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Dear Steve,
Sometimes when I scan the groin, I can see there is reducible fat within the superficial ring but I cannot seem to find a neck or movement of the fat. What is your differentials? Would this possibly be a cord lipoma? What are the signs to differentiate between this entity and a reducible fat containing hernia?
Best regards,
Linh -
Hi Linh,
This is a common question I am asked,
The way I define a cord lipoma is when I find some fat within the inguinal canal which is not reducible and does not increase in volume when the patient strains. It may move slightly during straining but not far as it is attached to the spermatic cord. The fat will also have a beginning and end point as you scan along the canal (think of it as a small egg shaped piece of fat living in the canal)
A hernia on the other hand (direct or indirect) is generally reducible, it grows in size and moves freely along the canal when the patient strains and it has no end point at the origin end (in other words it is still present as it passes into the deep ring or through the posterior wall depending if it is indirect or direct respectively)So I think they are quite different.
If you are seeing a small piece of fat at the superficial ring that is only slightly mobile into the distal canal and there is no defect in the posterior wall and it can not be reduced through the deep ring and it has a beginning and end point within the canal and it does not increase in size / volume during straining you have found a cord lipoma!
Steve
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I haven’t really encountered cord lipoma then. I read this article: Differential diagnosis of fat-containing lesions in the inguinal canal using ultrasound (Andrzej Smereczyński, Katarzyna Kołaczyk, 2019). They put cord lipoma as a misnomer for retroperitoneal fat in the patent processus vaginalis (if I understand the embryology correctly) and there is a separate entity of True Lipoma that can be in the inguinal canal. To me they look the same. What is your opinion?
Thanks for the tip!
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I think they behave a little differently.
A true lipoma can not pass in and out of the deep rings it is fixed to the spermatic cord. It also has a beginning and end point and will not increase in size during straining.The retroperitoneal fat and patent process vaginalis is what I refer to as a pre-peritoneal fat tongue and you see these from time to time.
A pre peritoneal fat tongue does enter the canal through the deep ring (patent process vaginalis). It is usually a thin slither of fat and it pokes into the proximal end of the canal when straining and then disappears back through the deep ring during relaxation. It does not distend the deep ring much at all ( a true indirect hernia DOES distend the deep ring as the head of the hernia passes through it) and hence the lack of distention means little or no pain is caused by it. The movement of the pre peritoneal fat tongue is often rapid as it slides through the deep ring into the proximal canal and back again.
I think of it as an ant eaters tongue poking into the ants nest, grabbing an ant and then retreating quickly!Steve
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