Successful Treatment of Inguinal Lymphocele After Angiomyomatous Hamartoma Resection During Inguinal Hernia Repair

Raphael H. Parrado, MD; Christopher S. Thomas, MD, MS; David Countryman, MD

Disclosures

Wounds. 2021;33(7):E42-E45. 

In This Article

Discussion

The authors presented a case of an open inguinal hernia repair with an incidentally discovered and excised angiomyomatous hamartoma. Postoperative recovery was complicated by inguinal lymphocele, which was explored and closed secondarily with NPWT with good results. Another consideration for the development of this postoperative fluid collection would have been an untreated communicating hydrocele; however, the authors did not find evidence of this during the second exploration. Although closer follow-up may have helped identify the problem early, initially the authors would have opted for conservative treatment based on the small size; thus, the outcome likely would have been the same.

Complications following inguinal hernia repair occur in up to 19% of cases; the most common complications are persisting pain and hematoma.[2] Lymphocele is a common complication following groin surgery (eg, inguinal lymphadenectomy, femoral artery exposure during vascular interventions).[5,6] Lymphocele is estimated to occur in approximately 1% to 4% of femoral artery dissections.[18] The major consequence of these lymph leaks or lymphocele is the development of wound infection, which has been reported in up to 57% of cases.[19] Attempted nonoperative repair of lymphoceles, such as aspiration, drainage, and sclerosis, is often unsuccessful. Long-term repair often includes surgical exploration with ligation of lymphatic vessels.[7]

With the advent of NPWT for effluent control and to aid in wound healing, this therapy has been used in the management of lymph leaks, although only case reports have been published to date.[8,20,21] In most of these cases, a persistent leak developed by the second or third postoperative week; in some instances, such leaking was refractory to other therapies such as exploration and ligation of visible ducts. Resolution of the leak after therapy initiation has been reported at about 2 to 3 weeks after start of therapy, which is compatible with the present case.[8,20] It is the authors' belief that in the absence of infection and with an adequate nutritional status, NPWT can be a safe and effective treatment option.[8,20,22] Historically, one of the main disadvantages of NPWT was the large device needed; however, portable devices are now available that permit patients to be more mobile and undergo treatment at home.

Inguinal masses can originate as primary masses from tissues native to the inguinal region or as metastatic masses from distant locations. Primary masses can form from connective tissue, nerve sheaths, muscle, fat, blood vessels, and lymphoid tissue.[23] Angiomyomatous hamartoma is a very rare primary mass of the lymph nodes, which has a predisposition for the inguinal region. Since the first description of angiomyomatous hamartoma in 1992,[12] there have been less than 50 documented cases.[13–16] Chan et al[12] described the condition as replacement of lymphoid tissue with vascular, smooth muscle, and connective tissues, starting at the hilum of the lymph node and spreading to the capsule. Due to these histological characteristics, diagnosis of angiomyomatous hamartoma is definitively made only after excision and pathologic examination, as was done in the case presented herein. In terms of lymphocele, to the authors' knowledge, there are no reports of it after angiomyomatous hamartoma excision; however, a case of lymphocele after a groin lymphoma excision treated successfully with NPWT has been reported.[8]

In general, extreme care should be taken during any inguinal dissection, whether for hernia repair or other purposes to prevent postoperative lymph leak when damaging lymphatic structures and potential lymphatic masses such as the angiomyomatous hamartoma. Injury to the structures risks postoperative lymphocele, which can require reoperation and advanced wound care.

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