Hernia https://doi.org/10.1007/s10029-021-02430-8 ORIGINAL ARTICLE Closed non‑suction drain placement as haematoma and seroma formation preventive measure post‑nylon darn surgery for inguinoscrotal hernias in adults Israel Hagbevor1  · Mahamudu Ayamba Ali2 · George Asare Awuku3 Received: 19 January 2021 / Accepted: 11 May 2021 © The Author(s) 2021 Abstract Purpose Inguinal hernia is a common male surgical disease. Intervention carries a wide range of complications such as scrotal haematoma and seroma which may require surgical re-intervention or predispose patients to developing infections, pains or feeling of mass. This could lead to long hospital stay. Scrotal tamponade by bandaging or wearing of tight pants and elevation are practiced to reduce bleeding and haematoma formation. These methods require prolong use. Closed suction drains are scarcely used in resource-deprived communities due to high cost and non-availability. Aim This study was to determine the effectiveness of a closed non-suction drain in preventing scrotal collection requir- ing further surgical intervention and the predisposition to developing surgical site infection following nylon darn repair of inguinoscrotal hernia. Methods Forty (40) participants were recruited for a preliminary study and assigned into control and interventional groups (CG, IG) for purposes of inserting flexible feeding tube (FFT) wound drain after nylon darn (ND) repair. Daily measurement of drained scrotal collection was carried out in the IG till the day drainage was zero. Residual volumes in IG and wound col- lection in the CG who were not candidates for re-intervention were determined at 14th and 28th post-operative days using ultrasound scan. Data were analyzed using SPSS version 25. Results Three (3) patients (15.8%) in the CG required re-intervention. Surgical site infection rates for the CG and IG were, respectively, 2/19 versus 0/21 (ρ = 0.134).There was a numerical significant difference in the mean volumes of scrotal col- lections between the control (0.95 ± 0.42 ml) and the intervention group (0.44 ± 0.33 ml) [p value of 0.041] but with no clinical impact. Conclusion Simple inexpensive flexible feeding tube placement significantly reduced scrotal collection which forms a base for larger sample size in subsequent studies. This could reduce the feared risk of re-intervention, wound infection and long hospital stay post-operative. Keywords Non-suction · Drain · Nylon darn · Inguinoscrotal hernia Introduction Inguinal hernia (IH) is a common surgical condition which affects males predominantly [1] with a prevalence ranging * Israel Hagbevor from 3.15 to 9.4% in Africa [2, 3]. In Ghana, about 12% of futagbiisrael@yahoo.com men with IH die without early surgical repair [4]. For the 1 period 2015–2019, 60 (9.3%) out of the 643 IH cases man- Surgical Unit, Margret Marquart Catholic Hospital, Kpando, Ghana aged at Margret Marquart Catholic Hospital (MMCH) pre- 2 sented with intestinal complications. The procedures for her- Department of Surgery, School of Medicine, University of Health and Allied Sciences, Ho, Ghana nia represented about 59.1% of general surgical operations 3 of MMCH, a percentage we believe is similar to most district Department of Medical Laboratory Sciences, School of Biomedical and Allied Health Sciences, University hospitals in the country. Most patients with IH present with of Ghana, Korle, Bu, Accra, Ghana Vol.:(012 3456789) Hernia longstanding huge scrotal swellings which predispose them to post-op complications including scrotal collection [5, 6]. Nylon darn is an example of a tissue-based repair tech- nique for IH. It is a tension-free approximation of the ingui- nal ligament to the conjoint tendon with nylon suture from the pubic tubercle to the internal ring. This weave in the posterior wall of the inguinal canal was first described by Moloney. This method was chosen based on competence, cost effectiveness and its relative good potential to withstand surgical site infection [7]. Scrotal haematoma and seroma are common post-opera- tive complications thought to result from the extensive sac separation in huge and long standing indirect inguinal her- nias with reported incidence of 8–22% [8, 9]. Warfarin usage, valvular heart disease, atrial fibrillation, hypertension, recurrent hernia and coronary artery disease are also significant pre-operative risk factors for hematoma formation post IH repair, even though warfarin usage and recurrent hernia are independent risk factors [10]. Scrotal haematoma and seroma predispose patients to developing surgical site infection (SSI) as the collection can form a good culture medium for inoculated bacteria growth. SSI may require additional surgical intervention when antibi- otic treatment fails. Other consequences of SSI include pro- Fig. 1 A huge reducible left complete inguinoscrotal hernia longed hospital admission, weak and ugly scar