Inguinal Lymphocele After Angiomyomatous Hamartoma Resection

Abstract and Introduction

Abstract

Introduction: Lymphocele is a relatively common complication following lymphadenectomy of the inguinal lymph nodes; however, it is less common after open inguinal hernia repair. Postoperative lymphocele is usually caused by unrecognized injury to lymphatic vessels during surgical dissection and commonly requires reoperation to ligate the leaking lymphatics. Angiomyomatous hamaromas are rare lymphatic formations of unknown cause that can be treated with aspiration, sclerotherapy, and drain placement, but surgical intervention is often required. This finding is associated with replacement of parenchymal lymph tissue with vascular and smooth muscle cells.

Case Report: The authors report the case of a 59-year-old African American male who underwent open inguinal hernia repair and was found to have incidentally an angiomyomatous hamartoma, which was excised but complicated with a postoperative lymphocele. The patient was successfully treated with the aid of negative pressure wound therapy.

Conclusions: Negative pressure wound therapy has rarely been used to treat postoperative lymphocele. To the authors' knowledge, this case is the first to document use of negative pressure wound therapy for lymphocele following angiomyomatous hamartoma excision.

Introduction

Each year, more than 20 million inguinal hernia repairs are performed worldwide.^[1] The most common complications following inguinal hernia repair include hematoma, seroma, wound/superficial infection, mesh/deep infection, vascular injury, visceral injury, chronic pain, chronic paresthesia, and recurrence.^[2] These complications can be reduced with use of an open repair technique, such as the Lichtenstein repair.^[3]

Lymphocele is defined as a cystic collection of lymphatic fluid without any inflammatory or granulomatous changes at the lymph leakage site, which occurs following trauma to the lymphatic channels.^[4] There have been few reports of lymphocele after open inguinal hernia repair; however, this complication occurs in up to 8% of inguinal lymph node dissections and lymphadenectomies for oncologic procedures.^[5,6] Treatment of symptomatic lymphoceles frequently involves needle aspiration, drain placement, and sclerosis.^[4] Even with use of these techniques, surgical intervention is often required to treat lymphoceles and prevent recurrence.^[7] Although negative pressure wound therapy (NPWT) has been documented as a treatment for many types of wounds, to the authors' knowledge, there is only one reported case in which NPWT was used to manage postoperative lymphocele.^[8,9]

In general, NPWT promotes formation of granulation tissue, removes fluid from the wound, and provides an approximation of tissues in open wounds.^[9] It is important to note that wounds must be cleaned and debrided prior to therapy to avoid making the condition worse with the use of NPWT. Conversely, NPWT can cause injury to healthy skin in the form of blister formation or bleeding, and in some studies it has been associated with protein loss, in which case nutritional status and support are important.^[10,11]

An even rarer finding than a lymphocele is of an angiomyomatous hamartoma. This pathology was first described in 1992 by Chan et al^[12] and has been reported fewer than 50 times since its discovery.^[13–16] These malformations are usually diagnosed in an excisional manner. The most common pathologic finding is the replacement of parenchymal lymph tissue by blood vessels, smooth muscle, and fibrous tissue without cellular fascicle formation.^[12] The exact cause of this pathology is unknown; however, it has been proposed that it is due to disruption of lymphatic flow^[17] or inflammation near the lymph nodes themselves.^[12] Neither recurrence nor metastasis has been reported after excision of angiomyomatous hamartoma. There seems not to be any malignant potential.^[13]

The case of an inguinal hernia repair in which an angiomyomatous hamartoma was found incidentally, then complicated by inguinal lymphocele, is presented herein. Treatment included wound exploration and ligation of lymphatic channels, followed by NPWT. To the authors' knowledge, this technique for repair has been documented only once previously;^[8] it was used following a lymphoma excision.^[8]