adhesion formation over the long term, suggesting a decreased risk of seroma recurrence. These findings highlight both the adhesive properties of NPs and their potential for clinical therapy.

The European Hernia Society Prehabilitation Project: A Systematic Review of Intra-Operative Prevention Strategies for Surgical Site Occurrences in Ventral Hernia Surgery

Background

Ventral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, pre- and intra-operative strategies have received increasing focus in recent years. To assess possible preventive surgical strategies, this European Hernia Society endorsed project was launched. The aim of this review was to evaluate the current literature focusing on pre- and intra-operative strategies for surgical site occurrences (SSO) and specifically surgical site infection (SSI) in ventral hernia repair.

Methods

A systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases used were Pubmed and Web of Science. Original retrospective or prospective human adult studies describing at least one intra-operative intervention to reduce SSO after ventral hernia repair were considered eligible.

Results

From a total of 4775 results, a total of 18 papers were considered suitable after full text reading. Prehospital chlorhexidine gluconate (CHG) scrub appears to increase the risk of SSO in patients undergoing ventral hernia repair, while there is no association between any type of surgical hat worn and the incidence of postoperative wound events. Intraoperative measures as prophylactic negative pressure therapy, surgical drain placement and the use of quilt sutures seem beneficial for decreasing the incidence of SSO and/or SSI. No positive effect has been shown for antibiotic soaking of a synthetic mesh, nor for the use of fibrin sealants.

Conclusion

This review identified a limited amount of literature describing specific preventive measures and techniques during ventral hernia repair. An advantage of prophylactic negative pressure therapy in prevention of SSI was observed, but different tools to decrease SSIs and SSOs continuously further need our full attention to improve patient outcomes and to lower overall costs.

Three-Year Clinical Outcomes and Quality of Life after Retromuscular Resorbable Mesh Repair Using Fibrin Glue

BACKGROUND

With 400,000 hernias repaired annually, there is a need for development of efficient and effective repair techniques. Previously, the authors' group compared perioperative outcomes and hospital costs of patients undergoing ventral hernia repair with retromuscular mesh using suture fixation versus fibrin glue. This article reports on 3-year postoperative outcomes, including hernia recurrence, long-term clinical outcomes, and patient-reported quality of life.

METHODS

Patients who underwent ventral hernia repair performed by a single surgeon between 2015 to 2017 were identified. Patients with retromuscular resorbable mesh placed were included and matched by propensity score. Primary outcomes included hernia recurrence, surgical-site infection, surgical-site occurrence, and surgical-site occurrence/surgical-site infection requiring procedural interventions. Secondary outcomes included quality of life as assessed by the Hernia-Related Quality of Life Survey.

RESULTS

Sixty-three patients were eligible, and 46 patients were matched (23 suture fixation and 23 fibrin glue), with a median age of 62 years, a median body mass index of 29 kg/m2, and a median defect size of 300 cm2 (interquartile range, 180 to 378 cm2). Median follow-up was 36 months (interquartile range, 31 to 36 months). There was no difference in the incidence of hernia recurrence (13.0 percent for suture fixation and 8.7 percent for fibrin glue; p = 0.636) or other postoperative outcomes between techniques (all p > 0.05). Five patients required reoperation because of a complication (10.9 percent). Overall quality of life improved preoperatively to postoperatively at all time points (all p < 0.05), and no differences in quality-of-life improvement were seen between techniques (p > 0.05).

CONCLUSION

Ventral hernia repair with atraumatic resorbable retromuscular mesh fixation using fibrin glue demonstrates equivalent postoperative clinical and quality-of-life outcomes when compared to mechanical suture fixation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Open epidural blood patch to augment durotomy repair in lumbar spine surgery: surgical technique and cohort study

BACKGROUND CONTEXT

Incidental durotomy during elective spine surgery is relatively common. While usually benign and self-limited, it can be associated with morbidity, increased cost, and medicolegal ramifications. Dural repair typically involves performing a primary closure using a suture or dural staple; repairs are then frequently augmented with a sealant, patch, or fat/fascial graft. Although primary repair of an incidental durotomy is standard practice, the ideal secondary sealant or augment choice remains unclear. A wide variety of commercially available dural sealant options exist, and while none have demonstrated consistent superiority, all are associated with single-use costs in the hundreds to thousands of dollars and have concerns regarding swelling, local inflammation, or short-lived dural adherence.