formation and hernia recurrence. Figures 1 and 2 are examples of hernia types commonly managed in MMCH. Post-surgical scrotal bandaging and or elevation, wearing of tight pants and closed-suction drains have been in prac- tice to minimize bleeding and or accumulation of blood at surgical sites which are either expensive or ineffective [11]. Treatment of large inguinoscrotal hernias has specific aspects that are challenging in an environment where guide- lines cannot always be followed and financial barriers for standard care are high. It is relevant to investigate the best and safest manner to treat inguinoscrotal hernias. Very little is written about non-suction drains which may effectively decrease post-op seroma/haematoma formation. The aim of the study was to determine the usefulness of inserting a flexible feeding tube as a non-suction wound drain in preventing any blood and seroma accumulation at surgical site and scrotum therefore reducing the incidence of re-intervention, patient anxiety, wound infection and further antibiotic treatment. Outcome measures Fig. 2 An obstructed left complete inguinoscrotal hernia The main outcome was a need for surgical re-intervention for scrotal collection as stated in Table 1. Evaluation for surgical site infection was done using Suspected sites of infection were swabbed for culture and clinical signs: erythema, wound discharge, wound gape. sensitivity testing. 1 3 Hernia Table 1 Outcome measures of the study Inclusion criteria Type of outcome Outcome measures Duration Complete inguinoscrotal hernia patients aged 18 years and Primary outcome 1. The need for re-intervention Assessed above at the surgical outpatient department and emergency for 1 month units who were diagnosed and clinically evaluated through post-op history to identify comorbidities or potential cause of bleed- Secondary outcome 1. Surgical site infection Was ing disorder were included in the study. 2. Post-operative pain from drain assessed site first 5 Exclusion criteria days post-op Was Patients who did not complete the follow up instructions assessed were excluded from the study. Furthermore, those in the 24–48 h intervention group whose flexible feeding tube fell off before post-op time for drain removal were excluded in addition to partici- pants who opted out of the study. Post-operative pain was assessed using Numeric Rating Study design Scale. All participants were requested to give an answer at post-operative days 1 and 2. Physical examination was carried out to identify any ecchy- mosis, petechiae, haemolysis with jaundice and general fit- Terminologies ness of the patient for surgery. Laboratory investigations included Full blood count indexes to ensure that the pre- For the purposes of this study, scrotal seroma is defined as operative haemoglobin level, leucocytes and differential any volume of fluid accumulation in the scrotum post-oper- counts and platelet levels were within normal range. Bed- ation readily visible on physical examination and of concern side clotting time and other necessary investigations such as to the patient. chest X-rays, electrocardiogram (ECG), urinalysis were also Scrotal haematoma is also defined as the accumulation of done to ensure patients’ optimization. The standard protocol blood of any volume in the scrotum post-operation which is for nylon darn repair was explained to all patients as well readily visible on physical examination and of concern to as available options for scrotal support post-operative and the patient. their expected outcomes. Those who were willing to par- Scrotal collection refers to haematoma and or seroma. ticipate in the study were taken through the protocol to their understanding. The information included an insertion of a secured flexible feeding tube connected to a collecting bag at the wound site as a drain which was to be maintained till the Materials and methods principal investigator instructed its removal. Any collection in the drain bag was emptied and measured by the investi- This was a preliminary study involving forty (40) adult gator. All clinical changes such as bleeding, fever, pains, males with complete inguinoscrotal hernia (Miserez type discharge from wound, etc. observed must be reported for C hernias or H3–H4 hernias) who sort nylon darn repair immediate evaluation apart from the routine scheduled ward at MMCH, in the Volta region of Ghana. The diagnosis of rounds during the period of the study. They were also made complete inguinoscrotal hernia was made preoperatively aware of the requirement to return after discharge from hos- through clinical assessment and confirmed intra-operatively pital for scrotal ultrasound scan on post-operative day 14 and by an existing sac which was completely separated from the 28. An informed consent was then obtained from the willing spermatic cord structures as described by BAJA [12]. participants (WP) and the ward