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Special Feature
June 15, 2009

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations:Third Department of Surgery, University of Athens School of Medicine, Attikon University Hospital, Athens, Greece.




Copyright 2009 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2009

Arch Surg. 2009;144(6):589-590. doi:10.1001/archsurg.2009.69-a

A 72-year-old patient presented with a bulging right scrotal hernia that caused worsening discomfort. The patient was a smoker and had hypertension that was being treated by medication. The hernia was repaired laparoscopically using the transabdominal preperitoneal polypropylene (TAPP) approach. At surgery the large sac of a direct hernia (with a small bowel loop within it) and the smaller sac of an indirect hernia were found. The hernia sac and its contents were reduced, and a piece of polypropylene mesh measuring 12 cm × 13 cm was placed preperitoneally and stabilized with tacks to the pubic symphysis and the pectineal ligament; thereafter, it was covered with a peritoneal patch.

Two months later the patient presented with a firm round mass, which was slightly tender upon palpation, in the area of the right internal inguinal ring. The patient was referred for ultrasonographic imaging, which revealed a nonhomogeneous round mass (4-5 cm in diameter), but surgeons could not identify any connection between this mass and the internal inguinal ring. The mass was excised using local anesthesia. An encapsulated multilocular cyst 5 cm in diameter, located next to the internal lacuna of the spermatic cord, was found (Figure 1). The cyst was opened, and a yellowish pulp was revealed in the interior (Figure 2). The cyst and pulp were sent for histological examination.

Figure 1.
Image not available

View of the intraoperative site. A 5-cm encapsulated cyst is seen adjacent to the spermatic cord.

Figure 2.
Image not available

After it was opened, the cyst was seen to contain a reactive capsule, multiple septa, and yellowish pulp.

What Is the Diagnosis?

A. Nonreducible recurrent hernia

B. Enlarged lymph nodes

C. Seroma

D. Chronic abscess