PURPOSE

The goal of this study is to compare the results of dural repair augmentation using an open intraoperative epidural blood patch to a hydrogel technique.

STUDY DESIGN/SETTING

Retrospective comparative cohort study at an academic referral center PATIENT SAMPLE: Adult patients undergoing lumbar spine surgery from March 2017 to January 2021 who sustained an incidental durotomy. Patients undergoing surgery for infection were excluded.

OUTCOME MEASURES

The primary outcome was failure of the repair as determined by a return to the operating room for re-exploration of a persistent cerebrospinal fluid (CSF) leak within 30 days of the index procedure. A secondary outcome was the incidence of a postoperative positional headache, and if present, the method used to obtain resolution. The primary predictor was use of a suture and hydrogel technique ("hydrogel" group), or the use of an epidural blood patch ("EBP" group).

METHODS

The method for applying an open epidural blood patch is presented in detail and involves primarily repairing the durotomy followed by allowing whole blood to pool and clot in the operative field until the durotomy is completely covered. This was compared with a group of patients undergoing secondary augmentation with commercially available hydrogel. In both groups, mechanical resistance to CSF leakage was confirmed with direct visualization and a Valsalva maneuver, respectively. Patients were instructed to remain flat until the morning after surgery. Chart review was used for data abstraction on preoperative, demographic, perioperative, and postoperative clinical factors. To compare between the hydrogel and EBP group, Wilcoxon rank-sum testing was used to test for non-parametric comparisons of means, and chi-square testing between binomial data.

RESULTS

Of 732 patients during the study period, forty-eight patients met study criteria. Twenty-five patients were in the hydrogel group and 23 in the EBP group. Mean age was 69.3 years (standard error 1.3 years). Patients were predominantly female (n = 31, 64.6%) with a mean BMI of 29.5 (SE 0.8), with no significant baseline differences between the hydrogel and EBP groups. Two patients in the hydrogel group (8.0%) and two in the EBP group (8.7%) had mild positional headaches postoperatively that resolved without intervention within 24 hours. One (4.3%) patient in the EBP group had positional headaches following an initial headache-free period; this patient was returned to the operating room and no evidence of a persistent CSF leak was found despite meticulous exploration.

CONCLUSIONS

An open, intraoperatively placed epidural blood patch may be an efficacious and cost-effective way to manage an incidental durotomy. This method merits further study as an allergy-free, no swell, cost-neutral method of dural repair augmentation.

Efficacy of Fibrin Sealants in Preventing Seroma Formation in Reduction Mammaplasty: A Single Surgeon's Experience

BACKGROUND

Fibrin sealant is a controversial method for reducing seroma formation. It is comprised of human proclotting factors, fibrinogen and thrombin. Fibrin sealants have been extensively studied for their efficacy in reducing the rates of seroma by sealing the dead space; however, in most studies, the sealants are used with surgical drains. According to the U.S. Food and Drug Administration, fibrin sealant carries the risk of life-threatening thromboembolic complications, gas emboli, and transmission of infectious agents. Despite these concerns, many plastic surgeons use such products in ambulatory surgeries even though its effect on seroma formation has yet to be elucidated. The aim of our study is to determine the efficacy of fibrin sealants in seroma prevention in reduction mammoplasty with and without surgical drains.

METHODS

A retrospective chart review was performed of all bilateral reduction mammaplasty by a single-surgeon from 2014 to 2018. Patients had at least 90 days postoperative follow-up. Exclusion criteria consisted of patients younger than 18 years, had prior breast surgery, or had an incidental cancer diagnosis in breast reduction tissue specimen.

