Ventral hernias (epigastric, umbilical, paraumbilical, and incisional defects of the anterior abdominal wall) are repaired in large numbers throughout general surgery and have become the standard of care due to the reduction in recurrence with the use of prosthetic mesh alone over suture alone. This balance is understood: the more densely meshed, the more dissected, and the larger the dead space created during the repair, the greater the risk for postoperative fluid collections. This is where the choice of the mesh plane is important. In a meta-analysis of randomized trials, onlay placement was shown to have a substantially higher seroma risk compared to sublay repair (RR 2.61; 95% CI 1.86-3.66) [1] and shows that seroma is not an incidental nuisance, but a technique-sensitive outcome.

Seroma rates have been reported to be quite variable based on definitions, detection, and approach. When the subclinical collections are counted using imaging, the figures can rise to 78% after laparoscopic repair and approximately 50% after open repair [2]. There are other factors, however, that can be used as predictors of retroprosthetic and persistent posterior collections, such as the size of the prosthesis and body mass index [3,4]. While most seromas heal on their own, a portion of them necessitate prolonging drain use, result in pain and delay wound healing, or lead to infection or aspiration or reoperation, which are all expensive realities in the limited-resource setting.

The mechanism of how seroma forms is fairly well known. Surgical dissection, by cutting through lymphatics and small blood vessels, creates an opening of these structures and the inflammatory exudate fills the dead space created between tissue planes. Local fibrinolytic activity prevents this fluid from solidifying into a firm clot and transudate persists. [5] A crucial point, where an anti-fibrinolytic agent might be able to intervene, is that mechanism.

Tranexamic acid is a synthetic lysine analogue that competitively inhibits plasminogen to plasmin conversion and prevents premature dissolution of fibrin clots, is cheap, widely available and can be given by intravenous, oral or topical routes [6]. It is known to decrease surgical bleeding in a large body of evidence [7] and has been demonstrated to decrease death rates due to haemorrhage in trauma when administered early without a significant increase in thrombosis [8]. It is therefore biologically plausible that the same fibrin-stabilizing effect could also help to reduce the risk of seroma.

As is well-known, the clinical outcome is not consistent beyond hernia surgery. Other studies of breast and body contouring have shown that fluid collection is decreased; a single randomized study in reduction mammaplasty demonstrated no benefit [9] and a meta-analysis concluded that TXA has limited impact on seroma even among patients in whom haematoma has been shown to decrease [10]. In this context, specifically for hernias, the evidence is sparse and limited to a few local studies such as those from Peshawar which indicate that ventral hernia repair resolves seroma faster compared to other studies [11,12]. This study directly answers the question by evaluating, in a local tertiary care cohort, the effect of TXA on the incidence and need for drainage after open ventral hernioplasty.

Study design and setting. The study was cross sectional comparative study conducted in Department of Surgery, Mercy Hospital, Peshawar from 1st May 2025 to 30th April 2026. This protocol has been submitted to the institutional ethical review committee [FILL: approval reference number] and informed written consent was obtained from all participants prior to enrolment. Participants. Sixty consecutive patients with elective open ventral hernioplasty with mesh were included. Patients eligible for the study were between 18 and 60 years of age [FILL: confirm the age range] and had a primary or an incisional ventral hernia that was a good candidate for elective open hernia repair. Those undergoing emergency surgery and strangulated-hernia surgery, had known bleeding disorders or were on anticoagulant therapy, had previously had venous thromboembolism, renal impairment, or were pregnant were excluded. These have been used to keep the comparison as clean as possible and to minimize recognized thrombotic contraindications to the use of antifibrinolytics. Grouping and intervention. The participants were divided into two groups, each with 30 participants, depending on TXA exposure. The TXA group were administered 1 g of IV TXA at skin closure and then 500 mg orally every 8 hours for 5 postoperative days, similar to the doses used in other regional trials of hernia repair [11,12]. In the non-TXA group, all patients were treated in the same way, except that the agent was not used. Standard polypropylene mesh was used for repairs and Each patient had an open suction vacuum drain in place to allow objective output measures. Outcome measures. Primary outcome seroma, which was defined as the appearance on clinical examination of a fluctuant collection, confirmed by ultrasonography if clinically indicated, within 30 days of surgery. The secondary outcomes included total drain output in milliliters, time to drain removal (when the drain output was less than 30 mL/day), time to clinical resolution of seroma, and surgical-site infection. Patients were evaluated at admission and then on postoperative 7th day and at 1 month. Throughout, adverse and thromboembolic events were noted. Data collection and analysis. Basic demographic and clinical data were collected on a structured proforma including age, sex, BMI, hernia type, and co-morbidities. The data were input and analyzed using IBM SPSS Statistics 26 (SPSS) software. Continuous variables were summarized as mean ± SD and compared using the independent-samples t-test; categorical variables were summarized as frequencies and percentages and compared using the chi-square test, with Fisher’s exact test used for cases where cell counts were less than five. Association between TXA exposure and seroma was presented as an odds ratio (OR) with corresponding 95th confidence interval (95th CI). The p value of <0.05 was considered statistically significant. Supplementary survey. A short-structured questionnaire was completed with surgical consultants and postgraduate trainees at the institution [FILL: confirm n surveyed] to record their reported use of TXA, preferred route and perceived impact on seroma. Descriptive analysis was used to analyze the answers given in the survey.

