morbidity and mortality

1. Monthly Morbidity Presentation
by
A1 Team
Title: Post TAPP repair Seroma
In charge: Dr. Farhan Alhamd.
Presenter: Dr. Muhammad Rashed Waheed.

2. Case Summary
• A 63 years old male with Diabetes, Hypertension and a previous
history of Percutaneous Coronary Intervention for IHD and Lap
Cholecystectomy, known to have groin swelling.
• Presented in emergency on 22nd November, 2023 with sudden onset
right sided inguino-scrotal pain and abdominal pain.
• First episode of this type of pain, dull, agonizing, in the inguino-
scrotal region not associated with vomiting.

3. Examination Findings:
• Soft, non distended abdomen but with an obvious swelling in the
right inguino-scrotal region.
• Tender to touch, irreducible contents with a negative cough impulse.
• Both testes palpable in the scrotal sac with no obvious swelling
appreciated in the left inguinal region.
• Rest of General physical and systemic examination findings were
normal.

4. Investigations
• CBC, Admission Profile, and Coagulation profile were normal.
• X ray Erect abdomen was normal with no air fluid levels.
• Chest x ray was normal.

5. Diagnosis:
• A diagnosis of irreducible right inguinal hernia was made
and the patient was admitted for Ct scan abdomen and
further management.

6. CT scan Findings

7. Ct Image

8. Steps of Management
• Patient was made Nil Per Oral.
• Antibiotics were started.
• Painkillers were started.
• Patient was started on iv fluids for good hydration.
Once the pain improved with analgesics, a taxis maneuver was done
and the hernial sac contents were reduced with significant reduction
in pain.

9. Management Contd,…
• Patient was operated the next day after formal preparation and
evaluation by anesthesiologist and physician.
• Patient had an uneventful surgery as bilateral Laparoscopic inguinal
hernia repair with mesh and was discharged home on first post
operative day.

10. Complication:
• The patient was re admitted from OPD with a Clinical diagnosis of
Post TAPP seroma on 4th of January, 2024
• A consultation with Interventional radiologist was made and the
seroma was drained by Interventional radiologist.
• A Pigtail catheter was placed and it continued draining for the next 04
days until the patient was finally discharged on 7th of January, 2024
after removal of pigtail catheter.

11. Clavien Dindo Class of Morbidity
• Class 3A
• Because the patient needed readmission to hospital with radiological
intervention under local anesthesia.

12. Questions to Answer
• 1. What is the worldwide incidence of Post TAPP seroma formation?
• 2. What are the risk factors for seroma formation?
• 3. Is it safe to do TAPP in emergency cases?
• 4. Intervention or conservative management for Seroma?
• 5. What is the long term outcome?

13. Blame the Surgery, Not the Surgeon
• 1. Creation of Dead Spaces(Space of Bogras, Space of Retzius)
• 2. Dependent area of the body.
• 3. Traction and counter traction dissection of tissues with small veins
around.
• 4.Foreign body in the form of mesh.

14. Dissection in Inguinal Hernia

15. Literature Review

16. Incidence of Post TAPP Seroma
• Reported incidence of seroma formation after literature review is
• 3.0% to 8.0% after TAPP repair.
• 0.5 to 12.2% after TEP repair.
• 0.5 to 1.2% after open hernia repair.
• Reference:
• Seroma following TAPP: incidence, risk factors and preventive measures.
• F.Kockerling R.Bittner D.Adolf R.Fortelny H.Niebuhr F.Mayer C.Schug-Pass
• Surgical Endoscopy (2018) 32:2222-2231

17. Risk Factors for Seroma formation
• 1. Old Age (Frailty of Tissues)
• 2. Large Inguino-scrotal hernias.
• 3. Transection of hernial sac.
• 4. Medial defect(Direct Hernia) (Transversalis Fascia Inversion)
• 5. Mesh Fixation technique( Glue vs Tacker, vs stitches)

18. Contd:
• Use of Energy Devices
• Tissue handling and hemostasis.
• Type of Mesh used (Light weight vs heavy weight mesh)
• Systemic Risk factors (modifiable and non modifiable)

19. Diagnostic Considerations.

20. Lax transversalis Fascia.

21. Diagnosis, Contd,
• Seromas noticed on physical examination by a surgeon are most likely
to be noticed by the patients as well prompting intervention.
• Sometimes mistaken for recurrence and ends up in groin exploration.
• Ultrasound must therefore be performed before attempting
intervention at the cost of over diagnosis of the seroma.

22. Measures to Prevent Seroma Formation

23. Contd,…

24. Conservative management vs Intervention
• Intervention needed for Seromas of Concerns
• 1. Large Seromas.
• 2. Persistent for more than 06 weeks.
• 3. Symptomatic in the form of pain, mild low grade fever.
• 4. Seromas in high risk patients.

25. Long term outcome
• 1. Complete resolution.
• 2. Repeated Interventions.
• 3. Chronic mesh infection/ Pus Formation.
• 4. Chronic pain.
• 5. Testicular Atrophy

26. Take Home Message
• 1. Seroma formation should be anticipated keeping in view the risk
factors and repair technique tailored accordingly.
• 2. informed consent regarding this common complication must be
explained to the patient to reduce post op anxiety.
• 3.Conservative approach is still better in small, asymptomatic
seromas rather than active intervention.

27. •Thank You
•Questions and Comments?