Overview of Postoperative Seroma Management
A seroma is a condition where a clear fluid, also known as serous fluid, unexpectedly gathers in areas of the body where there’s empty space, such as areas where surgery has recently been performed. This fluid is a mix of plasma and lymphatic fluid. Seromas are quite common, particularly amongst people who have had surgery for breast cancer, plastic surgery, or abdominal wall hernia repair. In fact, seromas can occur in 15 to 85% of people after mastectomy surgery (a type of breast cancer surgery), and nearly 11% of people after an ‘abdominoplasty’ or tummy tuck.
Doctors are not quite sure why seromas form, but it’s thought to be related to the disruption of the body’s natural systems for draining extra fluid out of tissues, such as the lymphatic and vascular (blood vessels) systems. This disruption can occur during surgeries involving extensive tissue re-alignment and result in extra serum, the liquid part of blood, and possibly inflammatory exudate, the liquid produced during inflammation, filling any empty space, including surgical areas.
Seromas can lead to discomfort and stress for patients and may require extra doctor visits or even hospital stays. This leads to increased health care costs. Seromas can also lead to local wound complications, such as wound openings and flap necrosis, which is when a section of tissue dies due to lack of blood supply. These complications often require additional surgery to fix. Seromas are also linked with a higher risk of wound infection, which could potentially develop into an abscess, a painful, pus-filled area.
While current research is mainly looking into how to prevent seromas, the usual way to deal with seromas after surgery involves careful monitoring and removing the fluid with a fine needle.
Anatomy and Physiology of Postoperative Seroma Management
The healing of surgical wounds generally happens in three phases. First, the blood clots and inflammation begins (this is called hemostasis/inflammation). Next, there’s a time of active cell growth and repair (the proliferation phase). Finally, the wound strengthens and regains some of its former functionality (the maturation phase). If all goes well and there’s no infection, the wound edges come together and healing is speedy.
However, sometimes things don’t go as planned – an infection may occur, the wound might not get enough oxygen, or the wound could reopen. In these cases, a different healing process takes place. This kind of healing involves forming what’s known as granulation tissue, which helps build new skin. It’s a slower process and there’s a higher chance of ongoing wounds or infections if the wound isn’t cared for properly. Experts think that this slower healing process could be linked to the building up of fluid, known as a seroma.
What causes a seroma isn’t entirely clear. There are many reasons why this fluid buildup might occur. For example, surgeries that involve a lot of cutting through soft tissue could accidentally cut blood and lymph vessels. This, in turn, might lead to fluid build-up. Also, if a lot of tissue has to be removed during surgery, healing could be more difficult. The emptiness left by the removed tissue could create a sort of vacuum that might contribute to inflammation and fluid buildup.
Scientists have studied the fluid taken from seromas to learn more about it. Different studies have found differing results – some suggest the fluid is a lot like lymph fluid (the fluid that circulates in the lymphatic system to remove waste and toxins from bodily tissues), while others suggest that it’s more like inflammatory exudate (fluid that oozes out from wounds).
In rare cases, untreated seromas can lead to the formation of pseudocysts. These are like regularly cysts, but the lining is made up of fibrous tissue, not regular epithelial cells. However, we still do not fully understand why and how this happens, and the research on it is quite limited.
Why do People Need Postoperative Seroma Management
If you have a small pocket of fluid, known as a seroma, that isn’t causing any pain, problems with moving, or strain on a healing wound, it’s likely that doctors will just monitor the situation. Over time, your body usually absorbs this fluid without needing further treatment.
On the other hand, large seromas holding between 75 to 100 milliliters of fluid can cause pain, increase the risk of infection, and interfere with the movement of the area around it. A good example of this is a seroma in the armpit area, which can limit your ability to move your shoulder. If you have a large seroma, a doctor might need to drain the fluid using a procedure called aspiration to ease your discomfort.
Keep in mind, if the seroma refills with fluid after being drained, the doctor might need to drain it multiple times. In special cases, such as when you have a breast implant, the doctor might use an ultrasound to guide the aspiration procedure to avoid damaging the implant.
In rare instances, if a seroma continues to be a problem, a doctor might need to perform an operation to drain the fluid and clean the area. This might be the case if the seroma has become encapsulated into a sort of fake cyst, or if there’s an infection in the area.