RESULTS

On analysis, 159 patients met inclusion criteria and were categorized into group 1, with fibrin sealant (n = 101) and group 2, no fibrin sealant (n = 58). There were no statistical differences in patient demographics. There was no significant difference in the incidence of seroma between group 1 and group 2 (21% vs 19%, P = 0.782). Group 1 incidence of seroma was further analyzed by sealant type: Tisseal, Floseal, and Evicel (12% vs 27% vs 23%, P = 0.436). In group 1, the use of sealant alone was more likely to result in seroma formation when compared with the combination of sealant and surgical drains (25% vs 8%, P = 0.069).

CONCLUSIONS

There is no difference in rate of seroma formation with the use of fibrin sealants in reduction mammaplasty. The use of fibrin sealants without surgical drains may increase the rate of seromas. Plastic surgeons could consider weighing the risk versus benefits in using fibrin sealants with or without drains in ambulatory surgeries.

Mixed Metal Oxide Nanoparticle Formulations for the Treatment of Seroma

Seroma formation is a well-recognized postoperative complication for many plastic and general surgical procedures. Although various tissue adhesives and substances have been used in an effort to treat seroma formation, no therapies have been established clinically. Recently, the nano-bridging phenomenon has been introduced as a promising approach to achieve tissue adhesion and strong closure of deep skin wounds in rats. The present study seeks to assess the potential of nano-bridging beyond skin wounds in a rat model of seroma. Seromas were induced in 20 Lewis rats through bilateral axillary lymphadenectomy, excision of the latissimus dorsi and cutaneous maximus muscles, and disruption of dermal lymphatics. On postoperative day (POD) 7, the seroma was aspirated on both sides. A bioactive nanoparticle (NP) suspension based on zinc-doped strontium-substituted bioglass/ceria nanoparticles (NP group) or fibrin glue (fibrin group) was injected into the right seroma cavity, while the left side was left untreated. On POD 14, the NP group showed complete remission (no seromas at all), while the fibrin group recorded a reduction of only 63% in the seroma fluid volume. The NPs exerted local anti-inflammatory and neo-angiogenic effects, without any detectable systemic changes. Moreover, the ceria levels recorded in the organs did not surpass the background level, indicating that the nanoparticles stayed at the site of application. This study is a promising first example demonstrating the ability of inorganic nanoparticle formulations to reduce seroma formation in a rat model, without any detectable systemic adverse effects. These results emphasize the potential of nanotechnological solutions in the therapeutic management of seroma in the clinical setting.

Role for fibrin glue (sealant) in seroma reduction after inguinal lymphadenectomy; a randomized controlled trial

BACKGROUND

Seroma is one of the most commonly encountered morbidities after inguinal lymph node dissection (ILND). It causes much nuisance to both patients and doctors and its presence can lead to many complications. This study aimed to evaluate the role and impact of using fibrin glue to decrease seroma formation in patients undergoing ILND.

MATERIALS AND METHODS

Thirty-two patients underwent ILND for various reasons. The patients were randomly divided into two groups; 16 in each group. In one group, fibrin glue sealant was applied with a dosage of 2 ml per 100 cm² surface area. Drain placement was then performed. In the control group, only drain placement was used. Preoperative, operative and postoperative data were recorded and analyzed.

RESULTS

There was a significant reduction in the incidence of seroma formation favoring the fibrin glue group when compared to the control group (P = 0.022). There was also a significant reduction of total cumulative amount of serous fluid (P < 0.001), time to remove drains (P < 0.001), and hospital stay (P = 0.012). There was no significant difference between the two groups in occurrences of hematoma, infection or superficial skin edge necrosis.

CONCLUSION

Fibrin glue sealant has a role to play in ILND as it significantly reduced the incidence of seroma formation. Standardization of definition of seroma as well as dosage and technique of fibrin glue have to be reached in future studies to determine the true role of fibrin glue in ILND.

