Inguinal canal "lipoma"

Cord lipoma in minimally invasive surgical repairs of inguinal hernias: a prospective study

Cord lipomas are frequent findings in laparoscopic inguinal hernia surgeries in male patients. The symptoms of lipoma and the potential benefits of removing them are often overlooked because the focus is on the primary pathology of the hernia itself. Current recommendations are to reduce this fatty content, when present. When inguinal cord lipomas are left untreated in inguinal hernia surgery they can potentially cause symptoms and be detected in follow-up imaging exams. The objective of this study was to study incidence of cord lipomas in a cohort operated on by a single group specializing in abdominal wall surgery, as well as to analyze the possible relationship of this finding with the patient's symptoms, the characteristics of the operated hernia and postoperative outcome. This is a prospective study of male patients operated on for inguinal hernia laparoscopically or robotically in a single reference center. Of the total of 141 hernias, the distribution according to European Hernia Society classification showed that 45.4% were lateral, 19.1% medial and 35.5% mixed, highlighting a variety in the presentation of hernias. Analysis of the size of the hernias revealed that the majority (35.5%) were ≤ 1.5 cm. Inguinal cord lipoma was present in 64.5% of the samples, with no statistically significant association between the presence of the lipoma and an indirect hernia sac or obesity. The incidence of surgical site occurrences (SSO) was 9,2%, with seroma and hematoma. No recurrences were observed during follow-up, indicating a successful approach. There were no statistically significant relationships between SSO, the presence of lipoma and indirect hernial sac.

Embryonic developmental process and clinical anatomy of the preperitoneal fascia and its clinical significance

PURPOSE

Many researchers have different views on the origin and anatomy of the preperitoneal fascia. The purpose of this study is to review studies on the anatomy related to the preperitoneal fascia and to investigate the origin, structure, and clinical significance of the preperitoneal fascia in conjunction with previous anatomical findings of the genitourinary fascia, using the embryogenesis of the genitourinary system as a guide.

METHODS

Publications on the preperitoneal and genitourinary fascia are reviewed, with emphasis on the anatomy of the preperitoneal fascia and its relationship to the embryonic development of the genitourinary organs. We also describe previous anatomical studies of the genitourinary fascia in the inguinal region through the fixation of formalin-fixed cadavers.

RESULTS

Published literature on the origin, structure, and distribution of the preperitoneal fascia is sometimes inconsistent. However, studies on the urogenital fascia provide more than sufficient evidence that the formation of the preperitoneal fascia is closely related to the embryonic development of the urogenital fascia and its tegument. Combined with previous anatomical studies of the genitourinary fascia in the inguinal region of formalin-fixed cadavers showed that there is a complete fascial system. This fascial system moves from the retroperitoneum to the anterior peritoneum as the preperitoneal fascia.

CONCLUSIONS

We can assume that the preperitoneal fascia (PPF) is continuous with the retroperitoneal renal fascia, ureter and its accessory vessels, lymphatic vessels, peritoneum of the bladder, internal spermatic fascia, and other peritoneal and pelvic urogenital organ surfaces, which means that the urogenital fascia (UGF) is a complete fascial system, which migrates into PPF in the preperitoneal space and the internal spermatic fascia in the inguinal canal.

Robotic hernia surgery I. English version : Robotic inguinal hernia repair (r‑TAPP). Video report and results of a series of 302 hernia operations

The treatment of inguinal hernias with open and minimally invasive procedures has reached a high standard in terms of outcome over the past 30 years. However, there is still need for further improvement, mainly in terms of reduction of postoperative seroma, chronic pain, and recurrence. This video article presents the endoscopic anatomy of the groin with regard to robotic transabdominal preperitoneal patch plasty (r‑TAPP) and illustrates the surgical steps of r‑TAPP with respective video sequences. The results of a cohort study of 302 consecutive hernias operated by r‑TAPP are presented and discussed in light of the added value of the robotic technique, including advantages for surgical training. r‑TAPP is the natural evolution of conventional TAPP and has the potential to become a new standard as equipment availability increases and material costs decrease. Future studies will also have to refine the multifaceted added value of r‑TAPP with new parameters.

