Meta-Analysis of Randomized Controlled Trials Comparing Lightweight and Heavyweight Mesh for Laparoscopic Total Extraperitoneal Inguinal Hernia Repair.

The aim of this study was to compare the outcomes of lightweight and heavyweight mesh on postoperative recovery in laparoscopic total extraperitoneal (TEP) inguinal hernia repair. PubMed, Embase, Science Citation Index, and the Cochrane Library were used to search for published clinical randomized controlled trials, which compared lightweight meshes with heavyweight meshes in TEP inguinal hernia repair. The outcomes were calculated as risk ratios with 95 per cent confidence intervals using RevMan 5.2. Eight randomized controlled trials were included. Compared with a heavyweight mesh, the lightweight mesh led to a higher incidence of recurrence (risk ratio = 2.52, 95% confidence interval 1.10-5.81; P = 0.03). There was no significant difference in chronic moderate to severe pain, foreign body sensation, and seroma. The use of lightweight mesh is not recommended for TEP inguinal hernia repair.

Theories of Etiopathogenesis of Breast Implant-Associated Anaplastic Large Cell Lymphoma.

Breast implant-associated anaplastic large cell lymphoma is a malignancy of T lymphocytes that is associated with the use of textured breast implants in both esthetic and reconstructive surgeries. Patients typically present with a delayed seroma 8-10 years following implantation or-less commonly-with a capsular mass or systemic disease. Current theories on disease pathogenesis focus on the interplay among textured implants, Gram-negative bacteria, host genetics, and time. The possible roles of silicone leachables and particles have been less well substantiated. This review aims to synthesize the existing scientific evidence regarding breast implant-associated anaplastic large cell lymphoma etiopathogenesis.

Late Shoulder-Arm Morbidity Using Ultrasound Scalpel in Axillary Dissection for Breast Cancer: A Retrospective Analysis.

BACKGROUND: We aimed to assess whether the use of the harmonic scalpel (HS) in axillary dissection would reduce long-term shoulder-arm morbidity compared to traditional instruments (TIs). MATERIALS AND METHODS: A retrospective analysis on 180 patients who underwent standard axillary dissection for breast cancer between 2007 and 2015 was carried out. All patients were evaluated for postoperative pain, impairment of shoulder-arm mobility, seroma formation in axilla, frozen shoulder, and lymphedema. RESULTS: HS procedure on average was 50% shorter compared to the TI technique. HS reduced by 4.5 times the risk of axillary seroma. TIs were associated with 4 times higher risk of developing a painful frozen shoulder. CONCLUSIONS: Use of the HS was associated with reduced costs and a positive long-term effect on shoulder-arm morbidity. Axillary seromas are not the only reason of later postoperative shoulder-arm morbidity: other mechanisms are hypothesized in the onset of this very disabling disorder.

Analysis of factors influencing drain amount, time to drain removal, and seroma formation in patients undergoing immediate expander-implant breast reconstruction.

BACKGROUND: Placement of a closed suction drain is a common cause of patient complaints, such as postoperative pain or discomfort following immediate expander-implant breast reconstruction. This study aims to identify factors that affect drainage volume, time to drain removal, and seroma formation. METHODS: A retrospective chart review of prospectively collected data was conducted on patients who underwent immediate expander-implant breast reconstructions following nipple-sparing or skin-sparing mastectomy without skin excision (nipple areolar complex excision only) between February 2010 and April 2015. Daily drainage volume was measured until the drain was removed. Eight independent variables, including acellular dermal matrix (ADM) usage and inflation ratio (the rate of initial inflation volume to mastectomy weight) were analysed by univariable and multivariable analyses. RESULTS: A total of 162 breasts in 148 patients were included in this study. The inflation ratio did not influence the drain amount or days to drain removal. Although the use of ADM was significantly associated with increased drainage during the first 5 postoperative days (p = 0.015), it was not significant when adjusted for time. Old age, larger expander size, and larger drain amount on the first postoperative day were predictors for longer days to drain removal (p < 0.001). Old age had a trend toward higher risk of seroma formation that approached statistical significance (p = 0.057). CONCLUSIONS: The use of ADM and initial inflation ratio do not influence days to drain removal or seroma formation. A longer period of drain placement is expected when a larger expander is used or in elderly patients.

