Lipoma of the spermatic cord, fatty herniation, liposarcoma

Summary

Speed [1914] reported the incidence of cord lipoma, encountered equally with both indirect and direct herniae, to be 47.4%. All appeared to arise, with their blood supply, from the preperitoneal fat pad. High excision was recommended to prevent hernial recurrence. Fawcett [1997] confirmed these observations, finding 1% arising from the cord itself, which is now known to form in the preperitoneal space of Bogros. Watson [1948] insisted that inguinal Hpomas “should be called hernias only when accompanied by a peritoneal sac”. However, 7% of cord lipomas are reported to be sac-less, associated occasionally with ureteral “prolapse”. To avoid medicolegal consequences, they now should also be considered hernias. Inguinal hernia classifications need to reflect this reality.

A case of an elderly, obese male with a giant cord lipoma who underwent excision of a large, irreducible, complete, sliding, sac-less, indirect fatty inguinal hernia is detailed. Three veterans, presenting with purported inguinoscrotal herniation, had large cord lipomas, which after funiculo-orchiectomy, were shown to be liposarcoma. One developed large retroperitoneal and local recurrences and received radiation and chemotherapy. Another underwent lymphadectomy and irradiation, while the third did well without adjuvant treatment.

In conclusion, ubiquitous cord lipomas are not tumors but essentially all are herniations of extraperitoneal fat. Proper inguinal hernia repair mandates their complete excision. Occasionally, they may be the only herniation. Inguinal hernia classifications need to include not only fatty hernias, but sac-less, fatty protrusions. Malignancy is a rarehazard, sometimes associated with the more commonly encountered sarcoma of non-herniated retroperitoneal fat. The risk does not warrant pathological examination of small cord lipomata.