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Case Reports and Images in Surgery

 
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Clinical Image
 
Computerized radiography of incarcerated 'Fatty Hernia'
Robert W. Ikard
Vanderbilt University Division of General Surgery and Department of Surgery VA Tennessee Valley Healthcare System.

Article ID: 100011Z12RI2016
doi:10.5348/Z12-2016-11-CL-3

Address correspondence to:
Robert W. Ikard
M.D., 308 Sunnyside Drive, Nashville
Tennessee 37205
USA

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Ikard RW. Computerized radiography of incarcerated 'Fatty Hernia'. J Case Rep Images Surg 2016;2:9–11.


Case Report

A 71-year-old male reported the presence of a left scrotal mass for "two to three years." Chronic systemic problems included diabetes mellitus II, gastric reflux, obesity, obstructive pulmonary disease, congestive heart failure, and groin lymphedema. Physical examination showed an obese man (BMI 40.1) who moved with difficulty and had exertional dyspnea. Penile and left scrotal skin were swollen. A large, soft, non-tender mass filled his left inguinal canal and scrotum. This could be partially reduced with the patient supine.

Ultrasound examination of his groin showed groin skin edema and a soft tissue mass in the scrotum. Computed tomography showed a 6x8 cm fat-containing hernia extending into the scrotum. The left kidney was ptotic (Figure 1) and (Figure 2). The hernia's contents did not seem to be at risk for strangulation because the hernia was very broad-based. For this reason and the patient's high operative risk, surgical therapy was not recommended.


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Figure 1: Coronal section of computed tomogram with contrast showing ptotic left kidney and large amount of retroperitoneal fat extending into inguinal canal.



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Figure 2: Coronal section of computed tomogram with contrast showing incarcerated 'fatty hernia.'


Discussion

A hernia is the protrusion of an organ or structure through an abnormal opening. An indirect inguinal hernia does not always have a sac, once considered a fundamental feature of that disorder. A lipoma is a discrete, encapsulated portion of fat and can occasionally be found in the spermatic cord. However, most so-called cord lipomas are extrusions of retroperitoneal fat alongside the cord. Thus they are hernias [1] [2].

Such fatty cord masses are common. They were noted in 33% of a clinical study and 75% of a cadaver study [2] [3]. They can be large and cause symptoms. On physical examination, they can be confused with a saccular hernia and are rarely diagnosed preoperatively.

Bondevik presented a case of massive prolapse of retroperitoneal fat and ureter into the scrotum. After considering various terms, the author dubbed this a "fatty hernia." It is rare, his case being the fifth reported in four patients [1]. Prolapse of retroperitoneal structures into the groin can be with ("paraperitoneal") or without ("extraperitoneal") a sac. All reported cases have been in obese patients. Renal ptosis is characteristic. Ureteral herniation can be caused by gravitational pull of the attached mass of fat [4]. When feasible, treatment consists of excision or reduction of herniated fat and closure of the abdominal inguinal ring defect. The potential for ureteral injury must be considered.


Conclusion

Fatty hernias are rare. Computed tomography reliably demonstrates their anatomy. If surgical treatment is chosen, the anatomic course of the ureter should be delineated preoperatively.

Keywords: Fatty hernia, Lipoma of cord, Obesity, Ptotic kidney, Ptotic ureter


References
  1. Bondevik H. Inguinal prolapse of retroperitoneal fat ("fatty hernia"). Report of a case also involving the ureter. Acta Chir Scand 1966 May;131(5):492–6.   [Pubmed]    Back to citation no. 1
  2. Fawcett AN, Rooney PS. Inguinal cord lipoma. Br J Surg 1997 Aug;84(8):1169.   [CrossRef]   [Pubmed]    Back to citation no. 2
  3. Heller CA, Marucci DD, Dunn T, Barr EM, Houang M, Dos Remedios C. Inguinal canal "lipoma". Clin Anat 2002 Jun;15(4):280–5.   [CrossRef]   [Pubmed]    Back to citation no. 3
  4. Giuly J, François GF, Giuly D, Leroux C, Nguyen-Cat RR. Intrascrotal hernia of the ureter and fatty hernia. Hernia 2003 Mar;7(1):47–9.   [Pubmed]    Back to citation no. 4
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Author Contributions
Robert W. Ikard – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2016 Robert W. Ikard. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



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