[Robotic hernia surgery : Part I: Robotic inguinal hernia repair (r‑TAPP). Video report and results of a series of 302 hernia operations]

The treatment of inguinal hernias with open and minimally invasive procedures has reached a high standard in terms of outcome over the past 30 years. However, there is still need for further improvement, mainly in terms of reduction of postoperative seroma, chronic pain, and recurrence. This video article presents the endoscopic anatomy of the groin with regard to robotic transabdominal preperitoneal patch plasty (r‑TAPP) and illustrates the surgical steps of r‑TAPP with respective video sequences. The results of a cohort study of 302 consecutive hernias operated by r‑TAPP are presented and discussed in light of the added value of the robotic technique, including advantages for surgical training. r‑TAPP is the natural evolution of conventional TAPP and has the potential to become a new standard as equipment availability increases and material costs decrease. Future studies will also have to refine the multifaceted added value of r‑TAPP with new parameters.

Intraoperative handling of spermatic cord lipomas during inguinal hernia repair: a nationwide survey

PURPOSE

Cord lipomas can clinically resemble groin hernias and missed cord lipomas can potentially result in persistent symptoms. However, no international guideline exists concerning the management of cord lipomas found during inguinal hernia surgery. This study aimed to gain insight into how surgeons typically manage cord lipomas found during inguinal hernia surgery.

METHODS

A questionnaire was sent to all general surgeons in Denmark performing unsupervised laparoscopic inguinal hernia repair and Lichtenstein repair. The survey contained questions about demographic details and questions about how surgeons would handle cord lipomas. The questionnaire was created by the research team and face-validated on general surgeons.

RESULTS

A total of 58 surgeons (60%) responded to the questionnaire. The majority agreed that cord lipomas should not be left untouched. During laparoscopic repairs, 53% of the surgeons recommended that cord lipomas should be resected and removed if the anatomical circumstances allowed it. During Lichtenstein repair, the surgeons recommended that cord lipomas should always be resected and removed (49%) or that resection should depend on the size of the lipoma (44%).

CONCLUSION

When asking surgeons about their preferred handling of cord lipomas, they answered that the management of cord lipomas found during inguinal hernia surgery depends on anatomical circumstances such as the pedicle appearance, the lipoma mobility, and its size. If the cord lipoma is left untouched, the patients' hernia resembling symptoms could persist, why the surgeons predominantly preferred to resect and remove cord lipomas.

Spermatic Cord Lipoma-A Review of the Literature

Introduction: A spermatic cord lipoma is found in 20–70% of all inguinal hernia repairs. The clinical picture of an inguinal hernia with bulging and pain but without an actual indirect hernia sac may become manifest in up to 8% of these cases. Missed spermatic cord lipoma can result in recurrence or pseudo-recurrence. This review presents the relevant literature on this topic.

Materials and Methods: A systematic search of the available literature was performed in February 2020 using Medline, PubMed, Google Scholar, Scopus, Embase, Springer Link, and the Cochrane Library, as well as a search of relevant journals and reference lists. Forty-two publications were identified as relevant for this topic.

Results: Spermatic cord lipoma seems to originate from preperitoneal fatty tissue within the internal spermatic fascia in topographical proximity to the arteries, veins, lymphatics, nerves, and deferent duct within the spermatic cord. Reliable diagnosis cannot be made clinically, but rather with ultrasound, CT, or MRI. In the absence of a real hernia sac, a spermatic cord lipoma is classified as a lateral inguinal hernia with a defect size <1.5 cm according to the European Hernia Society (EHS LI). Missed or inadequately treated spermatic cord lipoma results in recurrence or pseudo-recurrence. Since spermatic cord lipoma obtains its vascular supply from the preperitoneal space, it can be reduced or resected.

Conclusion: Spermatic cord lipoma is a common finding in inguinal hernia repairs and must be properly diagnosed and treated with care respecting the anatomy of the spermatic cord.