nurse assigned a consecutive The forty (40) participants were randomly assigned to count each time a participant was recruited starting from intervention and control groups (21:19), respectively. All 1. All odd numbered WP were pre-determined to belong team members were pre-trained on the protocols of the to the control group (CG), while even numbered WP were study. None bias was maintained by a pre-determined order assigned interventional group (IG). This order was main- of assigning patients to the groups which was handled by tained throughout the study independent of any influence. a ward nurse who was not part of the operating team. The A structured questionnaire, partly open-ended was admin- other team members comprising anaesthetists and the theatre istered for demographic data of WP prior to surgery. Partici- nurses were also blinded until the need for insertion of the pants then started our routine pre-operative counselling and FFT was communicated to them in theatre. anaesthesia review. 1 3 Hernia The pre-trained nurses at the surgical ward verified any- The drain was removed when it remained empty for 24 h. time a recruited participant was admitted to the ward after Scrotal ultrasound scan was carried out in both groups on going through the study protocol, understood the aim, expec- post-operative days 14 and 28 to measure volumes of scrotal tation of the study and if patient had any concerns regarding collections. his participation. The theatre assistant verified the assigned After each procedure, the pain management was the number and made the flexible feeding tube and collecting same for all participants as recommended by the hospital’s bag ready for any IG participant who was brought to theatre protocol. for the procedure. They were also always reminded by the The mean volumes of scrotal collections in IG and CG theatre assistant the right to withdraw anytime the tube was measured by ultrasound scan were compared using inde- shown to them. pendent sample t test. Other demographic characteristics were analyzed with descriptive statistics. Daily clinical Surgical procedure review for scrotal swelling and the need for surgical evacu- ation were done. Inspection for surgical site infection and Standard prophylactic antibiotic was given to all patients per the need to swab wound for culture and sensitivity test and the hospital protocol and continued in selected patients when institution of antibiotic treatment were also done. it was necessary per the intra-operative findings. Participants had either local, spinal or general anaesthesia based on the independent judgment of the anaesthesia team. Results The hernia sac separation and posterior wall re-enforce- ment was done using nylon darn technique described by The forty (40) participants aged 18–82 (46.3 ± 17.1) years. Moloney (Fig. 3). The mean ages of the CG and IG were 48.9 ± 17.4 years and 44.0 ± 16.9 years, respectively. The highest incidence of Intervention hernias occurred between 48 and 57 years with no significant difference between the two groups. Following closure of the external oblique aponeurosis, the One (4.8%) participant in the IG had diabetes mellitus. FFT connected to a collecting bag at an opposite end was Six (31.6%) in the CG and 3 (14.3%) participants of the IG advanced to the scrotum as described by Narayanswamy were hypertensive. et al. [13] and secured to the skin with nylon 2/0. Volumes Majority (52.5%) of participants had hernia for 1–5 years of fluid drained by intact tubes and bags in the IG were and 4 (10%) had the disease for over 10 years, while 3 (7.5%) determined post-operatively after carefully emptying it into of the participants had congenital hernia. The average dura- graduated measuring jar daily (Fig. 4). tion of participants’ hernia was 3.2 ± 1.0 years with the IG Fig. 3 Nylon darn repair of a posterior wall 1 3 Hernia Fig. 4 The right groin showing inserted flexible feeding tube Table 2 Patient characteristics Variable Control group (n = 19) Intervention group p value n (%) (n = 21) n (%) Average age (years) 48.9 ± 17.4 44.0 ± 16.9 0.203 Medical condition  Hypertension 6 (31.6) 3 (14.3) > 0.05  Diabetes mellitus 0 (0.0) 1 (4.8) > 0.05 Location of hernia > 0.05  Left 4 (21.1) 5 (23.8) > 0.05  Right 15 (78.9) 16 (76.2) Duration of hernia  < 1 year 2 (10.5) 2 (9.5)  1–5 years 8 (42.1) 13 (61.9)  6–10 years 5 (26.3) 3 (14.3)  > 10 years 3 (15.8) 1 (4.8)  Congenital 1 (5.3) 2 (9.5) Nature of hernia at presentation 0.036  Reducible 13 (68.4) 14 (66.7)  Obstructed 6 (31.6) 7 (33.3) Content of hernia sac  Viable small bowel 4 (21.1) 7 (33.3)  Viable caecum 0 (0.0) 4 (19.1)  Gangrenous caecum 1 (5.3) 2 (9.5)  Gangrenous small bowel 2 (10.5) 0 (0.0)  Empty sac 12 (63.2) 8 (38.1) 1 3 Hernia and CG averages 3.0 ± 0.9 and 3.4 ± 1.1 years, respectively Surgical site infection occurred in 2 participants of the CG (ρ > 0.05) (Table 2). who had small bowel resection