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O’Connor et al. Plast Aesthet Res 2019;6:26 I http://dx.doi.org/10.20517/2347-9264.2019.38 Page 3 of 9

In patients without systemic signs of sepsis, an effort toward mesh salvage should be attempted. Patients
should be immediately started on broad spectrum antibiotics and these can be narrowed based on
culture data. Percutaneous drainage of any fluid surrounding the mesh should be performed and the
drain should be left in place until source control is satisfactory. Any overlying necrotic tissue should
be surgically debrided; exposed mesh can be irrigated with antibiotics; and negative pressure wound
management systems can be placed to allow granulation formation over the mesh. Success rates of mesh
salvage protocols have been promising; however, this is very dependent on the structure of the mesh, with
[13]
macroporous mesh in the retrorectus position having the highest salvage rate . PTFE, multifilament
polyester, and heavy weight, microporous PPE, however, almost universally require explantation once
[14]
infected due to their poor tissue ingrowth and biofilm formation that prevent clearance of bacteria . Thus,
[12]
upfront excision of these mesh types is recommended to expedite recovery and ultimate reconstruction .
Seroma
Every patient who has an open hernia repair will develop some element of a seroma due to the potential
spaces created in the abdominal wall. The vast majority of seromas are asymptomatic and most resolve
[4]
without any intervention. Morales-Conde et al. created a seroma classification system, in which they
defined seromas as a complication only if they are symptomatic, persist longer than 6 months, or become
infected (Types III and IV). Clinically detected seromas that last less than 6 months (Types I and II) are
classified as an incidental finding, reflecting that these are considered normal sequela of the operation.
Type III seromas last longer than 6 months or become symptomatic, but do not require intervention, while
Type IV seromas are symptomatic and require intervention. In this classification system, only Type III and
IV seromas should be considered true complications as they affect the clinical progression of the patient.

Routine drain placement to prevent seromas has been debated over concerns that drains in direct
[15]
contact with the mesh could increase the risk of infection. In 2017, Krpata et al. queried the Americas
Hernia Society Quality Collaborative (AHSQC) and reviewed 200 cases where drains were placed in the
retromuscular space and 100 cases where they were not. These cases were matched based upon hernia
complexity and comorbidities. They found no difference in superficial, deep, or organ space SSI between the
groups, but there was an overall increase in SSO in the no drain group (20% vs. 10%, P = 0.02) with seroma
formation being the most significant increase (8% vs. 2%, P = 0.01). They did not, however, see a difference
in surgical site occurrences requiring procedural intervention (SSOPI), suggesting that most of these
seromas resolved without intervention. They concluded that routine drain placement does not increase the
risk for infection and may reduce the risk of seroma formation, although the clinical significance of seroma
formation continues to be debated.

Once a seroma has grown to cause pain, impede normal activities, or persist for longer than 6 months,
intervention is recommended for the alleviation of symptoms. The primary treatment option is
percutaneous drainage, which can be done with serial aspirations or by leaving a secured catheter in
place and monitoring the output overtime. These can either be performed in the office blindly or under
radiographic guidance with ultrasound or computed tomography, as long as a sterile technique is followed
to prevent secondary infection of the seroma. For seromas refractory to simple drainage, chemical or
mechanical sclerotherapy have both been described. Chemical sclerosing agents including talc, tetracycline,
doxycycline, ethanol, erythromycin, fibrin glue, and povidone/iodine have all been used with high
success rates and few complications; however, only small case series exist in the literature [16,17] . Lehr and
[18]
Schuricht described endoscopic ablation of the inner lining of the seroma using the argon beam in
extreme cases. Three ports are inserted into the seroma and the fluid is drained, followed by insufflation
to allow endoscopic guidance of the argon beam to ablate the entire lining of the seroma. These advanced
techniques should be used only in extreme cases, after failure of watchful waiting and percutaneous
drainage.