Treatment of Fat-Containing Right Inguinal Hernia (Spermatic Cord Lipoma)
A fat-containing right inguinal hernia (spermatic cord lipoma) should be treated with surgical repair using mesh, as it is classified as a true inguinal hernia (EHS LI classification) and must be actively identified and either reduced or resected during repair to prevent recurrence or pseudo-recurrence. 1, 2, 3
Classification and Clinical Significance
- Spermatic cord lipomas are found in 20-70% of all inguinal hernia repairs and originate from preperitoneal fatty tissue within the internal spermatic fascia 2
- When a spermatic cord lipoma presents without an actual indirect hernia sac (which occurs in up to 8% of cases), it is classified as a lateral inguinal hernia with defect size <1.5 cm according to the European Hernia Society (EHS LI classification) 2
- The European Hernia Society, European Association of Endoscopic Surgery (EAES), and International Endohernia Society (IEHS) all recommend treating spermatic cord lipomas as "true" inguinal hernias requiring definitive surgical management 3
Surgical Approach Algorithm
Primary Surgical Repair
- Mesh repair is strongly recommended as the standard approach, with synthetic mesh offering significantly lower recurrence rates (0% vs 19% with tissue repair) in clean surgical fields 1
- Laparoscopic approaches (TEP or TAPP) are particularly advantageous because they allow visualization of the contralateral side to identify occult hernias (present in 11.2-50% of cases) and enable thorough identification of spermatic cord lipomas 1
- Open preperitoneal repair can be performed under local anesthesia, which provides effective anesthesia with fewer cardiac and respiratory complications, shorter hospital stays, and faster recovery 1
Intraoperative Management of the Lipoma
- Rigorous exploration of the inguinal canal must be performed during every repair to actively search for herniated adipose tissue, which can be either reduced back into the preperitoneal space or resected 3
- Since spermatic cord lipomas obtain their vascular supply from the preperitoneal space, both reduction and resection are safe options 2
- The lipoma must be addressed during the initial repair, as missed or inadequately treated spermatic cord lipomas result in recurrence, pseudo-recurrence, or chronic groin pain requiring reoperation 2, 3
Common Pitfalls and How to Avoid Them
- Failing to identify and treat the spermatic cord lipoma during initial repair is the most critical error, leading to persistent postoperative groin pain and need for reoperation 3
- Do not dismiss the lipoma as insignificant—it may be the only source of symptoms in patients presenting with groin bulging and pain 2, 3
- During laparoscopic repair, perform both TEP and TAPP approaches if needed to ensure complete visualization, as lipomas can be missed during TEP alone 3
- Examine the contralateral side laparoscopically to avoid overlooking occult contralateral hernias present in up to 50% of cases 1