Each of the figures in this section (along with those in Tables 2 and 3 and Figure 1) is a generic representation of the range published in the literature and should be replaced by the actual values in the Mercy Hospital cohort.

Evidence for TXA and seroma published. Table 1 summarizes the studies that provide the context for the present work. But this is not a uniform pattern across them and that nuance is the point: the agent consistently lowers fluid-related outcomes in some settings, but not in others.

Table 1. Summary of key published studies on tranexamic acid and postoperative seroma/drainage

Baseline characteristics. There were no differences between the two groups at baseline. The mean age was 38.4 ± 9.6 years in TXA group and 37.1 ± 10.2 years in controls and a predominance of females was similar to the regional series. There were no significant differences in mean BMI, type of hernia and comorbidity burden between groups, providing some rationale for comparing outcomes.

Primary end point — seroma formation. The TXA group had 6 patients with seroma (20.0%) while the non-TXA group had 14 (46.7%). The difference was statistically significant (χ² = 4.80, df = 1, p = 0.028), and the odds of seroma weresubstantially lower with TXA (OR 0.29, 95% CI 0.09–0.90). In practical terms, about 20% of TXA patients had a clinically detectable collection compared to almost 50% of those who did not receive TXA.

Secondary outcomes. The same was true for the measures related to draining. Total drain output averaged 180 ± 55 mL in the TXA group versus 290 ± 80 mL in controls (p < 0.01), and the drain was removed earlier in TXA patients (4.2 ± 1.1 days versus 6.1 ± 1.6 days; p < 0.01). Those who did develop a seroma had a shorter time to resolve when treated with TXA (median ~5 days versus ~8 days). The incidence of surgical-site infection was numerically less with TXA (2/30, 6.7%, versus 4/30, 13.3%) although this difference was not significant (p = 0.39), reflecting the small number of absolute events, and the size of the cohort.

Table 2. Mercy Hospital cohort: baseline characteristics and outcomes by group (placeholder values)

Safety. No venous thromboembolic, seizure, or other serious adverse events attributable to TXA were recorded in either group during the follow-up period.

Practitioner survey. The survey of local surgeons and trainees gives context to these results and points to an uneven adoption of TXA in routine hernia practice (Table 3).

Table 3. Practitioner survey on TXA use for seroma prevention (n=25) (placeholder values)

The cohort data coupled with the survey findings indicate not only a clinical benefit that is measurable but also a need, among local surgeons, for a more standardized approach with a minor percentage of surgeons remaining skeptical of the thrombotic safety of the approach.

The key result of this study is simple: There was no thrombotic cost, and patients receiving tranexamic acid had less seroma after ventral hernioplasty. The direction of these results is in the right order and the approximate magnitude is in the ballpark with that of the regional hernia literature. In a similar TXA protocol, Tarar et al. reported that most seromas healed within 6 days after repair of a ventral hernia [11] and another Pakistani series revealed that most patients who received the TXA treatment had seromas resolve within a short period [12]. The current group builds on these observations by having a concurrent comparison group, so that an estimate of effect, in this case the odds ratio of 0.29, can be obtained, not just a single arm description of the resolution time.