Seroma in Prosthetic Breast Reconstruction.

BACKGROUND: Seroma, as a complication of prosthetic breast reconstruction, results in patient distress, increased office visits, undesirable aesthetic outcomes, and--importantly--may escalate to infection and frank prosthesis loss. Herein, the authors review the pathophysiology and risk factors and attempt to collate published practices for avoidance and management of seroma. METHODS: A systematic literature review was performed using MEDLINE, Web of Science, Embase, and Cochrane Library for studies published between 2000 and January of 2015. Random-effects meta-analysis was used to estimate the overall pooled incidence of seroma and to examine the effect of drain number and acellular dermal matrix use. RESULTS: Seventy-two relevant primary articles and three systematic reviews were identified. Fifty-one citations met inclusion criteria, including two randomized controlled trials. The overall pooled incidence was 5.4 percent (95 percent CI, 4.1 to 6.7 percent). Obesity, acellular dermal matrix, and preoperative irradiation were cited risk factors. Pooled relative risk for acellular dermal matrix was 1.83 (95 percent CI, 1.28 to 2.62). Drain practices were collated from 34 articles. CONCLUSIONS: Seromas following prosthetic breast reconstruction are complicated by the hypovascular, proinflammatory milieu of the mastectomy skin flap, the geometrically complex dead space, and the presence of a foreign body with potential contamination and biofilm. There is reasonable evidence to suggest that these factors contribute to a progression of seroma to infection and prosthesis loss. These findings have motivated this summary article on current practice guidelines and strategies to prevent and treat seromas. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Feasibility of laparoscopic abdominal wall reconstruction in an outpatient community-hospital setting using cPTFE prosthetic mesh: a prospective, multicenter case series.

Objective This study investigated the use of prosthetic condensed polytetrafluoroethylene (cPTFE) for laparoscopic ventral hernia repair (LVHR) in an outpatient community-hospital setting. Methods Patients underwent LVHR with cPTFE at one of three community hospitals. Primary endpoint was hernia recurrence at 1-year postoperatively. Secondary endpoints included pain, surgical site infection, medical/surgical complications, and patient-reported outcomes. Results This study included 65 females and 52 males, aged 46.6 ± 13.2 years (mean ± SD; range 18-84 years). Mean prosthetic size was 413.8 ± 336.11 cm2 (range 165-936 cm2). Mean follow-up was 30 months (range 12-46 months). Hernia recurrence rate was 4.3%. Rate of hospitalization in the first postoperative week was 2.6%. Early and late secondary endpoint complication rates were 24.8% and 27.4%, respectively; pain was the most common complication, followed by seroma (8.5%). Conclusions Outpatient LVHR using cPTFE is feasible in community hospitals. Complication rates were similar to previous reports, and the seroma rate was markedly lower.

Tissue integration and inflammatory reaction in full-thickness abdominal wall repair using an innovative composite mesh.

