Postoperative seroma is an accumulation of serous fluid in the suture area caused by soft tissue injury. It is a complication of surgical interventions. It resolves on its own or takes a chronic course. It is manifested by swelling in the seam area, a feeling of bursting, unpleasant sensations and the effect of fluid transfusion when changing the position of the body. With large seromas, there is a violation of the general condition, subfebrility. Pathology can be complicated by infection, the formation of necrosis. Treatment – puncture or drainage with active aspiration on the background of drug therapy. In some cases, repeated operations are required.
ICD 10
T81.8 Other complications of procedures, unclassified in other headings
Meaning
Postoperative seroma (suture seroma) is a common complication of the early postoperative period. It is most often found in general surgery, mammology, oncology and plastic surgery. According to various data, the frequency of formation of clinically significant seromas after operations accompanied by significant detachment of soft tissues ranges from 0.8% to 80% or more. The complication can develop in patients of any age and gender, it is more common in women of the middle and older age group.
Causes
Seroma is a polyethological condition, considered as a complication of extensive surgical interventions. Some experts are of the opinion that the accumulation of fluid in the projection of a postoperative wound cannot be considered a complication, since it represents a normal healing process in the exudation phase.
In support of their point of view, scientists cite ultrasound data, according to which postoperative seromas (including clinically insignificant ones) are detected in 100% of patients. The main provoking factors of the formation of large seromas that require active therapeutic measures are:
- significant detachment of adipose tissue;
- large wound surface;
- rough surgical manipulations with tissues (numerous incisions, seizure with a crushing instrument, etc.);
- excessive use of coagulation;
- large thickness of subcutaneous fat (more than 5 cm).
Predisposing conditions include individual characteristics of the body, immune disorders, diabetes mellitus and chronic somatic diseases that negatively affect the wound healing process. Most often, postoperative seromas are formed after abdominoplasty, hernioplasty, mammoplasty, mastectomy, appendectomy, cholecystectomy. When using implants, irritation of surrounding tissues and the development of aseptic inflammation due to contact with the endoprosthesis is important.
Pathogenesis
There are different points of view on the pathogenesis of serom. According to the most popular, extensive incisions, detachment of soft tissue structures, crushing or cauterization of tissues and other factors cause significant damage to small lymphatic vessels. Lymphatic vessels are thrombosed slower than blood vessels, as a result, lymph pours into the tissues for a long time. At the stage of exudation, the liquid part of the blood goes beyond the blood vessels, which increases the amount of fluid in the tissues.
Straw-yellow liquid containing macrophages, mast cells, leukocytes and protein fractions accumulates in the cavities that have arisen in the area of the postoperative wound. Normally, this liquid is aseptic. If microorganisms enter, suppuration with the formation of an abscess is possible. Large accumulations of fluid exert pressure on the surrounding tissues, disrupt blood supply, as a result of which areas of necrosis may form along the edge of the sutures.
Classification
In clinical practice, classification is used, which is based on the need and tactics of pathology treatment. According to this systematization, there are three groups of postoperative seromas:
- Group 1. Asymptomatic formations that do not require therapeutic measures.
- Group 2. Symptomatic seromas, which can be eliminated by punctures or active drainage.
- Group 3. Symptomatic fluid accumulations requiring repeated surgery.
Symptoms
Small formations do not cause unpleasant sensations and disorders of the general condition. The only signs of seroma are swelling and a positive symptom of fluctuation in the area of postoperative sutures. Sometimes patients notice a feeling of fluid transfusion during a change in body position. Hyperemia of the skin in the suture area is usually absent.
Patients with large seromas complain of non-intense pulling pain, a feeling of pressure or bursting, which increase in the standing position. A roller-like fluctuating swelling is revealed in the projection of the sutures. The length of the swelling usually coincides with the length of the seam, the width can vary from 2-3 to 10 centimeters or more. Local hyperemia, weakness, fatigue, and an increase in body temperature to subfebrile figures are possible.
Complications
The most serious complication is suppuration of seroma. With a large amount of fluid, large abscesses form. It is possible to melt the underlying tissues with the development of peritonitis. Some patients develop sepsis. Necrosis with seromas, as a rule, proceeds more favorably, seizing small areas of tissue in the suture area. Chronic seromas worsen the quality of life, significantly increase the period of disability after surgery.
