Chronic encysted giant seroma post-ventral hernia repair masquerading as peritoneal cyst and its laparo-seroscopic management: A case report and literature review.

Seroma formation is one the most common occurrence post-ventral hernia repair, with varied presentation from asymptomatic collection to infected collection to chronic collection, which may sometimes present as a diagnostic dilemma and therapeutic challenge. We report a case of giant abdominal swelling presenting as an encysted peritoneal cyst, which was ultimately found to be a chronic seroma and was managed successfully with combined laparo-seroscopic approach.

INTRODUCTION

Seroma formation is one of the most commonly reported complications after ventral hernia surgery. It occurs early after operation in virtually all patients, at least to some extent. Most seromas resolve spontaneously over a period of weeks to months, and with fewer than 5% persisting for more than 8 weeks, seromas are rarely clinically significant.[1]

However, seromas presenting late without any antecedent noticeable event (complication or discourse in recovery) related to hernia repair, may present diagnostic dilemma. We report a case of giant abdominal swelling presenting as an encysted peritoneal cyst, which was ultimately found to be a chronic seroma and was managed successfully with combined laparo-seroscopic approach.

CASE REPORT

A 46-year-old obese woman presented to the outpatient department with abdominal discomfort for 1 month. She also reported of progressive abdominal fullness over the past several months which patient attributed herself for obesity. The patient denied fever, chills, nausea, vomiting, diarrhoea and constipation. Surgical history included laparoscopic intraperitoneal onlay mesh repair with a composite mesh for umbilical hernia, performed 6 years back with uneventful recovery and follow-up.

Medical, family, drug and social history were unremarkable. On examination, the patient had normal vital signs. Body mass index 37 kg/m2. The abdomen was soft, lax and tense cystic non-tender, mass of size 15 cm × 15 cm was palpable, in lower abdomen, which appeared intraperitoneal on leg raising test and was mobile and divarication of recti present. Overlying skin was normal. Complete blood count and basic metabolic panel were normal. Imaging of abdomen on contrast computed tomography [Figure 1a] showed a cystic lesion in lower abdomen and pelvis, abutting anterior abdominal wall of size 16 cm × 12 cm × 10 cm, with punctate calcifications. Thin wavy serpiginous strands noted in cyst (on magnetic resonance imaging screening) with significant septations, with D/D of hydatid cyst with collapsed daughter cyst or mesenteric cyst. Hydatid serology was negative. Although a chronic seroma was also thought of as possible differential diagnosis (D/D), it was kept as a last D/D, in view of its atypical presentation.

Figure 1

(a) Contrast computerised tomography axial image of abdomen. (b) Laparoscopic view of the seroma after adhesiolysis. (c) Seroscopic view showing previous mesh and tackers. (d) Repeat intraperitoneal view showing the seroma completely decompressed and posterior wall of seroma adherent to anterior abdominal wall. (e) Ports position for laparoscopic view (blue arrow) and seroscopic view (black-arrow) with port sizes used and 5 mm port used for negative suction drain at the end. (f) Excised Composite mesh with tackers (arrow). (g) Drained seroma fluid

The patient was provisionally diagnosed with an intraperitoneal cyst and was planned for diagnostic laparoscopy. The patient was placed supine and Palmer's point Veeres needle insufflation and camera with working ports inserted in the left subcostal area. During diagnostic laparoscopy, after adhesiolysis, a thick-walled encysted lesion seemed to adherent to anterior abdominal wall [Figure 1b] with no bowel, mesenteric or omental communication, thus ruling out possibility of intraperitoneal cyst. We planned for cutaneous trocar drainage by inserting a 10 mm trocar into cyst cavity under an intraperitoneal camera guidance. Approximately 2 L of turbid fluid drained out. Once all fluid was drained out, the cavity was insufflated with CO2 at 8 mmHg pressure and Laparoscopic camera was inserted into seroma to get inside view-seroscopy [Figure 1c]. Two 5 mm working ports were placed into cavity under vision. The previously used mesh was lying loose inside cavity with metallic tacks; hence, the diagnosis of chronic seroma was confirmed. Mesh along with tacks was removed via 10 mm trocar. Cavity was thoroughly irrigated with normal saline and a negative suction drain was placed. Repeat intraperitoneal view showed the seroma completely decompressed with posterior wall of seroma snuggly adherent to anterior abdominal wall under negative suction [Figure 1d]. Ports for laparoscopy and seroscopy are shown in Figure 1e. Excised mesh [Figure 1f] and drained fluid [Figure 1g] were sent for culture.

