Why Spermatic Cord Lipomas Must be Treated as “True” Inguinal Hernias

Lipomas of the cord are common and generally associated with an indirect hernia sac, but not always, as the lipoma may be the only pathology identified during groin exploration. Missed lipoma of the spermatic cord is unfortunately not infrequent and may lead to persistence of post-operative groin pain, with confirmation of unresected cord lipoma on postoperative ultrasound, often necessitating reoperation. We present an interesting case of a 40-years-old male with symptomatic re-recurrent left inguinal hernia following previous open and subsequent endoscopic totally extraperitoneal (TEP) mesh repair. At laparoscopy, the previously inserted extraperitoneal mesh seemed well integrated with no evidence of recurrent hernia sac. Further transabdominal preperitoneal (TAPP) approach identified a moderate-size cord lipoma that had been missed twice before. His postoperative recovery was uneventful, and his previous symptoms completely subsided. This is of significant value as lipomas of the cord may sometimes represent the only source of chronic groin pain in patients with no other clinical findings. Consequently, they should be viewed and treated as “true” inguinal hernias as per the European Hernia Society (EHS). During every inguinal hernia case, the surgeon must perform rigorous exploration of the inguinal canal, looking for any herniated adipose tissue that can be easily cleared by either reduction or resection. This is further supported by both the European Association of Endoscopic Surgery (EAES) and the International Endohernia Society (IEHS) who recommend an active search for spermatic cord lipomas in all laparo-endoscopic inguinal hernia repairs.