Outcomes Associated With Fibrin Sealant Use in Lateral Neck Dissections

Objective

To determine whether the use of fibrin sealant tissue adhesives during lateral neck dissections is associated with a change in postoperative outcomes.

Study Design

Retrospective cohort.

Setting

Institutionally affiliated tertiary care center.

Methods

Various demographic, disease, and surgical data were collected for patients who underwent lateral neck dissections. Univariate regression analysis was performed with the following outcomes: total drain output and duration of drain placement, as well as incidence of postoperative infection, hematoma, seroma, chyle leak, and salivary leak.

Results

A total of 133 patients underwent lateral neck dissections. Fibrin sealant was used in 35% of cases (n = 46). Its use was not associated with differences in total drain output (P = .77) or the number of days that the drains were in place (P = .83). On secondary analysis, the use of fibrin sealant was not associated with a difference in postoperative incidence of hematoma (P = .65), seroma (P = .68), chyle leak (P = .42), or salivary leak (P = .73). These results were consistent when stratified by the presence of intraoperative complications. Its use accompanied an average cost of $674 per case.

Conclusions

Fibrin sealant use during lateral neck dissections was not associated with a reduction in drain output or days that the drains remained in situ. Although the current study was limited by sample size, fibrin sealant use was not associated with a decreased risk of postoperative adverse events. The evidence in this report suggests that the routine use of these products adds cost without clear benefit.

Suture and Fixation of the Transversalis Fascia during Robotic-Assisted Transabdominal Preperitoneal Hernia Repair to Prevent Seroma Formation after Direct Inguinal Hernia Repair

Background. Seroma formation after videoendoscopic repair of inguinal hernias, known as "pseudorecurrence", may vary from an asymptomatic, self-limiting occurrence to a painful, chronic problem. The aim of this study was to investigate the incidence of postoperative seroma in robotic-assisted transabdominal preperitoneal hernia repair (R-TAPP), modified by suturing and fixating the transversalis fascia to the Cooper ligament. Methods. The study was approved by the local ethics committee (2019-01132 CE-3495). Patients undergoing R-TAPP for direct inguinal hernia from October 2017 to December 2019 were included. In all patients, a barbed running suture of the transversalis fascia was performed to close the cavity resulting from the direct hernia reduction and to fix it to the Cooper ligament, then a lightweight mesh was placed. Demographic and clinical data were collected and analysed. Results. Over the study period, 67 R-TAPP in 51 patients were identified. All patients were male, with a mean age of 63.1 ± 12.7 years. There was 1 case of conversion to open surgery due to adhesions of the caecum to the groin as a result of perforated appendicitis. The mean length of the hospital stay was 1.8 ± .6 days. After discharge, no cases of seroma or recurrence at 30 days nor chronic pain at a mean follow-up of 10.3 ± 6.8 months was detected. Conclusions. In the treatment of direct inguinal hernia with R-TAPP, suturing and anchoring the transversalis fascia to the Cooper ligament are safe, feasible and recommendable in order to prevent postoperative seromas.

Fibrin sealants as an adequate treatment alternative to traditional suturing for confined bowel lesions: A hypothesis for future experimental research

Bowel perforation is a rare, but serious complication of laparoscopic surgery with a mortality rate that reaches 20%. There are several risk factors that could predispose to bowel perforation, but the surgeon's experience and the difficulty of each case play the most important role. Delayed bowel injuries happen due to conduction of electrical energy through the abdominal cavity, and in the majority of cases require reoperation. Early bowel injuries are caused by thermal injury of an electrosurgical instrument or during the insertion of the laparoscopic instruments inside the peritoneal cavity. Such injuries are recognized during the operation and are usually fixed by placing sutures. TISSEEL™ is a fibrin sealant with various applications in several surgical specialties, that simulates the latter stages of the coagulation cascade, and could be used as an alternative treatment for confined bowel perforations during laparoscopy. The efficacy of fibrin sealants in closing bowel gaps has been tested in some experimental models as well as its adequacy in enhancing bowel anastomoses performed with sutures. In addition, there is scarce evidence that fibrin sealants enhance the healing process after bowel enclosure either combined to suturing or not, which is supported by an experimental pilot study, that was conducted by our study group. The present study tries to combine all the available data in order to propose an effective alternative treatment for confined bowel injuries or controversial cases, that happen during laparoscopic surgery. In that way, every surgeon could face them even without huge expertise, conversions to open surgery would diminish and the disadvantages of suturing would disappear. Future experimental studies should be designed in the terms of extensive comparison of the two methods, with the purpose of this comparison to be tested in humans in the future.

