A seroma is defined as a clinically identifiable collection of serous fluid within a surgical cavity¹. It can develop gradually over days to weeks and is not associated with any bruising. A lymphocele refers to a collection of lymph fluid as a result of surgery specifically involving axillary lymph nodes. For the remainder of this document seroma aspiration will refer to both types of collections. Within studies it is shown that approximately 50% of patients following axillary dissection require further aspiration². There has been much debate whether the use of post-operative drains have an impact on seroma formation. A study that compared the incidence with or without a drain saw 8.3% of patients in the drain group and 50% in the no drain group requiring aspiration³.

With the role of nurses evolving, nurses are now undertaking more specialist roles to support initiatives such as nurse led services.  In order for nurse led services to be implemented successfully there needs to be collaboration within the multi-disciplinary team and robust guidelines / protocols developed to support the service.

Purpose of the guideline

This guideline has been produced to ensure that the procedure for seroma aspiration is performed safely and to a high standard within NHS Ayrshire & Arran. The intention is to prevent the occurrence of inconsistent practice in seroma aspiration.

Scope

This guideline will have an impact on all registered nurses employed by NHS Ayrshire & Arran who are deemed competent in seroma aspiration.

• To provide guidance to all registered nurses who have been deemed competent in seroma aspiration.
• To positively impact on the quality of care for patients requiring seroma aspiration.

Definition of terms

Seroma: A seroma is defined as a clinically identifiable collection of serous fluid within a surgical cavity. It can develop gradually over days to weeks and is not associated with any bruising.

Lymphocele: A lymphocele refers to a collection of lymph fluid as a result of surgery specifically involving axillary lymph nodes.

SACT: Systemic Anti-Cancer Therapy (SACT) encompasses both biological therapy (therapies which use the body's immune system to fight cancer or to lessen the side effects that may be caused by some cancer treatments) and cytotoxic chemotherapy (a group of medicines containing chemicals directly toxic to cells preventing their replication or growth, and so active against cancer).

A seroma presents as a visible swelling to an area of surgery. On palpation fluid movement can be felt. The presence of a seroma can increase the risk of infection, prolong hospital stays and delay the start of adjuvant cancer treatments such as Systemic Anti Cancer Therapy (SACT) or radiotherapy⁴.

As a result of tissue removed or undermined during surgery, a cavity is created. This permits the collection of serous fluid. This may resolve spontaneously, however this is dependent on influencing factors such as position, patient mobility and gravity. A seroma differs from haematomas; the fluid contains no red blood cells and a haematoma collection usually would become apparent in the first 24-48 hours after surgery. It is associated with firmness and bruising with pain when palpated. A seroma is softer when palpated and collects over a longer period of time. This may range from a few days to weeks after surgery. Seromas can be uncomfortable due to their size, but should not be painful. Pain could be a sign of infection so should be carefully assessed to exclude this.

Indications for seroma drainage

It is appropriate to aspirate a seroma when:

• It is visible to the naked eye, is palpable fluid and is free from infection; a clearly infected area should be assessed by the clinical team.
• It is causing pain, discomfort and/or pressure/tightness.
• It is affecting the function of the associated area.
• Any previous aspiration that is over 100ml, indicative of a potentially substantial seroma.

Contraindications to seroma drainage

It is not appropriate to aspirate a seroma when:

• There is presence of breast implant that could be ruptured (ultrasound guidance necessary).
• Swelling is minimal resulting in no alteration to function and no associated pain. Repeated aspirations of small collection carry a risk of introducing infection. In addition, it may delay the normal process of locating alternative routes to which the fluid can drain resulting in a longer period before the seroma settles down.
• There are signs of infection in the surrounding tissue, which may or may not exist in the seroma. Should be assessed by a medical clinician.
• There is a high risk of blood vessel rupture during the procedure.
• The swelling pulsates.
• The presence of haematoma is suspected.
• The patient is undergoing treatment or has pre-existing condition that could complicate aspiration, such as clotting disorders, SACT, radiotherapy.
• The patient does not consent to the procedure.
• If the patient is an adult with incapacity the appropriate national guidance must be adhered to.
• The health care professional (HCP) is not comfortable to undertake the procedure.

Potential complications of seroma drainage

• Damage to underlying structures e.g. pneumothorax, blood vessel puncture.
• Local infection/systemic infection.
• Drainage fails to resolve the seroma.
• Fluid aspirated includes pus.
• Seroma development is recurrent or increases.

Inclusion criteria

• Seroma to chest wall following mastectomy.
• Seroma to axilla following lymph node biopsy/axillary clearance.
• Seroma in lateral aspect of upper back in the latissimus dorsi muscle region following use of this muscle as a donor for reconstruction.

Exclusion criteria

• Patient who does not consent to having the procedure.
• Any patient who has an implant in place that could be punctured during aspiration.
• In patients where surgery has been anatomically complicated.
• Where swelling is minimal and causing no discomfort.
• In patients undergoing SACT/radiotherapy.
• Pulsating swellings which could have a vascular component.

Training

• The HCP must observe seroma aspirations performed by a senior team member already assessed as competent in the procedure.
• Under supervision of a competent practitioner, the HCP will be assessed using the Seroma aspiration competency document (appendix 1).
• The HCP must maintain competency. If the HCP has not aspirated a seroma for a period of 6 months the HCPs competency must be re-assessed.

