Management of Fat-Containing Inguinal Hernias
All fat-containing inguinal hernias (cord lipomas) should be surgically repaired, as they represent true inguinal hernias that can cause chronic groin pain and require the same treatment approach as hernias with peritoneal sacs. 1, 2
Why Fat-Only Hernias Require Repair
Cord lipomas are herniation of extraperitoneal fat through the inguinal canal and should be counted as true inguinal hernias requiring treatment, even when no peritoneal sac is present. 3
The European Hernia Society explicitly classifies spermatic cord lipomas as "true" inguinal hernias that warrant surgical repair. 1
Fat-containing hernias occur in 72.5% of patients with indirect inguinal hernias, making them extremely common findings during groin exploration. 3
Missed or untreated cord lipomas frequently lead to persistent postoperative groin pain, often necessitating reoperation. 1
Clinical Significance and Risk Factors
Cord lipomas represent a continuation of extraperitoneal fat tissue that can be clearly visualized during laparoscopic exploration of the preperitoneal space. 3
The incidence is higher in patients with larger hernias (Nyhus Type II and IIIb) and correlates with slightly higher body mass index (25.7 vs 24.6). 3
Unresected cord lipomas may be the sole source of chronic groin pain in patients with no other clinical findings, making their identification and treatment critical. 1
Surgical Approach
During every inguinal hernia repair, surgeons must perform rigorous exploration of the inguinal canal, actively searching for any herniated adipose tissue that should be either reduced or resected. 1
Both the European Association of Endoscopic Surgery (EAES) and International Endohernia Society (IEHS) recommend active search for spermatic cord lipomas in all laparo-endoscopic inguinal hernia repairs. 1
Mesh repair is recommended as first choice for all groin hernias, either by open procedure or laparo-endoscopic technique (TEP or TAPP). 2
Laparoscopic approaches offer advantages including faster recovery times, lower chronic pain risk, and ability to identify contralateral occult hernias present in 11.2-50% of cases. 4
Common Pitfalls to Avoid
Failing to identify and treat cord lipomas during initial hernia repair leads to re-recurrent hernias and persistent symptoms requiring reoperation. 1
Surgeons should not dismiss fat-only findings as insignificant—these require the same definitive treatment as hernias with peritoneal sacs. 3, 1
During laparoscopic repair, the surgeon must look beyond obvious peritoneal defects to identify extraperitoneal fat herniation through the internal ring. 3