Intraoperative adjunctive techniques to reduce seroma formation in laparoscopic inguinal hernioplasty: a systematic review

BACKGROUND

Seroma formation is the most common postoperative complication after laparoscopic inguinal hernia repair. Recurrence and seroma formation may be difficult to distinguish. Many adjunctive techniques with which to reduce the incidence of seroma formation after laparoscopic inguinal repair have been described in the literature; however, the evidence for using intraoperative adjunctive techniques is limited. Therefore, the present systematic review was performed to evaluate the effects and limitations of adjunctive techniques used during laparoscopic inguinal hernia repair.

METHODS

Major databases (PubMed, Embase, Springer, and Cochrane Library) were searched using the terms "seroma," "laparoscopic inguinal hernia", "TAPP", "TEP", "inguinal hernia", "tack", "barbed suture", "drainage", "Endoloop technique", and "fibrin sealant". All studies involving adults undergoing laparoscopic/endoscopic inguinal hernioplasty with at least one intervention designed to reduce seroma formation were included.

RESULTS

Of the 965 studies identified, 8 met the inclusion criteria. Six adjunctive techniques were described in the literature. Transversalis fascia (TF) inversion with tacking: one prospective non-randomized controlled study revealed a lower incidence of postoperative seroma after TF inversion with tacking for direct inguinal hernias (4.17% vs. 14.29%, P < 0.05). Endoloop technique: one prospective study of 76 cases involving this technique revealed a low incidence of seroma formation (3.9% at 2 weeks) in direct hernias. Barbed suture closure of TF: one prospective study of 36 direct hernias reported only one clinical palpable seroma that resolved 1 month later. Surgical drains: three trials reported the results of drains, and the pooling results demonstrated significantly less seroma formation in patients with surgical drains (2.1 vs. 23.8%; odds ratio 0.12; 95% confidence interval 0.08-0.19; P < 0.0001). Fibrin sealant: one prospective clinical study of 40 patients with indirect inguinal hernias reported a lower volume (P < 0.001) and lower incidence (5% vs. 15%) of seroma formation in the fibrin group. Distal sac fixation technique: in one prospective study of six patients with large inguinoscrotal hernias, one patient developed a seroma on postoperative day 8.

CONCLUSION

Seroma formation is a natural process that cannot be completely prevented following laparoscopic inguinal hernioplasty, especially in patients with direct and large indirect inguinal hernias. Some intraoperative adjunctive techniques are effective in reducing clinically palpable seroma formation in select patients. More randomized controlled trials are needed for further evaluation.

To Glue or Not to Glue? Analysis of Fibrin Glue for Split-thickness Skin Graft Fixation

Background:

Split-thickness skin grafting (STSG) is a commonly used tool in the plastic surgeon’s reconstructive armamentarium. Fibrin glue (FG) consists of a combination of clotting factors and thrombin whose key properties include adherence and hemostasis. This preliminary study aimed to assess clinical outcomes and cost of FG for STSG fixation in a general wound reconstruction.

Methods:

A retrospective review was conducted in all patients undergoing STSG placement by a single surgeon (JPF) from January 2016 to March 2018. Twenty patients were identified and matched by wound location and wound size. Patients were then divided into 2 groups based on the method of STSG fixation: FG (n = 10) or suture only (SO) (n = 10).

