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.

Extraprostatic incidental findings on prostate mpMRI: A pictorial review from the ESUR junior network

The role of multiparametric MRI (mpMRI) in prostate cancer setting is increasingly consolidated and, as a result, its usage in clinical practice is in exponential growth. However, beyond the prostate gland, several key structures are included in the field of view of mpMRI scans. Consequently, various extra-prostatic incidental findings (IFs) belonging to different anatomical systems can be accidentally recognized. Therefore, it is mandatory for a radiologist to be familiar with the wide range of pathologies potentially encountered, to guide management and avoid patient anxiety and costs due to additional work-up prompted by clinically insignificant extra-prostatic findings. With this pictorial review, we aim to illustrate a wide range of IFs that can be detected when performing mpMRI of the prostate, focusing on their imaging characteristics, differential diagnosis, and clinical relevance. Additionally, we propose the CheckDEEP, the Checklist for DEtection of ExtraProstatic findings, to be used for a thorough evaluation of target areas within each anatomical system.

Abdominal wall hernia repair: from prosthetic meshes to smart materials

Hernia reconstruction is one of the most frequently practiced surgical procedures worldwide. Plastic surgery plays a pivotal role in reestablishing desired abdominal wall structure and function without the drawbacks traditionally associated with general surgery as excessive tension, postoperative pain, poor repair outcomes, and frequent recurrence. Surgical meshes have been the preferential choice for abdominal wall hernia repair to achieve the physical integrity and equivalent components of musculofascial layers. Despite the relevant progress in recent years, there are still unsolved challenges in surgical mesh design and complication settlement. This review provides a systemic summary of the hernia surgical mesh development deeply related to abdominal wall hernia pathology and classification. Commercial meshes, the first-generation prosthetic materials, and the most commonly used repair materials in the clinic are described in detail, addressing constrain side effects and rational strategies to establish characteristics of ideal hernia repair meshes. The engineered prosthetics are defined as a transit to the biomimetic smart hernia repair scaffolds with specific advantages and disadvantages, including hydrogel scaffolds, electrospinning membranes, and three-dimensional patches. Lastly, this review critically outlines the future research direction for successful hernia repair solutions by combing state-of-the-art techniques and materials.

Association of pediatric inguinal hernia contents with patient age and sex

BACKGROUND

Although pediatric inguinal hernia (IH) is a very common disease, systematic reviews of herniated organs are scarce. The current study aims to clarify the contents of pediatric IH using preoperative ultrasonography (US) in association with patient age, sex, and risk for developing irreducible/strangulated hernia.

METHODS

The medical records of pediatric IH patients who underwent inguinal US examination prior to surgery between 2014 and 2019 were reviewed. Hernia contents were categorized into four groups based on US findings: bowel, omentum, ovary with or without fallopian tube, and ascites.

RESULTS

A total of 524 IH lesions found in 220 men and 304 women were analyzed. The most common hernia content in patients under 12 months of age was the bowel (91.0%) in males and ovaries (89.5%) in females. The omentum became the most common herniated organ in both men (78.6%) and women (88.0%) aged 2 years and older. Emergency operations were performed in 3 patients (0.57%) due to irreducible IH, where 2 patients with irreducible ovaries, 5 and 7 months old, developed ovarian torsion and needed to undergo emergent salpingo-oophorectomy.

CONCLUSIONS

The contents of pediatric IH depended on patient age and sex. Herniated ovaries in infants can twist in the hernia sac and become strangulated. It is important for clinicians to expect the herniated organ and take appropriate measures in the pediatric primary care setting.

Adrenal ectopy and lipoma of an inguinal hernia sac: A case report & literature review

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Ectopic adrenocortical tissue is accessory adrenal cortex tissue outside of the adrenal glands.

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Ectopic adrenocortical tissue is a rare finding during inguinal hernia repair in adults.

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Adrenocortical tissue in inguinal hernia sacs can mimic metastatic deposits.

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Surgical excision of adrenocortical tissue may have endocrine implications.

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We have described a case of adrenocortical tissue identified in a lipoma of an inguinal hernia sac.

Introduction & importance

Ectopic adrenocortical tissue is the presence of accessory adrenal cortex tissue located outside of the adrenal glands. It is a rare, incidental finding during inguinal hernia repair. This case report aims to discuss the anatomy and important patient implications related to this finding.

Case presentation

A 61-year-old male presented with a long-standing right direct inguinal hernia increasing in size and pain frequency. During open right anterior inguinal hernia repair, a lipoma was identified inside the hernia sac and removed. Further histopathological examination of the specimen revealed the presence of adrenocortical tissue inside the lipoma. No further interventions were performed. The postoperative and 2-year follow-up course were uneventful.

Clinical discussion

Adrenocortical tissue can parallel the descent of the gonads during embryogenesis, arresting at any point along this path, including the inguinal region. Ectopic adrenocortical tissue is commonly found during inguinoscrotal procedures in infants, suggesting early involution. Its incidence in hernia sacs should be recognized to prevent misdiagnosis as neuroendocrine tumors or melanomas. If adrenocortical tissue is identified during hernia reduction, further surgical exploration is not recommended. In terms of prognosis, endocrine imbalances following surgical removal cannot be ruled out, promoting careful patient monitoring. The lipoma containing the adrenal tissue in our case is a common finding during hernia repair, identified in 22% of patients at operation.

Conclusion

Ectopic adrenocortical tissue is a rare, incidental finding during inguinal hernia sac analysis in adults. This finding should be well-documented following removal and further studies are required to evaluate long-term outcomes.

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.