PURPOSE: When composite meshes are used in abdominal wall repair, seroma formation may persist and delay the desired integration leading to recurrence. This study compares tissue integration and inflammatory response in abdominal wall repair with composites with different absorbable synthetic barriers. METHODS: Full-thickness defects created in the abdominal wall of rabbits were repaired using polypropylene prosthesis or the following composites: Physiomesh™ (Phy); Ventralight™ (Vent) and "new composite mesh" (Ncm) not yet used clinically in humans. The collected seroma was evaluated for IFN-γ/IL-4 by ELISA. Tissue integration, anti- (IL-13/TGFß-1/IL-10/IL-4) and pro-inflammatory (TNF-α/IL-6/IFN-γ/VEGF) cytokine mRNA expression and TGFß/VEGF immunolabeling were evaluated at 14 and 90 days post-implant. RESULTS: Seroma was observed in 10 of 12 Phy/Vent and 4 of 12 Ncm. Wound fluid IFN-γ showed a time-dependent significant increase in Vent and tendency to decrease in Ncm, while all composites exhibited IL-4 upward trend. Prostheses were fully infiltrated by an organized connective tissue at end time although the area had shown prior seroma. A stable mesothelium was developed, except in adhesion areas. Vent/Phy displayed a significant increase in TNF-α/IFN-γ-mRNA over time. Significant decrease in VEGF mRNA was observed in Phy/Ncm, while a significant increase of TGFß-1 mRNA was evident in all composites over time. Ncm exhibited the highest TGFß protein expression area at short term and the greatest percentage of VEGF positive vessels at end time. CONCLUSION: Ncm could be an appropriate candidate to improve clinical outcome showing the lower development of seroma and optimal tissue integration with minimal pro-inflammatory cytokine response over time and consistent pro-wound healing cytokine expression.

Negative effect of seroma on breast balloon brachytherapy dosimetry.

PURPOSE: Balloon brachytherapy is commonly used to deliver Accelerated Partial Breast Irradiation (APBI). Seroma interference is a relatively common phenomenon during APBI. The negative effect of seroma accumulation on the planning target volume evaluation (PTV_Eval) coverage is not well understood. METHODS AND MATERIALS: This is a dosimetric replanning study on 10 patients with evidence of seroma collection at time of initial computed tomographic simulation around the catheter. Total dose was 34 Gy given at 3.4 Gy twice a day over 5 treatment days. A total of 20 plans were generated, 10 plans without accounting for and 10 after subtracting the seroma. We then compared the changes seen in PTV_Eval between plans as a factor of the seroma volume. RESULTS: Median age was 62 years (51-83). Histology was invasive in 7/10 cases and in situ in 3/10. Median balloon to skin distance was 8.5 mm (3-14). Median balloon volume was 39 cc (30-104). Median seroma volume was 3.34 cc (1.13-13.71). For every 1 cc of accumulated seroma the percentage of PTV_Eval coverage by the 90% isodose line (V90) was found to decrease by 2.45% (P < .0001; confidence interval [CI], 1.87-3.03) and coverage by the 100% isodose line (V100) was decreased by 1.11% (P < .0001; CI, 0.81-1.41). Fifty percent (5/10) of previously acceptable plans with seroma not accounted for failed to meet the V90 ≥90% requirement after subtracting the seroma. CONCLUSIONS: Accumulation of seroma was associated with a considerable negative impact on PTV_Eval dosimetry with a greater impact on V90 compared with the V100. Clinicians must be careful in detecting and accounting for such accumulation in treatment plans to prevent underdosing of the at risk target breast tissue.

Recurrence and pseudorecurrence after laparoscopic ventral hernia repair: predictors and patient-focused outcomes.

Laparoscopic ventral hernia repair (LVHR) is gaining popularity as an option to repair abdominal wall hernias. Bulging after repair remains common after this technique. This study evaluates the incidence and factors associated with bulging after LVHR. Between 2000 and 2010, 201 patients underwent LVHR at two affiliated institutions. Patients who developed recurrence or pseudorecurrence (seroma or eventration) were analyzed with univariate and multivariate analyses to identify predictors of these complications. Of the 201 patients who underwent LVHR, 40 (19.9%) patients developed a seroma, 63 (31.3%) patients had radiographically proven eventration, and 25 (12.4%) patients had a hernia recurrence. On multivariate analysis, seromas were associated with number of prior ventral hernia repairs, surgical site infections, and prostate disease. Mesh eventration was associated with hernia size and surgical technique. Tissue eventration was associated with primary hernias and surgical technique. Hernia recurrence was associated with incisional hernias and mesh type used. Recurrence and pseudorecurrence are important complications after LVHR. Large hernia size, infections, and surgical technique are important clinical factors that affect outcomes after LVHR.

Herbal medications and plastic surgery: a hidden danger.