Results:

In patients with FG fixation, we observed trends of decreased adjusted operative times (34.9 versus 49.4 minutes, P = 0.612), a similar length of stay (2.8 versus 3.5 days, P = 0.306), and liberation from the use of negative pressure wound therapy (0 versus 10 wounds, P < 0.0001). There were no observed differences between the 2 groups in terms of graft-related complications at 180 days (1 complication FG versus 0 complications SO). Time to 100% graft take was also not different (20.2 versus 29.4 days, P = 0.405). Additionally, total direct cost ($16,542 FG versus $24,266 SO; P = 0.545) and total charges ($120,336 FG versus $183,750 SO; P = 0.496) were not statistically different between the FG and SO groups.

Conclusions:

In this preliminary comparative assessment, FG for STSG fixation has shown no difference in clinical outcomes to SO fixation, trends of decreased operative time, and afforded complete liberation from negative pressure wound therapy dressings.

Retromuscular Mesh Repair Using Fibrin Glue: Early Outcomes and Cost-effectiveness of an Evolving Technique

Background

Retromuscular hernia repairs (RHRs) decrease hernia recurrence and surgical site infections but can cause significant pain. We aimed to determine if pain and postoperative outcomes differed when comparing suture fixation (SF) of mesh to fibrin glue fixation (FGF).

Methods

Patients undergoing RHR (n = 87) between December 1, 2015 and December 31, 2017 were retrospectively identified. Patients received SF of mesh (n = 59, 67.8%) before the senior author changing his technique to FGF (n = 28, 32.2%). These 2 cohorts were matched (age, body mass index, number of prior repairs, mesh type, defect size, and wound class). Outcomes were analyzed using a matched pairs design with multivariable linear regression.

Results

Two matched groups (21 FGF and 21 SF) were analyzed (45.2% female, average age 56 years, average body mass index 34.7 kg/m², and average defect size 330 cm²). Statistical significance was observed for FGF compared with SF: length of stay (3.7 versus 7.1 days, P = 0.032), time with a drain (17.2 versus 27.5 days, P = 0.012), 30-day postoperative visits (2 versus 3, P = 0.003), pain scores (5.2 versus 3.1, P = 0.019) and activity within the first 24 hours (walking versus sitting, P = 0.002). Operative time decreased by 23.1 minutes (P = 0.352) and postoperative narcotic represcription (3 versus. 8 patients, p=0.147) also decreased. Average cost for patients receiving SF was $36,152 compared to $21,782 for FGF (P = 0.035).

Conclusions

Sutureless RHR using FGF may result in decreased pain when compared with a matched cohort receiving SF, translating to enhanced recovery time, shortened hospital stay, and decreased costs.

Lymphostasis and Hemostasis in Body-Contouring Surgery Using a Polysaccharide Based Hemostat (4DryField PH)

Background:

Following liposuction, abdominoplasty is the most frequent body-contouring intervention in the world. The transection of small blood vessels in large areas and subsequent bleeding is a viable risk during this procedure. The resulting microvascular bleedings should be stopped thoroughly to reduce the probability of related complications. In this prospective, monocentric, randomized study, the efficacy of the polysaccharide-based hemostat 4DryField PH (4DF) (PlanTec Medical, Lueneburg, Germany) is examined in classic abdominoplasty and lower body lift after Lockwood.

Methods:

For this prospective, monocentric, randomized study, 40 patients underwent surgery for both interventions. Twenty patients received an abdominoplasty, and 20 patients underwent a body lift. In each group, 10 patients have been treated with 4DF, whereas 10 have been served as the untreated control group.

Results:

4DF had neither a beneficial nor a negative effect on necessity of drainages, drainage volume and duration, length of hospital stay or frequency of postoperative seromas, wound healing disturbances, and infections, independent of surgical intervention. Patients in the 4DF group, however, had more individual risk factors, and required extended surgical interventions that might mask primary outcome results.

Conclusions:

This is the first prospective, monocentric, randomized study on 4DF in body-contouring surgery. The use of 4DF did not lead to a better postoperative outcome regarding hemostasis and lymphostasis. Potential benefits need further evaluation in high-volume studies.