Spermatic cord liposarcomas incidentally found during hernia surgery: is histology of any lipoma mandatory? A review of the literature

Purpose: Liposarcomas found incidentally during open or laparoscopic inguinal hernia surgery are extremely rare. It is unclear, whether any adipose tissue being removed during inguinal hernia surgery must be sent for histology due to the potential risk of liposarcoma of the spermatic cord. This study aims to evaluate the frequency of liposarcomas incidentally found in the inguinal canal during hernia surgery and tries to derive evidence-based recommendations regarding the optimal management of any fatty tissue found in the inguinal canal.Methods: A literature review of the PubMed/Medline electronic databases between January 1980 and January 2019 was performed using the search terms 'inguinal hernia' and 'liposarcoma'. There was only one study available on this topic. Therefore, an additional literature review was performed analyzing all reports on patients with incidentally detected liposarcomas of the spermatic cord in the inguinal canal during hernia surgery.Results: There was only one retrospective study evaluating the frequency of inguinal liposarcoma found at hernia operations with a frequency of less than 0.1%. There were 18 cases of spermatic cord liposarcomas that were truly found incidentally during operation for an unsuspected symptomatic or incarcerated inguinal hernia. These included 16 case reports with a total of 18 patients and 19 liposarcomas. All patients were male with a median age of 62.5 years (range: 24-86 years) years. Median size of liposarcoma was 10.5 cm (range: 3-30 cm). In seven patients, the inguinal liposarcoma was an extension of a retroperitoneal sarcoma. Treatment consisted of radical orchidectomy during the primary operation in 12 patients. Three out of the seven patients with retroperitoneal extension of the tumor underwent a secondary operation with complete resection of the tumor.Conclusions: Currently, there is no evidence-based recommendation available regarding the management of lipomas detected during open or laparoscopic inguinal hernia surgery. Due to the extremely low risk of the presence of a liposarcoma, routine histologic examination cannot be recommended unless the diameter exceeds 10 cm.

Retrospective study on prevalence of recurrent inguinal hernia: a large-scale multi-institutional study

Purpose

We conducted a multi-institutional analysis to establish the epidemiological characteristics of recurrent inguinal hernia following hernia repair in patients across 4 institutions in Korea.

Methods

The retrospectively reviewed data included patient characteristics, hernia location, year of primary operation, type of hernia, timing of recurrence, primary operation type, and whether a mesh was used.

Results

Among 4,604 patients who underwent hernia repair surgery, 255 patients (5.5%; 13 females and 242 males; mean age, 63 years) were found to have recurrent hernia from January 2010 to April 2017. Recurrent indirect inguinal and direct hernias were observed in 47.1% and 49.4% of the patients, respectively. The recurrence of hernias within 1 year of surgery was the highest at 17.25%. Early and late recurrences was observed in 23.5% and 66.5% of the patients, respectively. Among the patients, 81.6% underwent open hernia repair at the time of initial surgery.

Conclusion

Recurrence of hernia is most common in the first year after the initial surgery, and 23.5% of recurrent inguinal hernia was developed within 2 years. Patients underwent surgery after an average of 116 months (median value, 64 months) following the first operation. In patients with recurrent hernia, direct hernia was seen more frequent than indirect hernia whereas indirect hernia occurred more in patients with primary hernia.

Differential diagnosis of fat-containing lesions in the inguinal canal using ultrasound

Abdominal hernias are usually located in the inguinal canals. Differential diagnosis of hernias should consider other pathologies, which typically occur at this site. The aim of this review paper is to present fat-containing lesions located in the inguinal canal based on both our own experience and literature. The first part of the paper describes the embryogenesis and differences in the structure and content of male and female inguinal canal. The canal is clearly wider in men, which results from the presence of the spermatic cord and its components. The female canal contains only the narrow round ligament of the uterus. The second part of the paper discusses the incorrect use of the term “lipoma” for retroperitoneal fat, which penetrated into the lumen of the patent processus vaginalis – the authors using this term acknowledge its incorrectness. These lesions often coexist with oblique inguinal hernia and should be excised during a surgery as they may cause inguinal pain. As for other fat-containing inguinal pathologies, we discussed lipomatosis of the spermatic cord, liposarcoma and the greater omentum. Differential diagnosis of these lesions considers their echogenicity, echostructure and vascularity. Furthermore, attention was paid to the adipose tissue surrounding the lower epigastric vessels, which may be incorrectly localized in the inguinal canal. Finally, the importance of proper diagnostic methodology and knowledge of the inguinal anatomy for the correct ultrasonographic diagnosis was emphasized.