When a Person Should Avoid Postoperative Seroma Management
There are certain situations where it’s not recommended to drain a seroma, a pocket of clear fluid that sometimes develops in the body after surgery:
– If the seroma is small, isn’t causing pain, and doesn’t interfere with movement or wound healing, it’s usually best to leave it alone.
– If there’s a pulsing bulge (pulsatile mass) in the area of the seroma, draining it may not be safe.
Equipment used for Postoperative Seroma Management
When you go to the doctor or hospital for certain treatments, the medical staff uses a set of tools to ensure that the procedure is performed properly and safely. Here is a list of what they might use:
- A clean cart that holds all the medical supplies
- A dressing pack containing bandages and other products used to cover and protect your wound
- A special wipe or device used to clean your skin and reduce the risk for infections
- A needle or cannula (a thin tube) typically size 18G, used to draw fluid or inject medicines
- A sterile (completely clean) syringe that can hold 20, 30, or 50 milliliters of fluid
- A universal container for collecting samples, such as urine or blood
- Disposable gloves and an apron that the medical staff use to protect both you and them from germs
- Sterile gauze to absorb fluid and protect your wound
- A sharps container, which is a safe place to dispose of used needles and other sharp medical tools
- A disposable absorbent pad that can soak up any leaks of fluid
- A disposable waste bag for any non-sharp medical waste
- A sterile dressing to cover and protect your wound after the procedure.
If you have a large amount of fluid built up under your skin, which professionals call a complex or periprosthetic seroma, your doctor might need to use a process guided by imaging technology to draw out the fluid. This is called radiologically guided aspiration.
Who is needed to perform Postoperative Seroma Management?
A seroma is a pocket of clear fluid that sometimes develops in the body after surgery. Seroma aspiration is a procedure to remove this fluid. A doctor or a specially trained nurse can perform this procedure at your bedside or in a clinic. However, if there’s a chance that the seroma might be infected, have blood in it, or be causing a surgical wound to split open (wound dehiscence), a doctor should examine it.
If the seroma is difficult to locate and requires an ultrasound to guide the procedure, and the doctor or nurse isn’t trained to do this, you may be referred to a radiologist. It is a doctor who uses imaging techniques like ultrasound to diagnose and treat diseases.
Preparing for Postoperative Seroma Management
Before beginning any medical procedure, it’s important that doctors properly identify the patient and assess their needs. This includes understanding why the procedure is necessary. The doctor must explain the procedure to the patient, including the risks and benefits, and get their agreement to move forward. This agreement is called ‘informed consent’. Some possible risks of medical procedures include pain, the chance of infection, the need to do more procedures in the future, or injury to other parts of the body around the area being treated.
In some cases, for instance, if fluid is being removed from around a joint replacement (called a ‘periprosthetic seroma’) or from the chest wall, there is a risk of damaging the artificial joint or causing a collapsed lung (known as a ‘pneumothorax’).
The procedure should start with the preparation of a clean space for the operation. This space should include all the necessary equipment and should be arranged in such a way that it remains sterile, or free of any germs, throughout the procedure. The doctor should follow a ‘non-touch technique’, meaning they avoid touching anything that’s not sterile as much as possible to reduce the risk of germs being introduced.
It’s also important that the doctor protect themselves from exposure to any bodily fluids. They do this by wearing personal protective equipment like gloves, a covering for their body (an apron), a mask, and a shield for their face (a visor). This helps keep both the patient and the doctor safe.
How is Postoperative Seroma Management performed
The doctor will start by placing you in the right position and carefully examining the seroma (an abnormal build up of fluid) to decide where to draw out this fluid. This is done so the doctor doesn’t have to touch the skin a lot after it has been cleaned, reducing the chance of causing an infection. If it’s possible and won’t hurt too much, the doctor may opt to insert the needle through the surgical scar. If they think there might be an infection in the fluid, they’ll prepare to take a small sample to be examined under a microscope and tested for bacteria.
Next, the doctor will clean the skin with a germ-killing solution. They’ll use a sterile sheet, with a hole in the middle, to keep the clean skin at the drainage site away from the unclean skin around it. The doctor will insert the needle in the middle of the fluid-filled area, angling it at about 45 degrees, in line with the body structures just underneath the skin. Once the needle is through the skin, the doctor will gently push it deeper while pulling back on the syringe, until they feel less resistance and fluid starts to come out. If the fluid stops flowing but the seroma isn’t completely gone, the doctor might move the needle somewhat to drain fluid from a different area. If they need to try again, they will use a new needle, but they will avoid repeating this too many times to minimize the risk of causing an infection.