Use of a Lysine-Derived Urethane Surgical Adhesive as an Alternative to Progressive Tension Sutures in Abdominoplasty Patients: A Cohort Study

BACKGROUND

Fluid accumulation is a common complication after abdominoplasty procedures, and is typically managed by the placement of post-surgical drains. Progressive tension sutures (PTS) have been shown to be an effective approach to reduce the dead space by point-wise mechanical fixation, allowing for drain-free procedures. Lysine-derived urethane surgical adhesive provides an alternative approach for mechanical fixation and reduction of dead space, and may reduce surgery time compared to PTS.

OBJECTIVES

This prospective, controlled, single center clinical study compared progressive tension suture wound closure technique without drains (control) to tissue adhesive wound closure technique without drains (test) during abdominoplasty surgery. The objective was to determine if lysine-derived urethane surgical adhesive is an effective alternative to PTS for drain-free abdominoplasty procedures.

METHODS

Patients undergoing abdominoplasty who met the established inclusion/exclusion criteria were consented and enrolled in the study. Ten PTS (control) cases were performed, followed immediately by 10 tissue adhesive (test) cases.

RESULTS

Surgeries were completed over an 8-month period. No statistical differences were identified between the two groups with regard to age, BMI, dissection surface area or flap weight. No clinical seroma formation was observed in either group. In the control (PTS) group, two patients developed small areas of dermal closure suture abscess requiring removal of suture material. One control patient developed drainage and fat necrosis thought to be related to PTS above the incision and later required a scar revision. One tissue adhesive patient developed hypertrophic scars of both her breast reduction and abdominoplasty scars requiring additional treatment.

CONCLUSIONS

Lysine-derived urethane surgical adhesive was applied in less time than PTS, even after accounting for holding pressure for 5 minutes. The tissue adhesive provided four times the number of attachment points compared to PTS, although the significance of this is not clear. Based on these results, the use of lysine-derived urethane surgical adhesive was found to be a safe and effective alternative to PTS to reduce seroma formation in drain-free abdominoplasty procedures.

LEVEL OF EVIDENCE 2

Using quilting sutures in decreasing seroma formation after managing large ventral hernias: a comparative study

PURPOSE

The aim of this study was to evaluate using quilting sutures in a prospective randomized controlled manner the decrease in the incidence of seroma formation among patients subjected to ventral hernia repair.

METHODS

The study was a prospective randomized controlled study. 370 patients with large ventral hernias were randomly distributed among two groups. Group A (control group) included 180 patients in whom the repair was done without quilting sutures. Group B (quilting group) included 190 patients, all performed with quilting. Method of dissection was unified as far as possible. All cases had an attached closed suction drain that was removed after two successive days of output ≤ 50 cc. The output of the suction drain was recorded; accumulation of clinically detected seroma after 1, 2 and 4 weeks of removal of the drain was monitored.

RESULTS

There was no statistical difference between both groups as regards the demographic data and the hernia characteristics. There was significantly smaller amount of output of the drains in every day of the first five postoperative days as well as the total amount of the output before drain removal in favor of the quilting group. Drains were removed earlier in group B. The incidence of clinically detected seroma was less in group B as well.

CONCLUSIONS

Quilting sutures is an effective and easy technique to reduce post-ventral hernia seroma accumulation.

The use of adjuncts to reduce seroma in open incisional hernia repair: a systematic review

BACKGROUND

Seroma formation remains a common complication after an incisional hernia repair. The use of surgical drains is widespread, but evidence for their use and other adjuncts is limited. Our aim was to perform a systematic review of the literature on techniques used to reduce the incidence of post-operative seroma formation.

METHODS

A systematic search of PubMed and Embase databases was conducted using terms including "incisional hernia" and "seroma". All studies on adults undergoing open incisional hernia repair with at least one intervention designed to reduce seroma formation were included.