and anastomosis and none in The commonest cause of delay in seeking surgical IG (ρ = 0.134). Blood culture in both participants isolated Cit- intervention was financial constraint (75.0%) followed by robacter koseri species which was sensitive to Amikacin and preference for herbal medicine (45.0%) and fear of surgery Ciprofloxacin. (35.0%). Scrotal oedema occurred in 3 (15.8%) CG and 2 (9.5%) IG Thirteen (32.5%) presented with intestinal complica- (p = 0.561). No mortality was recorded in this study. tions with three having resection for gangrenous caecum Participants of the IG stayed between 2 and 6 days with a and 2 gangrenous small bowel. The other eight had intestinal mean duration of 2.5 ± 1.0 day, while those of the CG stayed obstruction with viable bowel in the sac, four each for small between 1 and 34 days with a mean of 8.2 ± 6.3 days. The three and large bowel. participants who underwent haematoma evacuation stayed for Most participants 27 (67.5%) had a reducible hernia. 10, 11 and 14 days each. Those who had surgical site infection Majority (50.0%) of the participants presenting for elective also stayed for 19 and 34 days before discharged from hospital hernia repair had empty hernia sac, while 17.5% had viable (Table 4). small bowel as the hernia sac content. Spinal anaesthesia was The volumes of ultrasound measured scrotal collections in used in 31(77.5%) and local infiltration for 6 (15.0%) of the the CG (excluding three participants that underwent haema- participants. Three (7.5%) underwent general anaesthesia. toma evacuation) ranges between 0.8 and 28.9 ml with a mean The mean length of drains inserted was 15.2 ± 5.8 cm. volume of 0.95 ± 0.42 ml and that of the IG was between 0.0 Majority of the participants (76.2%) in the IG had their and 5.8 ml with a mean of 0.44 ± 0.33 ml which was statisti- wound drain in-situ for 2 days and 19.0% had it in-situ for cally significant (p 0.041). 3 days. The duration of wound drain ranges between 1 and 3 days with a mean of 2.1 ± 0.5 days. The measured volumes Discussion of all collections drained in the intervention group range between 3.5 and 190 ml with a mean of 33.4 ± 26.5 ml. Hernia repair as with other surgical procedures is not without Regarding the level of restriction of movement with the complications. One of the commonest complications follow- inserted drain, only one patient (4.8%) reported moder- ing inguinal hernia repair is scrotal seroma and haematoma ate restriction of his movement due to the presence of the formation [9, 10, 14]. These scrotal collections do not only inserted drain. Six (28.5%) experienced mild restriction, affect the patients psychologically but also could act as suit- while majority (66.7%) did not report any restriction at all. able medium for inoculated bacterial growth with resulting The incidence of scrotal haematoma/seroma between surgical site infection and its attendant complications. Con- the CG and IG was (4/19) 21.1% and 0.0%, respectively tinuous research that seeks the use of cost effective and readily (ρ = 0.027). Three (15.8%) of them required re-intervention available biomaterial to prevent collections is useful especially (evacuation) with drain insertion and wound closure. The among trainee surgeons. volume of evacuated scrotal haematoma ranges between 350 Several factors such as warfarin use, hypertension, atrial and 400 ml with a mean of 384.3 ± 17.9 ml (Table 3). fibrillation, valvular heart disease, recurrent hernia and cor- onary artery disease have been identified as significant pre- operative risk factors [10]. Most of these likely confounders Table 3 Post-operative complications of post-operative haemorrhage such as bleeding disorders and use of blood thinners such as warfarin, aspirin and clopidogrel Complication Control Intervention p value have been excluded among the participants. The other modifi- group group (n = 21) (n = 19) n (%) able risk factors such as hypertension and diabetes mellitus n (%) have been appropriately managed to eliminate their influence on the outcome of this study. Scrotal seroma/haematoma 4 (21.1) 0 (0.0) 0.027 Hypertension, an important risk factor for post-operative Scrotal oedema 3 (15.8) 2 (9.5) 0.561 scrotal haematoma formation was a comorbidity in 9 willing Surgical site infection 2 (10.5) 0 (0.0) 0.134 participants. However, these patients had achieved good blood Table 4 Ultrasound measured Study groups Drain inserted No drain inserted Total scrotal collections among the n = 21 n = 16 N = 37 participants Mean SD Mean SD t-value df p value Scrotal collections 0.44 0.33 0.95 0.42 0.837 7 0.041 1 3 Hernia pressure (BP) control (BP < 140/90 mmHg) on oral antihyper- Furthermore, this will be readily available, accessible to low tensives prior to and after the surgery. Its influence to forma- income and developing regions. tion of haematoma or seroma was not statistically significant between the two groups (ρ > 0.05). Intestinal complication of hernia posed a significant risk to scrotal haematoma, seroma formation and surgical Appendix 1 Materials used for the surgery site infection [15]. Elective hernia repair was carried out in majority (67.5%) of the participants which is consistent Material Description with general trend in most studies [16]. Six (31.6%) control and 7 (33.3%) intervention group participants underwent an Sutures Round bodied ½ C 40 mm Nylon emergency hernia repair with varied hernia sac contents. 