When all the fluid is removed, the doctor will take out the needle and apply some pressure with a piece of sterile gauze to stop any bleeding. They will then cover the area with a sterile bandage. The fluid they drained should be clear; if it’s cloudy or pus-filled, it will be sent for tests, and you might be prescribed antibiotics if an infection is thought to be present.
After the procedure, you’ll need to arrange a follow up appointment soon to check and see if all the fluid is gone or if you need another drainage procedure.
Possible Complications of Postoperative Seroma Management
Seroma aspiration is generally a safe procedure – it’s a process where doctors use a needle to draw out fluid from a part of your body called a seroma. However, it may still come with some complications.
One such risk is bleeding. There might also be neurovascular damage, which is harm to your nerves and blood vessels. It’s important to remember that all procedures that break the skin can risk infection, and the more times you need fluid to be drawn, the higher this risk could be. Interestingly, research indicates that leaving a seroma untreated could lead to infections as well, so doctors must assess the risks before deciding to perform the aspiration.
If you’ve recently had surgery, like getting a breast implant, seroma aspiration carries the risk of puncturing and rupturing the implant. This could potentially require another surgery to fix. Trace this risk back, doctors might use ultrasound to guide them during the process and use a special type of needle.
Lastly, if the seroma is located on your chest wall, doctors have to be careful not to harm the pleura (the thin layer of tissue around your lungs), which could cause pneumothorax, or a collapsed lung. If you experience difficulty breathing or sudden shortness of breath during or immediately after aspiration, inform your doctor right away as it requires immediate medical attention. They might request a chest x-ray to check on the situation.
What Else Should I Know About Postoperative Seroma Management?
Seromas are pockets of fluid that can form after surgical operations where parts of the tissue have been extensively handled. These fluid collections often appear around 7 to 10 days after the surgery or after the removal of a surgical drain. Symptoms can vary, with some people not feeling anything, while others might experience discomfort, difficulty moving the affected area, or see the surgical wound reopening.
There are some conditions that a seroma can be mistaken for, such as:
- Hematoma: This means an abnormal gathering of blood outside blood vessels, which usually appears as a bruise.
- Abscess: This means a pocket of pus forming within body tissue. It often appears red and feels warm. The person might feel unwell or have a fever. To resolve it, the abscess must be opened and drained and antibiotics may be needed.
- Lymphedema: This is swelling in the body’s tissues caused by damage to the lymphatic system, a part of the immune system that helps remove excess fluid from the body’s tissues. It often happens after surgeries that require the removal of lymph nodes, such as those for breast cancer. The swelling might affect a localized area or an entire limb.
If a patient suspects a seroma after surgery, doctors will conduct a thorough examination and possibly perform blood tests. Ultrasound scans may also be necessary if the diagnosis is unclear or if previous treatments have been unsuccessful.
Seromas can be a common side effect of different surgeries such as breast cancer surgery, hernia repair, and abdominoplasty (commonly known as a tummy tuck). Each type of surgery carries unique risks and considerations. For example:
- In breast cancer surgery, the treatment of a seroma can be complicated as it could lead to complications such as losing an implant or harming the skin flap. The decision to drain a seroma in this context is complex and depends on several factors, including the patient’s symptoms, risk of wound reopening, and the potential impact on the appearance of the reconstructed breast.
- In hernia repair surgery, seromas could be mistaken for a recurrence of the hernia, which can lead to unnecessary additional surgery. Decisions around draining seromas in these circumstances need to be handled carefully due to the risk of infecting the surgical mesh used in the procedure.
- In tummy tuck procedures, seromas are the most common complication, but the chances of getting them are decreasing due to improvements in surgical techniques and preventative measures. These include a specific type of suture, special drains, and techniques that preserve a type of fascia (connective tissue) in the abdomen.
As a general note, draining the fluid from large seromas is a common way to provide relief for patients. It’s also possible that by examining the removed fluid, doctors can confirm the diagnosis. For example, the fluid in a seroma would appear clear/straw-colored, whereas if it is blood or pus, this might imply a hematoma or abscess, respectively.