Diagnostics
Usually seromas develop during inpatient postoperative treatment, so the diagnosis is made by the attending physician. Diagnostics is based on the data of an objective examination, if necessary, additional studies are prescribed. The survey program may include:
- Physical examination. In favor of seroma, the presence of limited swelling of tissues in combination with a positive symptom of fluctuation indicates. In the absence of infection, hyperemia is not detected or insignificant, palpation is not painful. When infected, the skin is purplish-cyanotic, the feeling is sharply painful, dense swelling of the surrounding tissues is determined.
- Ultrasound of soft tissues. It is indicated to confirm the diagnosis with a doubtful symptom of fluctuation, to clarify the size of large seromas at the stage of preparation for surgery. Indicates the presence of a cavity filled with liquid.
- Laboratory tests. To study the nature of the contents of the seroma, a cytological examination is carried out. If infection is suspected, a liquid is pumped to determine the pathogen, a general blood test is prescribed to assess the severity of inflammation.
Postoperative seroma treatment
Treatment is carried out in a hospital setting. With large formations, the absence of signs of resorption, complex therapy is indicated, including conservative and operative measures.
Conservative therapy
The goal of conservative treatment is to reduce the likelihood of infection, eliminate aseptic inflammation, and reduce the amount of fluid. Medicines of the following groups are used.
- Antibiotics. In the absence of suppuration, patients are prescribed broad-spectrum drugs intramuscularly for prevention. When signs of infection appear, the antibiotic therapy plan is adjusted taking into account the sensitivity of the pathogen.
- NAIT. Nonsteroidal anti-inflammatory drugs reduce the manifestations of inflammation and the amount of fluid released into the lumen of the cavity of postoperative seroma. Intramuscular administration or oral administration is possible.
- Glucocorticoids. Hormonal drugs eliminate aseptic inflammation, block the formation of fluid. Medications are injected into the seroma cavity after fluid removal.
Surgical treatment
The tactics of surgical treatment is determined by the size of the seroma, the effectiveness of therapeutic measures at previous stages. With uncomplicated seromas , the following options are possible:
- Punctures. The easiest way to remove liquid. It is performed 1 time every few days, usually 3-7 punctures are required for a complete cure.
- Active aspiration. If punctures are ineffective, a significant volume of seroma is installed in the cavity of the formation with a drainage device for active aspiration.
- Reconstructive operations. They are indicated for persistent chronic gray course, lack of results after treatment in more gentle ways.
With suppurated seromas, an autopsy is performed, drainage of the purulent cavity. When necrosis sites are formed, bandages are performed until the scab is rejected and the wound is completely healed. All surgical methods are used against the background of conservative therapy.
Forecast
The prognosis is favorable in most cases. Small seromas often resolve on their own within 1-2 weeks. The effectiveness of punctures for seromas on the background of planned plastic and abdominal operations is about 90%. Reconstructive interventions are rarely required. The percentage of suppuration is insignificant, the complication develops more often after emergency operations, in the presence of concomitant pathology, overweight.
Prevention
Preventive measures include a thorough assessment of the risk of surgical interventions, a detailed preoperative examination, compliance with the technique of operations. Surgeons need to refrain from too wide incisions, rough manipulations with tissues, excessive use of the coagulator.
Literature
- Pollock TA, Pollock H. Progressive tension sutures in abdominoplasty: A review of 597 consecutive cases. Aesthet Surg J. 2012 link
- Skillman JM, Venus MR, Nightingale P, Titley OG, Park A. Ligating perforators in abdominoplasty reduces the risk of seroma. Aesthetic Plast Surg. 2014
- Titley OG, Spyrou GE, Fatah MF. Preventing seroma in the latissimus dorsi flap donor site. Br J Plast Surg. 1997 link
- Pollock H, Pollock T. Progressive tension sutures: A technique to reduce local complications in abdominoplasty. Plast Reconstr Surg. 2000
- Jain PK, Sowdi R, Anderson AD, MacFie J. Randomized clinical trial investigating the use of drains and fibrin sealant following surgery for breast cancer. Br J Surg. 2004 link