Appendiceal fibroma in an Amyand's hernia mimicking a supernumerary testis: a case report

Amyand's hernia describes the presence of an appendix within the sac of an inguinal hernia. Both an inflamed and non-inflamed appendix within the hernia sac have been reported in the literature with various recommendations on approach to management. However, a tumour of the appendix is a rare finding in an Amyand's hernia. We hereby report the unusual presentation of a fibroma of the appendix complicating the rare Amyand's hernia in a young man with a scrotal mass.

Thinking beyond hernia: a review of non-hernia groin lumps

With increasing reliance on imaging, a large number of patients presenting with a groin lump are being referred to radiology to confirm the diagnosis of hernia, usually with an ultrasound in the first instance (occasionally MRI or CT). However, when imaging of the groin was performed, we have encountered many different kinds of non-hernia lesions in our practice. Such lesions can be categorized based on their tissue of origin and pathology. A specific diagnosis can often be reached using ultrasonography, MRI or a combination of imaging modalities. This review article will help general, musculoskeletal and abdominal radiologists to understand the anatomy of the groin, diagnose and characterise soft tissue lesions that may present as a groin lump, provide guidance for further imaging and insight into imaging features which may need specific investigations like core biopsy, tertiary referral and review at multidisciplinary meetings.

Imaging of Abdominal Wall Masses, Masslike Lesions, and Diffuse Processes

Abdominal wall masses, masslike lesions, and diffuse processes are common and often incidental findings at cross-sectional imaging. Distinguishing among these types of masses on the basis of imaging features alone can be challenging. The authors present a diagnostic algorithm that may help in distinguishing different types of abdominal wall masses accurately. Hernias may mimic discrete masses at clinical examination, and imaging is often ordered for evaluation of a possible abdominal wall mass. Once a discrete mass is confirmed to be present, the next step is to determine if it is a fat-containing, cystic, or solid mass. The most common fat-containing masses are lipomas. Fluid or cystic masses include postoperative abscesses, seromas, and rectus sheath hematomas. Solid masses are the most common abdominal wall masses and include desmoid tumors, sarcomas, endometriomas, and metastases. Multiple masses and other diffuse abdominal wall processes are often manifestations of an underlying condition or insult. The most frequently found diffuse processes are multiple injection granulomas from administration of subcutaneous medication. This article offers an algorithmic approach to characterizing abdominal wall masses on the basis of their composition and reviews abdominal wall diffuse processes. Online supplemental material is available for this article. ^©RSNA, 2020.

Extrahepatic Fat-Containing Lesions of the Abdomen and Pelvis: An Organ-Based Approach to Differential Diagnoses

The presence of intralesional fat provides an invaluable tool for narrowing the differential diagnosis for both benign and malignant neoplasms of the abdomen and pelvis. The ability to characterize intralesional fat is further expanded by the ability of magnetic resonance imaging to detect small quantities (intravoxel) of fat. While the presence of intralesional fat can help to provide a relatively narrow set of diagnostic possibilities, depending on the type of fat (macroscopic vs intravoxel) that is present and the organ of origin, radiologists must be aware of uncommon mimickers of pathology, both benign and malignant.

Preoperative Abdominal Computed Tomography at Rest and During Valsalva’s Maneuver to Evaluate Incisional Hernias

Background. Incisional hernias (IHs) can develop in up to 15% of patients who underwent an abdominal surgical procedure. Abdominal computed tomography (CT) is the best examination to evaluate these patients before surgical repair. The aim of this study is to assess the usefulness of the abdominal CT scan during Valsalva’s maneuver in patients who are candidates for surgery. Methods. A retrospective cohort analysis conducted on prospectively recorded data was performed on 26 consecutive patients affected by IHs who underwent a preoperative abdominal CT scan both at rest and during Valsalva’s maneuver between January 1, 2015, and December 31, 2016. Results. Five patients (19%) had IH classified as M1-M2, 10 (39%) as M3, and 11 (42%) as M4-M5. Both the median IH orifice area (IHOA) and the median volume of the IH increased during straining ( P = .001 and P < .001, respectively). The percentage of the difference in volume ratios increased as the localization of the IH moved caudally. At the binary logistic regression analysis M3 IH, body mass index >28, IHOA > 156 cm2 at rest, and IHOA > 138 cm2 during Valsalva’s maneuver were risk factors for posterior component separation. Conclusions. The preoperative CT scan both at rest and during Valsalva’s maneuver seemed useful to estimate the risk of difficult IH repairs. Moreover, it could allow surgeons to decide if the patient should be addressed to more specialized centers.

Fatty masses of the abdomen and pelvis and their complications

There are numerous common and rare macroscopic fat-containing masses found in the abdomen and pelvis. These include benign masses, such as lipoleiomyoma, ovarian teratoma, mesenteric teratoma, and lipoma, as well as malignant masses, including liposarcoma and malignant transformation of benign entities. Any mass may become symptomatic due to the development of a complication which may range from ovarian torsion to intussusception to hemorrhage. Imaging plays a vital role in diagnosis and treatment planning when confronted with a symptomatic fat-containing mass.

Ultrasound of Soft Tissue Masses and Fluid Collections

Soft tissue masses and fluid collections are frequently encountered in sonographic practice, either as principal indication for diagnostic examination or as an incidental finding during an examination performed for other indications. Sonography is a good first-line imaging modality for evaluation of superficial masses and fluid collections, but requires meticulous attention to technique to avoid diagnostic pitfalls. Although many superficial masses are diagnosed with ultrasound, there are several potential diagnostic challenges, including differentiating hematomas from sarcomas. This article provides an image-rich review of the sonographic features of common soft tissue masses, with emphasis on practical tips to accurately recognize important pathology.