Scrotal Lipomatosis Mimicking Varicocele: A Case Report and Review of the Literature

Scrotal lipomatosis is a rarely seen disease with an etiology that is not fully understood. Some information suggests that this disease may be associated with infertility. It is characterized by pain-free scrotal swelling. In this study, we reported a scrotal lipomatosis case presenting due to infertility and pain-free scrotal swelling. It was operated on with the initial diagnosis of varicocele, but once fatty tissue was observed in the scrotum, the case was diagnosed as scrotal lipomatosis. Here, we present this rare case with a literature review.

Missed lipoma of the spermatic cord

The aim of the research was to determine the incidence, significance, and anatomy of spermatic cord and round ligament lipomas. Between 2000 and 2010 we evaluated 969 consecutive patients with 1,070 indirect inguinal hernias, who underwent open repair. A total of 22 lipomas of the spermatic cord or round ligament were identified and resected in 22 patients. No neoplastic changes confirmed in histopathologic examinations of the specimens were reported. Lipomas of the cord and round ligament occur with a considerable incidence. We believe that even if there is no peritoneal sac, the herniation of extraperitoneal fat through the inguinal canal should be counted as an inguinal hernia, and it requires adequate treatment.

Giant lipoma of the spermatic cord

The authors present a case of a huge right inguinal bulge that was referred as a right inguinal hernia. At surgery, it was confirmed to be a giant lipoma of the spermatic cord. A description of the case, pictures of clinical appearance and operative specimen, and a short literature review are presented.

Large lipoma of the spermatic cord presenting as post-operative recurrent hernia in a middle aged gentleman: a case report

A gentleman who presented with a left inguinal hernia was operated and treated by hernioplasty. After a few years he presented with a clinical scenario of recurrent hernia. During surgery the lump was found to be a large lipoma that was not documented and found during the first operation.

Laparoscopic surgery for chronic groin pain in the general population: a prospective study

BACKGROUND

Chronic groin pain is a challenging problem among not only athletes but also the general population. The aim of this study was to evaluate the role of laparoscopic surgery in the management of these patients.

PATIENTS AND METHODS

Prospective data including the outcomes were collected and analyzed for 43 patients who had groin pain without clinical or radiologic evidence of hernia. All patients had magnetic resonance imaging scan and had consulted an orthopedic surgeon when appropriate. All patients were followed in clinic 2 weeks after operation and 6 months after the operation by phone call, and all were asked to call our unit in case of partial or no improvement.

RESULTS

From September 1999 to August 2006, we performed 1617 laparoscopic groin hernia repairs in 1209 patients using the transabdominal preperitoneal approach. Forty-three patients (3 women and 40 men) with variable life activities and employment were included in this study. Only five patients played football at a professional level. The mean age of these patients was 38 years (range, 17-74 years), and the mean follow-up was 43 months (range, 14-72 months).The clinical invagination test showed wide external inguinal ring in 27 (62.7%) patients and tender inguinal canal in another 6 (13.95%) patients. Negative laparoscopy was reported in 7 (16.27%) patients. All patients had mesh insertion. The operation cured groin pain in 30 (69.76%) patients, and the pain improved in another 9 (20.93%) patients. Three (6.97%) patients had no change in their symptoms, and the pain became worse in 1 (2.32%) patient.

CONCLUSION

We suggest offering laparoscopic groin exploration and mesh insertion for any adult patient presenting with chronic groin pain without clinical evidence of groin hernia or radiologic abnormality regardless of age, life activities, and employment.

The inguinal canal: anatomy and imaging features of common and uncommon masses

A variety of benign and malignant masses can be found in the inguinal canal (IC). Benign causes of masses in the IC include spermatic cord lipoma, hematoma, abscess, neurofibroma, varicocele, desmoid tumor, air, bowel contrast material, hydrocele, and prostheses. Primary neoplasms of the IC include liposarcoma, Burkitt lymphoma, testicular carcinoma, and sarcoma. Metastases to the IC can occur from alveolar rhabdomyosarcoma, monophasic sarcoma, prostate cancer, Wilms tumor, carcinoid tumor, melanoma, or pancreatic cancer. In patients with a known malignancy and peritoneal carcinomatosis, the diagnosis of metastases can be suggested when a mass is detected in the IC. When peritoneal disease is not evident, a mass in the IC is indicative of stage IV disease and may significantly alter clinical and surgical treatment of the patient. A combination of the clinical history, symptoms, laboratory values, and radiologic features aids the radiologist in accurately diagnosing mass lesions of the IC. Supplemental material available at radiographics.rsnajnls.org/cgi/content/full/28/3/819/DC1.