This effect is mechanistically feasible. TXA prevents plasminogen activation and thus helps to maintain the fibrin matrix that would otherwise be broken down in early postoperative wound and thereby restricting the ongoing transudation responsible for the seroma [5,6]. The same anti-fibrinolytic effect seen with surgical bleeding during various procedures [7] seems to carry over in some degree to reduced fluid accumulation in the dead space of a mesh repair. Support comes from an experimental mastectomy model which demonstrated that topical TXA reduced formation of seroma similarly to corticosteroid instillation [18].

A level of honesty with regard to the broader evidence is important in this instance, as it is not all positive. No significant decreases in seroma or haematoma were found with use of TXA in a randomized trial of reduction mammaplasty [9], and a breast-surgery meta-analysis suggested that TXA seemed to offer little benefit for seroma despite its effectiveness in decreasing haematoma in cosmetic surgery [10]. There are several explanations that explain the mixed messages and the current findings. Surgical context should not be neglected, as the dead space and the lymphatic drainage, as well as the fluid dynamics of a subcutaneous breast pocket are not those in an abdominal-wall mesh repair and the most common complication in breast surgery is not seroma but haematoma. Doses, routes and time also differ between studies, and one dose during surgery can have a different effect compared to a combination of an intravenous and oral dose given over several days after surgery. The same applies to the body-contouring literature, in which reports of less drainage and earlier drain removal with TXA are reported but selective use is advised instead of routine use [15,16]. The evidence as a whole indicates that TXA can be of benefit when continued fibrinolysis in a fluid-filled space is the rate-limiting step, which is a good match with ventral hernioplasty.

The secondary outcomes reinforce the interpretation. Reducing overall drain output and timely removal of drains is not just a statistical quirk, but it will also reduce the time for drain-related discomfort and subsequent infection, and may alleviate strain on the inpatient and follow-up services. Although the difference in the TXA group was not statistically significant, it is consistent with the notion that the fewer the amount of residual fluid, the fewer culture media for bacterial colonization, and this was observed in mastectomy surgery, which found that TXA decreases the amount of seroma and wound infection [14]. The lack of thromboembolic events is similar to the overall safety profile of TXA in patients at high thrombotic risk [8,17] who were not included here.

The practitioner survey provides a practical perspective. A definite majority of local surgeons felt there was benefit, but not routine use and a significant minority was worried about thrombosis. This is another discovery: the obstacle to adoption is not so much a lack of efficacy as a lack of an agreed institutional protocol and safety in the right patient in the right context.

There were a number of caveats that temper these conclusions. The generalizability and the statistical power of the single-center cross sectional design and the limited sample size, especially for low frequency outcomes like infection and thromboembolism are limited. Although baseline characteristics were comparable, potential residual confounding due to grouping by TXA exposure and not randomization. Detection of seromas was dependent in part on clinical examination, meaning that subclinical collections (those that may only be found during imaging) may not have been identified, and follow up was not performed beyond one month, which would not detect late or recurrent collections. Lastly, all the values reported in this draft are provisional until the values for the cohorts and the survey are added; conclusions should be reevaluated after analysis of the actual values for the cohort and the survey. Randomized controlled trial (RCT) with imaging outcome measurement and more long-term follow up is the natural next step,

For open ventral hernioplasty, tranexamic acid use in a comparative cohort was correlated to lower rates of seroma and lower drain burdens with no reported increase in thromboembolic events. The effect is biologically plausible, fits the hernia trend and is similar to what other surgical areas have seen in other trends after adjusting for context, dose, and route. Considering the ease of administration, familiarity and low cost of TXA, the results of this study suggest its use as an inexpensive adjunct in seroma prevention in appropriate patients until an institutional protocol is established. The cross-sectional design and small number of patients means that results need to be confirmed in a properly-powered randomized trial with imaging data before it is advised to be adopted by routine clinical practice

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