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.
View of the intraoperative site. A 5-cm encapsulated cyst is seen adjacent to the spermatic cord.
After it was opened, the cyst was seen to contain a reactive capsule, multiple septa, and yellowish pulp.
A. Nonreducible recurrent hernia
B. Enlarged lymph nodes
D. Chronic abscess
Misiakos EP, Liakakos T, Preza U, Fotiadis C, Macheras A. Image of the Month—Quiz Case. Arch Surg. 2009;144(6):589–590. doi:10.1001/archsurg.2009.69-a