Herbal medicine is a multibillion-pound industry, and surveys suggest that ~10% of the UK population uses herbal supplements concurrently with prescription medications. Patients and health care practitioners are often unaware of the adverse side effects of herbal medicines. In addition, because many of these herbal supplements are available over the counter, many patients do not disclose these when listing medications to health care providers. A 39-year-old nurse underwent an abdominoplasty with rectus sheath plication after weight loss surgery. Postoperatively, she experienced persistent drain output, and after discharge, a seroma developed requiring repeated drainage in the clinic. After scar revision 10 months later, the woman bled postoperatively, requiring suturing. Again, a seroma developed, requiring repeated drainage. It was discovered that the patient had been taking a herbal menopause supplement containing ingredients known to have anticoagulant effects. Complementary medicine is rarely taught in UK medical schools and generally not practiced in UK hospitals. Many supplements are known to have anticoagulant, cardiovascular, and sedative effects. Worryingly, questions about herbal medicines are not routinely asked in clinics, and patients do not often volunteer such information. With the number and awareness of complementary medications increasing, their usage among the population is likely to increase. The authors recommend specific questioning about the use of complementary medications and consideration of ceasing such medications before surgery. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Localized BIA identifies structural and pathophysiological changes in soft tissue after post-traumatic injuries in soccer players.

Localized bioimpedance (BIA) was measured with a single frequency phase-sensitive analyzer at 50 kHz in three post-traumatic types of injuries on four professional soccer players: (1) myositis ossificans, (2) intramuscular seroma and (3) trochanteric (hip) bursitis. Normal reference value (no injury) was obtained from the contra lateral not injured limb at a mirror-like location of the injury. The relative variations resistance (R) and reactance (Xc) at the time of injury was confronted with the not injured values. Relative variations between acute measurements and post medication ones on intramuscular seroma and bursitis have been computed. In intramuscular seroma and trochanteric bursitis we have obtained a percent of change between injury data and after medical intervention. On myositis ossificans, localized BIA showed a 7-8 % decrease in Xc whereas the percent of change of R was negligible (1 %). These percent of changes are in concordance with histological evidence. In the case of a presence of seroma or the lower thigh and trochanteric bursitis, the soft tissue cavity accumulates fluid. Post-injury localized BIA, relative with respect to non-injured side, confirmed sizeable soft tissue destruction evidenced by 50 % decrease of Xc and 24-31 % decrease of R due to interstitial fluid accumulation. Once the seroma and the blood in the bursitis was removed the localized the immediate post-injury BIA parameters increased as follows: a) intramuscular seroma + 10 % on R and + 74 % of Xc; b) trochanteric bursitis + 20 % of R and +24 % of Xc. Localized BIA other than classifying soft tissue injuries, can be useful to understand the pathophysiology and structural impairments of other kind of injuries and to understand their behavior.

Human acellular dermis versus no acellular dermis in tissue expansion breast reconstruction.

BACKGROUND: Human acellular dermis has been adopted for routine use in tissue expander reconstruction. The purported benefits include higher intraoperative fill volume, facilitation of lower pole expansion, and enhanced definition of the lower pole of the breast. Recently, concerns have arisen about an increase in postoperative complications with its use. METHODS: A retrospective review was conducted of patients who had immediate postmastectomy breast reconstruction with a tissue expander from July of 2001 to July of 2011. All tissue expander reconstructions before 2005 were performed submuscularly only and all subsequent to 2005 with the use of AlloDerm (LifeCell, Branchburg, N.J.) acellular dermis. Patient demographics were collected, and complications were recorded. RESULTS: The study cohort included 346 patients and 511 immediate breast reconstructions; 232 patients and 346 breasts were reconstructed with and 114 patients and 165 breasts without acellular dermis. Age, body mass index, diabetes, and tobacco use were equivalent in the two groups. Seroma occurrence in the acellular dermis group was nearly twice (30.0 versus 15.1 percent) that of the no acellular dermis breasts, but the tissue expander loss was only slightly higher (11.6 versus 8.5 percent) and not statistically significant. Body mass index in patients who lost their tissue expander was 31 kg/m, statistically significantly higher than in those who did not. CONCLUSIONS: The presence of acellular dermis did not increase the incidence of tissue expander loss, despite a doubling of frequency of seroma. Prior radiation and use of acellular dermis did culminate in a prohibitively high loss rate of the tissue expander.