Postoperatively, serous drain output was 25 ml/day for 3 days. Culture showed Escherichia coli and Klebsiella and appropriate antibiotics were given. The patient was discharged with negative drain and called for follow-up. On 8th post operative day, drain output was <10 ml/day and drain was removed. Follow-up visits, at 1st month, 3rd month, 6th month and 12th month, showed no repeat collection. No hernia recurrence seen.

DISCUSSION

Seromas following hernia repair are predominantly asymptomatic and self-resolving. They usually occur within the 1st month postoperatively and may be undetected on clinical examination. However, they may progress into a symptomatic complicated State, usually resolving with or without drainage within 4–6 weeks.[2]

Prolonged seroma following laparoscopic ventral hernia repair (LVHR) has been described as those seromas that persist longer than 8 weeks. A large study of 850 consecutive LVHRs reported only 2.6% symptomatic prolonged seromas. Most of these passive seromas did not require intervention.[3]

Six-year latency in diagnosis, in this case, implicates a possible large seroma which was clinically asymptomatic for years until infection supervened. It was possibly missed at clinical initial follow up due to the intra-abdominal nature of the swelling with no obvious external component and patient's habitus (obesity) despite the size and lack of symptoms. From the clinical history, the likely focus of infection that might have triggered the presentation is unknown.

Literature review is scare with such delayed presentation and found only one case report[4] presented 5 year later, however it was managed with an open approach, and to our knowledge, this is the only case report which have reported with delayed onset seroma and which was managed laparoscopically so as to maintain the integrity of abdominal wall.

It is difficult to know, based on the literature, the best method to manage patients presenting as chronic seromas and their complications in the post-operative period, due to the rarity of this delayed presentation. A simple aspiration in most chronic seroma fails as most seromas that persist for prolonged period develop a pseudo capsule lined by fibrous tissue that lacks a proper epithelium and seroma may re-accumulate. Such seroma will usually require additional procedures for its treatment including percutaneous drain placement, chemical decortication,[5] or even surgical decortication.[6] Chemical decortication is done using sclerosing agents, such as talc, tetracycline, doxycycline, ethanol, erythromycin, fibrin glue and povidone/iodine, have all been used with variable success rates and few complications; however, only small case series exist in the literature.[7]

Lehr and Schuricht[8] described a novel laparoscopic approach for the treatment of persistent seromas after laparoscopic post-incisional hernia repair. This group proposed a laparoscopically controlled evacuation of both the serous fluid and the fibrinous debris followed by argon beam scarification of the seroma pseudo capsule in order to produce an irritative reaction. However, when seroma develops a thick surrounding capsule and recurrent seroma collection, capsule removal might be the only curative option.[6]

Since there was a diagnostic dilemma due to prolonged latency in presentation, conventional therapies such as percutaneous drainage was not attempted. For such cases, diagnostic laparoscopic plays an important role for confirmation and avoids unnecessary open surgery.

Instead of resorting to this open procedure, we attempted a novel, minimally invasive technique for treating this seroma. Since this technique requires general anaesthesia, patient should be carefully selected. On seroscopy (laparoscopy of seroma), the mesh was lying loose in the cavity along with tacks, hence mesh was removed along with tacks. However, we did not do any additional procedure of decortication due to unpreparedness. This technique will not disturb the integrity of the abdominal wall since the well-formed pseudo capsule was left intact, which possibly may prevent hernia recurrence. This technique provides all the advantages of minimally invasive surgery (MIS), such as less pain and early recovery. At the follow-up of 1 year, no seroma or hernia recurred.

The case presented herein is due to its relative rarity atypical delayed presentation, associated with diagnostic dilemma. What we learned from this case is that late onset seroma formation may follow gradual subclinical process that eventually becomes apparent in later periods as well and should be considered in the differential diagnosis of patients with prior LVHR presenting with unremitting abdominal symptoms even after 5 years postoperatively. Laparoscopic approach assisted by seroscopy helps in successful resolution of this problem in select cases and should be used as one of the options in surgeon's armamentarium in today's world of ever-growing usage of MIS. Appropriate diagnosis, adequate preparedness and treatment, should help to resolve it successfully.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

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Conflicts of interest

There are no conflicts of interest.