Seroma, The Pocket of Fluid to Keep Quiet

This is Molly, a bouncy and bubbly six month old Rottweiler who was spayed at our veterinary clinic about a week ago.

I talk often about how important it is to have a good history and a guardian who is attentive and watchful. It really can make all the difference in the world when you want a fast and economical diagnosis, which is imperative to tailor a successful (and the most affordable)  treatment plan.

Molly's mom noticed a baseball sized soft fluid filled "bump" at her spay incision site a day ago and brought her in to see me.

I have spoken about masses, lumps, and bumps often here. I always stress how important it is to not diagnose them based on a photo. You see a patient is more than the bump they are attached to. They are the storyteller to your puzzling problem. To find the answers quickly it is helpful to have a medical record, a loving pet guardian who pays attention, and a vet who is a part of your pets short and long term care.

Here is how I approached Molly's water balloon looking belly bump:

1. History: Spayed two weeks ago here. It is very helpful to know who spayed her, what surgical protocols were used, and how the patient did during their surgery. This is available through the patients record and the surgeon. This is hugely important when you think about where to have your pets care provided. There are lots of wonderful surgical facilities around us, but knowing this information is extremely helpful for any post-operative questions or concerns.

2. Examination: Molly doesn't seem to like either restraint, nor, me touching her belly. This is where the benefit of an inpatient examination and not diagnosing from a photo has the real value of a good client-patient relationship. Molly was bright, playful, had a normal temperature (very helpful in assessing infection) and seemed to be acting completely normally..but that belly bump needed to be classified and Molly wasn't convinced that this was any fun.

A wiggly girl is somewhat difficult to assess with just your hands. Every time I touched her belly she got tense. When palpating we use our fingers to "feel" for texture, consistency, and help our head decide what our hands are seeing.

The big dilemma with these cases are;

1. Is the incision (both the abdominal wall and the skin incision intact? This can only be assessed by your vet. There are two layers that are incised to get into the abdomen; the skin, and the muscle of the abdomen. These are ALWAYS sutured closed separately and must be assessed independently by a vet. If the skin incision is opening we often will staple or glue the edges closed, and place a e-collar to curb the pet form licking or chewing it open any further. BUT, if the abdominal wall is opening we go have to go back in and close it. If you don't the intestines can spill out of the abdomen and get trapped between the layers. Intestines are squeezing, flexing, highly active tubes, like writhing, slithering tentacles. They get into trouble if not kept contained. They twist on themselves and strangulate. This can lead to death of the intestines and cause death to the pet.

2. If these incisions are intact where is the fluid coming from?

I could palpate Molly's incisions and knew that they were all still completely intact. She did allow me to do this. She was however not so patient with my fingers probing her belly fluid pocket.

If she was a quiet patient I would have summised based on all of her clinical findings that she did not have an infection.... but she kept squirming and protesting to my probing... so I did the next best thing.... I drew off a sample.

This is what we call "serosanguinous" fluid, or blood tinged serum.

And, now Molly had a diagnosis; Molly had a seroma. A seroma occurs after a surgery has been done. The body planes (the example here is the abdominal wall and the skin layers) have been separated and the body doesn't like empty or dead space so it tries to 'fill it in' by adding fluid. The result is a collection of fluid between the layers of skin and muscle. It should be 'quiet' or non-painful, soft fluid, without heat or other signs of infection associated with it.

My treatment of choice for a seroma is to just leave it alone. The body will slowly reabsorb the fluid and it will eventually shrink until it looks completely like it was never there to begin with. It is in essence a cosmetic lesion until this happens. This resolution of the seroma can take weeks and should be monitored for infection during this time.

Some people think that drains being placed to allow the fluid to drain continuously are a good option, but, I am not a big drain fan. Drains allow stuff to crawl and seep into the space that is now sterile and clean. The whole point of all of this detective work was to identify infection, and now we are going to leave a highway open for it? These days I only place drains to remove infection. Another point to consider is that the body will often keep making fluid if there is a space to fill, so the drains allow the body to keep the fluid factory in business. That is a big mess to deal with for about two weeks. If we attempted to put a needle into the seroma and pull off all of the fluid it will refill in a few hours,, so this is almost always futile. There are a few occasions that you cannot outsmart or speed up what the body wants to do. You just have to let it heal on its own and on its own time.

Molly's plan is to keep an eye and a hand on her incisional seroma daily. If anything changes, to include her behavior, activity level, or eating enthusiasm we will re-check her. Like all of my patients she left with a plan  and my email.

Molly's spay cost was; $250.
Her re-check was free, (we usually do not charge for post-operative rechecks of our patients).

Post publishing note; I receive many inquiries on Pawbly about this condition.
Here is my advice;

• Your vet should be seasoned and comfortable helping you manage this. 
• It is my firm opinion that drains are not indicated to correct it, and, that they have potential to do more harm than good. 
• If your pet has a seroma after a routine surgery (say a spay) it is most likely because the vet undermined excessive subcutaneous tissue. I do not believe it is the clients responsibility to pay for post op complications if the vet is at fault. This is a tricky thing to prove, BUT, a responsible and experienced vet has a much less likelihood to cause a seroma. Ask about your vets experience level before surgery. If you use a high volume clinic you are responsible for any post-op complications. It is the inherent risk of not knowing your vet. Seromas are in my experience a novice surgeons complication. (This applies to routine surgeries).
• Diagnose before guessing. Your vet is there for this. Make them a wager at the beginning of your exam. Let it go something like this,, "Doc, before you stick that needle in that want to make me a wager? If it is a seroma from the surgery she had here I am not paying for this exam. Right?" Now mind you You should be willing to promise that you kept her quiet post-op.
• After the diagnosis of a seroma it is not realistic or in the best interest to restrict a pet to a cage. I know this advice is provided often, but it is not fair to the healthy active pet. A seroma IS NOT A CONSEQUENCE of a failure of the sutured incision. These pets should not dehisce. They need monitoring, quiet activities without over exertion BUT the post-op instructions should not be any different than the patients who don't have a seroma. Cage rest makes everyone crazy UNLESS they are systemically ill or the suture/incision, or closure is in jeopardy. 
• If your vet is asking you to pay for a drain ask them for an explanation, discuss the size of the incision, the difficulty of the surgery and understand why and how this happened. If finances are tight decline the drain IF your pet is happy, healthy and acting normally.
• Expect the seroma to take weeks to resolve. 
• Let your pets attitude and behavior dictate if more invasive treatments are warranted or needed.

If you have a pet question of any sort you can find me trying to educate and inspire other pet people at Pawbly.com. Pawbly is a free open community built around all things pet. Please visit and share your pet knowledge with others.

I am also on Twitter @FreePetAdvice and at the clinic, Jarrettsville Vet in Jarrettsville Maryland.