2, Reverse cutting ½ C 31 mm Nylon 2/0 and Round bodied The contents of the hernia sac invariably affected the risk of ½ C 40 mm Polyglycolic acid infection as well as scrotal collection formation. Violet 2. All manufactured by Surgical site infection occurred in 2 out of the 19 (10.5%) Shangai Channelmed Import & participants in the control group, while none was observed in Export Co, Ltd, China the intervention group despite the resection and anastomo- Drain Sterile non-toxic stomach tube, 16 FR, 49-inch-long. Manu- sis of gangrenous bowel segments in both groups. Indeed, factured in China and supplied the less than 1 ml ultrasound measured scrotal collection by SHANGHAI HESN IMP & difference between the two groups may appear irrelevant. EXP.CO LTD However, regarding risk of surgical site infection, the least volume of scrotal collection that may occur in the presence of bowel content contamination at time of surgery may sig- Acknowledgements I am grateful to Cynthia Dzigbordi Larnyoh, my wife for been very supportive in the write-up. I thank Dr. Eric Gyamfi nificantly increase the risk of surgical site infection and its and Mr. Hanson Emmanuel Torde for permission granted me to use the attendant complications. This therefore buttresses the point facility. My appreciation also goes to the following persons Dr. Sedem that near zero scrotal collection post-operative should always Agbovi, Dr. Sally Foli, Mr. Johnson Pewudie, Mr. Richard Dzaka, Mr. be aimed at. SSI may require additional surgical intervention Patrick Dakurah, Mr. Emmanuel Abedi, Mr. Ibrahim, Mr. Sebastian Babanonkanta, Mr. John Ocansey, Selina Ayiku, Jordan, Abigail, when antibiotic treatment fails. Ruth, George, Anthoinette, Sahadatu, Xornam, Joyceline, Bright Akiti, In addition, while no participant in the intervention group Ernestine Deh, Diana, Peace Agbavitor, Alfred Anati and Justice. As developed scrotal haematoma/seroma, four (4) (21.1%) of well as all staff of MMCH who played various roles in the care of the the participants in the control group developed scrotal hae- subjects from admission to discharge and follow-up visits, I say thank you very much. matoma post-operative (p < 0.05). The scrotal collections were significant among three (15.8%) of the participants Funding The research was solely funded by the authors. necessitating a re-intervention, an outcome which the use of the drain is intended to avoid. It was observed that all Availability of data and materials The data that support the findings three participants who underwent re-intervention had an of this study are available from the corresponding author, [I.H], upon emergency hernia repair with one requiring bowel resection reasonable request. and anastomosis for a gangrenous caecum. Code availability The custom code of this research is available from Length of hospital stay was reduced significantly in the the corresponding author, [I.H] upon reasonable request. intervention group (2–6 days with a mean of 2.5 ± 1.0 days) compared to the control group (1–34 days with a mean of Declarations 8.2 ± 6.3 days) (p = 0.012). This intervention had demon- strated effectiveness in significantly reducing the risk of Conflict of interest The authors declare that there is no conflict of in- re-intervention, length of hospital stay, and surgical site terest. infection especially during emergency repair of huge ingui- Ethics approval The study was approved by the Ethics Committee of noscrotal hernias. the University of Health and Allied Sciences (UHAS), Ho with Proto- col Identification Number: UHAS-REC A.4[7] 19-20. Conclusion Open Access This article is licensed under a Creative Commons Attri- bution 4.0 International License, which permits use, sharing, adapta- The function of flexible feeding tube as a closed non-suction tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, drain in this preliminary study provided a promising alter- provide a link to the Creative Commons licence, and indicate if changes native scrotal collection preventive measure after inguino- were made. The images or other third party material in this article are scrotal hernia repair with nylon darn without side effects. included in the article’s Creative Commons licence, unless indicated 1 3 Hernia otherwise in a credit line to the material. If material is not included in 9. 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