Governance

• The HCP will complete a comprehensive assessment and determine that the patient and presenting seroma meet the criteria for seroma aspiration.
• The HCP will ensure none of the contraindications (see section on indications and contraindications above) apply to the patient prior to considering the procedure.
• The HCP will prepare the patient by fully explaining the procedure and obtaining informed verbal consent prior to the procedure.

• Trolley
• Sterile dressing pack
• Sterile gloves
• Apron
• Skin prep and antiseptic
• 20-30ml and 50ml syringes
• Sterile needles (16g white and 21g green)
• 3 way tap for large seromas
• Antiseptic skin preparation solution
• Sterile bowl/jug for aspirate
• Sterile dressing
• Gauze
• Sharps container
• Universal container and Microbiology request form if indicated.

• Prepare and position the patient.
• Set out a trolley and equipment adhering to a strict non-touch technique with sterile equipment.
• Prepare skin around anticipated puncture site.
• If the volume is anticipated to fill more than one syringe, then attach a syringe to the 3-way tap and the needle to the end of the 3-way tap or if no access to a 3-way tap, then attach the needle directly to the syringe.
• Insert needle at a 45 degree angle towards the seroma with bevel pointing upwards. Keep the needle as parallel as possible to the underlying structures to prevent puncturing them. Special care must be taken with the chest to avoid puncturing the lung.
• Entry through the surgical scar may assist with reducing discomfort as this will be insensate; however aim for the pointing of the seroma is more likely to be the best access for aspiration.
• There will be some resistance to the needle as it passes through the skin and once the needle is in the seroma the resistance should cease. At all times the needle should be kept as shallow as appropriate to avoid underlying structures but allow access to the seroma.
• If the seroma cannot be accessed, an ultrasound guided procedure may be indicated; to be discussed with the medical team if indicated.
• Once through the skin and in the fluid pocket, gently draw back on the syringe. If there is resistance then it is not in the fluid space and may need to be carefully positioned.
• Gentle re-positioning of the needle can assist in seroma drainage but insertion of a new needle may be needed if the collection is not in one area.
• No more than 3 unsuccessful attempts should be made before seeking advice from a senior member of staff.
• If a three way tap is not available but syringe is full the syringe can be disconnected and a second syringe used. Continue process until the seroma is resolved.
• If using a three way tap alter to halt fluid flow between syringe changes.
• If the fluid is cloudy a specimen can be sent for microbiology as it may indicate an infection. This can be sent in universal pot with request form.
• When seroma has resolved remove the needle and discard in the sharps bin.
• Apply pressure over the entry site with gauze for one minute.
• Clean area and apply a sterile dressing.
• Advise the patient that the dressing can be removed in 24 hours.
• Ensure the patient is aware of action to take if the seroma re-collects or has any other concerns including signs of infection.
• Record the amount and colour of the fluid in the medical notes.
• Recurrent aspirations may be required and should be discussed with the consultant in charge of the patient’s care.

• Unable to aspirate the fluid, could be due to incorrect placement of the needle. This may require re-positioning or re-insertion of needle.
• Pneumothorax, if the patient suddenly describes shortness of breath or chest pain. Stop immediately apply pressure to wound and seek immediate medical review of patient.
• Aspirating bright red blood. If this then becomes straw like it is due to puncturing a small blood vessel and aspiration can continue. However if the fluid remains bright red then it is due to a larger blood vessel being punctured. The needle should be removed and pressure put over the area for at least 5 minutes. If after this it continues, contact the appropriate medical team while continuing to administer pressure.
• The patient finds it too uncomfortable. The procedure should be abandoned.
• The patient develops an infection 48 hours after the aspiration. Ensure that patient knows the signs to look out for and that they have the correct contact details of whom to call.

Employees are reminded that they may have patients/carers who require communication in an alternative format e.g. other languages or signing. Additionally, some patients/carers may have difficulties with written material. At all times, communication and material should be in the patient’s/carer’s preferred format. This may also apply to patients with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on clinical guidelines e.g. choice of gender of health care professional. Consideration should be given to these issues when treating/examining patients.

Some patients may have a physical disability or impairment that makes it difficult for them to be treated/examined as set out for a particular procedure requiring adaptations to be made.

Patients’ sexual orientation may or may not be relevant to the implementation of this guideline, however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexual orientation may be relevant, tailored advice and information may be given.

This guideline has been impact assessed using the NHS Ayrshire and Arran Equality Impact Assessment Tool Kit. No additional equality & diversity issues were identified.

References

1. Woodworth, PA, McBoyle, MF, Helmer, SD, Beamer, RL (2000) Seroma formation after breast cancer surgery: incidence and predicting factors. American Journal of Surgery 66(5),444-50.
2. Petrek,JA, Peters,M and Nori,S (1990) Axillary Lympadenectomy. Arch.Surg 125, 378-382.
3. Zavostky J, Jones RC and Brenna, MB (1984) Evaluation of axillary lymphedenectomy without axillary drainage for breast conserving therapy. Annals of Surgical Oncology,158, 327-330.
4. Thompson,D, Sadideen,H and Furniss, D, (2013) Would drainage after axillary dissection for carcinoma of the breast. The Cochrane Collaboration. Wiley & Sons Ltd.

Bibliography

Dougherty, l and Lister,SE (2008).The Royal Marsden Hospital Manual of Clinical Procedures. Seventh Edition.

Seroma aspiration competency document