RESULTS

Of the 1093 studies identified, 9 met the inclusion criteria. Medical talc: one cohort study of 74 patients undergoing talc application following pre-peritoneal mesh placement found a significantly decreased rate of seroma formation of 20.8 versus 2.7% (p < 0.001), but a retrospective study including 21 patients with onlay mesh found an increased rate of 76% seroma formation from 9.5% (p = 0.001). Fibrin glue: one comparative study including 60 patients found a reduction in seroma formation from 53 to 10% (p = 0.003), whereas a retrospective study of 250 patients found no difference (11 vs. 4.9% p = 0.07). Negative pressure wound therapy: four retrospective studies including a total of 358 patients found no difference in seroma outcome. Others: one randomised study of 42 patients undergoing either suction drainage or "quilting" sutures found no difference in seroma formation.

CONCLUSIONS

There is currently insufficient quality evidence to recommend any of the investigated methods, some of which incur significant additional cost.

Operative Outcomes after Open Abdominal Wall Reconstruction with Retromuscular Mesh Fixation Using Fibrin Glue versus Transfascial Sutures

Ideal fixation techniques have not been fully elucidated at the time of complex open abdominal wall reconstruction (AWR). We compared operative outcomes and quality of life with retromuscular mesh fixation using fibrin glue (FG) versus transfascial sutures (TS). Retrospective review identified complex hernia patients who underwent open AWR with mesh from November 2012 through April 2016. Multivariate analysis examined postoperative outcomes between groups. Quality of life was assessed using the Carolinas Comfort Scale. Seventy-five patients (18 FG vs 57 TS) with mean age (54.3 vs 53.9 years, P = 0.914), body mass index (35.8 vs 34.7 kg/m2, P = 0.623) and American Society of Anesthesiologist score (2.6 vs 2.5, P = 0.617) were reviewed. No differences in wound (P = 0.072) and nonwound (P = 0.639) related complications were noted between groups. Risk of reoperations (P = 0.275) and 30-day readmissions (P = 0.137) were also comparable. The TS group was twelve times more likely to report pain at six-month follow-up compared with FG (12.29 OR, 95 per cent confidence interval 1.26–120.35, P = 0.031). No hernia recurrences were noted in either group at a mean follow-up of 390 ± 330 days. The use of FG to secure mesh in the retromuscular space during complex open AWR may be a safe alternative to penetrating transfascial fixation with potential to reduce chronic pain.

Successful treatment of a chronic abdominal wall seroma with the polysaccharide 4DryField® PH - A case report

INTRODUCTION

Seroma formation is one of the most prevalent complications after liposuction, abdominoplasty, mastectomy or hernia repair. They can disappear without treatment, but also may persist and require complex therapy. This report describes how 4DryField^® PH polysaccharide powder successfully was applied for chronic seroma therapy.

PRESENTATION OF THE CASE

An 80year old male patient presented with a persistent seroma (1000cm³ volume) resulting from liposuction about 15 years ago. In a first approach he was treated using en bloc excision without opening the capsule. Three month later the patient presented with a recurrent seroma of the same size. This time 1100cm³ bloody discolored fluid was aspirated. The skin was lifted using a redon tubing drawn through the whole length of the wound cavity. This allowed even distribution of 4DryField^® PH powder (10g) within the former seroma cavity. Computed Tomography (CT) imaging after 4.5 month and sonographic examination after an additional year confirmed treatment success.

DISCUSSION

Besides conventional methods for hemos-/lymphostasis several adjunct measures like fibrin sealants, medication with corticoids and diurectics have been proposed for seroma prevention/therapy, unfortunately, with conflicting evidence. In an experimental study seroma prevention with a polysaccharide was demonstrated; however, clinical proof is missing. This case provides first clinical evidence that 4DryField^® PH polysaccharide powder evenly distributed in the former seroma cavity can prevent its recurrence.

CONCLUSION

4DryField^® PH powder treatment of seroma is a promising new approach for prevention and treatment of chronic seroma.