Management of herniated retroperitoneal adipose tissue during endoscopic extraperitoneal inguinal hernioplasty

BACKGROUND

Herniation of retroperitoneal adipose tissue into the inguinal canal, traditionally called cord lipoma, is frequently encountered during endoscopic totally extraperitoneal inguinal hernioplasty (TEP). Failure to recognize and manage the cord lipoma accounted for 30%-50% of recurrent hernia after TEP. The present study was undertaken to evaluate the incidence, risk factors, and management of herniated retroperitoneal adipose tissue during TEP.

METHODS

Between December 2002 and November 2005 all patients who underwent TEP were prospectively evaluated for the presence of cord lipoma. Clinical outcomes of patients who were treated for their cord lipoma were compared with those without cord lipoma. Risk factors for the occurrence of cord lipoma were also examined.

RESULTS

A total of 498 patients underwent unilateral (n = 386) or bilateral (n = 112) TEP. The overall incidence of cord lipoma was 26.5% (n = 132). A higher body weight, a higher body mass index, and a larger hernial defect were significantly associated with the presence of cord lipoma. Most of the cord lipoma cases (n = 119) were reduced to pelvic peritoneal reflection line after division of the feeding vessels from surrounding structures, while the rest (n = 13) were resected. Early postoperative outcomes, including pain score, morbidities, and other recovery variables, showed no significant difference between the two groups. No recurrence occurred in the present series.

CONCLUSIONS

Herniation of retroperitoneal adipose tissue into the inguinal canal occurred in more than one-fifth of the patients with inguinal hernia. Awareness and appropriate treatment of the cord lipoma helped to reduce the risk of recurrence. During TEP, the internal inguinal ring and inguinal canal should always be cleared of any herniated adipose tissue by either reduction or resection. This clearing posed no adverse effects on postoperative outcome.

Sonography in identification of abdominal wall lesions presenting as palpable masses

OBJECTIVE

Abdominal wall lesions often present as palpable masses. The purpose of this presentation is to provide an overview of the sonographic appearances of different abdominal wall lesions.

METHODS

Patients were scanned with high-frequency (5- to 12-MHz) linear transducers. Extended or panoramic views were recorded often to show the lesion in perspective to adjacent structures in the abdominal wall.

RESULTS

The different layers of the abdominal wall could be clearly shown on high-frequency sonography, and the abdominal wall abnormalities were recognized in all the patients.

CONCLUSIONS

Hernias are the most common abdominal wall lesions. Herniated bowel loops have variable appearances depending on their air-fluid content and degree of obstruction. Localized fluid collections in the abdominal wall (seromas, liquefying hematomas, and abscesses) can be well visualized. More infrequently, tumors or vascular lesions can be identified in the abdominal wall.

Sliding lipoma: an indirect inguinal hernia without a peritoneal sac

With the increasing application of endoscopic hernioplasty, surgeons have now recognized that the peritoneal sac is sometimes absent in patients who present with a reducible inguinal hernia. Sliding lipoma refers to a sliding herniation of preperitoneal fat into the inguinal canal forming a reducible indirect inguinal hernia in the absence of a peritoneal sac. In this report, we describe a patient who underwent bilateral endoscopic totally extraperitoneal inguinal hernioplasty (TEP), followed by an early recurrence of left inguinal hernia, secondary to a sliding lipoma. Sliding lipoma is a challenging condition specific to endoscopic repair of inguinal hernia. All lipomas should be reduced and excised whenever feasible. Awareness and appropriate management of the sliding lipoma will help to reduce the risk of recurrence after endoscopic hernioplasty.

Giant Lipoma of Spermatic Cord Mimics Irreducible Inguinal Hernia: A Case Report

Inguinal herniorrhaphy is the most common general surgical operation performed. Although fatty protrusions are often observed along the path of the spermatic cord, true lipomas are not commonly reported. We encountered a 42-year-old male patient who developed a large lipoma of the right spermatic cord with indirect inguinal hernia. After herniorrhaphy and tumor excision, the patient had an uneventful convalescence. There has been no recurrence up to the time of writing (20 months).