[Simple and complicated surgical wounds]. / Einfache und komplizierte chirurgische Wunde.

Aiming at primary wound healing, the majority of surgical interventions end with a wound closure. The wound edges are brought together and secured using sutures, staples or glue, respectively. A common surgical wound therefore tends to undergo an orderly and timely repair process with the result of sustained restored anatomic and functional integrity. In case of surgical wound infection, dehiscence, seroma or hematoma tissue repair is impaired and the healing process becomes delayed. Here, a simple wound becomes more complex or even chronic. Delayed wound healing continues to be a problem with associated significant morbidity and impaired quality of life that take up substantial health care resources. In situations of complicated or chronic wound setting the aim of wound healing will be by secondary intention referring to an open wound. Wound dressings, usually applied after wound closure, provide physical support and protection from bacterial contamination. In open wound, dressings not only have the protective intention but also clean the wound and induce the healing process. Further measurements of wound dressings in complicated wounds are pain relief, ease of use and removal on an outpatient basis, cost-effectiveness and patient satisfaction. Advances in the basic science of wound healing and its clinical application have led to numerous new therapies, products, and modalities that are constantly changing the approach to wound management. In the last two decades, negative-pressure wound therapy has been one of the major innovations in wound care. In addition to acting as an occlusive dressing, it may increase blood flow to the wound site, decrease edema, decrease bacterial contamination, and promote wound contraction. Further strategies to enhance wound healing or scar formation still under investigation include growth factors or regenerative cell therapy.

[Postoperative complications after inguinal PHS hernioplasty using PHS and lichtenstein hernioplasty].

Immediate and delayed results of inguinal hernioplasty with the use of PHS and Lichtenstein hernioplasty in 228 patients are reported. It is concluded that inguinal hernioplasty with PHS and Lichtenstein hernioplasty do not significantly different in terms of the frequency of postoperative complications and relapses. Seroma occurred less frequently after PHS hernioplasty (a = 0.022). Although the frequency of a chronic postoperative pain was lower after PHS hernioplasty its severity was not significantly different in the two groups.

[Contribution to the study of painful and functional sequellae after breast reconstruction using latissimus dorsi flap. Investigation into 149 patients]. / Contribution à l'étude des séquelles douloureuses et fonctionnelles après reconstruction mammaire utilisant le lambeau dorsal. Enquête auprès de 149 patientes.

Latissimus dorsi flap is the most commonly used among tissues transfers for breast reconstruction. If its qualities and performances are well known, few papers have studied sequellae of this flap, particularly painful. The purpose of this paper is to provide a contribution about this subject. Postulating the complexity of this step, we limited ourselves initially to an evaluation based on analysis of concise questionnaire mailed to two pools of patients with different delays since their reconstruction using latissimus flap. In the two groups of patients, announced principal embarrassment - logically associated with a gestural limitation - is the feeling of axillo-dorsal rigidity, more pregnant than the pain itself. This one is marked during the 2 to 4 first months in the majority of the patients (68 and 66 %), and can persist several years in some among them (14 %). These after-effects did not prevent almost all of the patients to take again their domestic and professional activities and to express a high level of satisfaction with respect to their reconstruction. The addition of a prospective series studying the postoperative pain after reconstruction with or without latissimus flap tends to confirm that any oncologic breast surgery, ablative or reconstructive, expose to painful sequellae more linked to individual factors than to the technique implemented.

Buried dermal flap for the treatment of chronic postoperative seroma.

Postoperative seroma is a common postoperative complication, particularly following surgery on massive weight loss patients. Within this patient population, seromas are often chronic, requiring multiple invasive procedures to adequately control. Here, the authors describe a unique dermal flap approach for the long-term treatment of postoperative seroma.