Cord lipoma is a clinical entity frequently encountered during inguinal hernia surgery, yet often overlooked. It holds significant importance in terms of correct diagnosis and surgical management. In this blog post, I share practical information about the identification, differentiation, and management of cord lipomas in both open and laparo-endoscopic repairs.

During open inguinal hernia repairs, when we open the inguinal canal, we may come across a lipomatous structure within the cord elements, with a stalk extending into the preperitoneal space. This is what we call a cord lipoma. In fact, in some patients who have been clinically and radiologically diagnosed with an inguinal hernia before surgery, no direct or indirect hernia may be found — yet a cord lipoma is present. Is this a misdiagnosis? Certainly not. A cord lipoma is a hernia.

Cord lipomas are lipomatous masses originating from preperitoneal fat. They pass through the internal inguinal ring and reside within the inguinal canal. Sometimes, they can grow as large as an orange. They are mostly benign in nature; however, liposarcomas have also been reported.

Diagnosis

They are usually palpable as soft masses in the groin. They are not reducible. They may become more prominent with Valsalva. Completing the physical examination with ultrasound is always a good approach in the clinical evaluation of inguinal hernias. It provides information about the hernia content and also allows examination of the opposite groin to detect any asymptomatic or occult hernias. Click here to read my blog post on this topic! If clinical suspicion persists, cross-sectional imaging with MRI is the gold standard in the groin. MRI is particularly valuable for evaluating soft tissue. Cord lipomas appear as fat tissue associated with the spermatic cord along the inguinal canal: hyperintense on T1- and T2-weighted sequences and showing signal loss on fat-suppressed sequences.

Treatment Approach

In open inguinal hernia repairs, we either excise the lipoma at the level of the internal ring or perform a high dissection and reduce it back toward the preperitoneal space. I apply the same technique to cord lipomas as I do to indirect hernia sacs — I generally reduce them.

What about in laparo-endoscopic inguinal hernia repair? Seeing the unseen!

The approach does not differ. Cord lipomas are almost always located lateral to the cord structures at the internal ring. Therefore, it is crucial to check for their presence in this area. There’s a practical method to assess this without dissection: if the pearly white line of the iliopubic tract is visible lateral to the internal ring, there is no cord lipoma. If it is not visible, a cord lipoma is likely present. In that case, dissection should be performed to reduce the cord lipoma.

Despite having a thin stalk, some cord lipomas can be quite large and may be reducible. The fat tissue beneath the iliopubic tract, in the lower portion of the internal ring, is distinct from the cord lipoma. This tissue tends to have a light brownish color. Dissection should not be performed in this area, as lymph nodes and branches of the genitofemoral nerve reside here, posing a risk of injury. Additionally, lymph nodes tend to bleed easily.

To Remove or Not to Remove the Cord Lipoma

So, you’ve reduced the lipoma endoscopically. What next? Should you excise it or leave it in place? Both approaches are acceptable. I always leave it in place. The key is ensuring it stays behind the mesh you’ve placed. Just before releasing the carbon dioxide at the end of the operation, a final check should be made. Attempting to excise it and remove it through a trocar is tedious and time-consuming. There is no harm in leaving it in place, provided the fine vascular pedicle supplying it is preserved; otherwise, there is a risk of necrosis.

I strongly recommend you read the article ‘The 10 Golden Rules of Minimally Invasive Inguinal Hernia Repair’ — a structured, published, and widely adopted approach to groin hernias among hernia surgeons. Rule number 6 says: ‘Check the cord lipoma.’ In some patients who have had previous laparo-endoscopic inguinal hernia repairs at other centers and later experienced recurrence, I have encountered forgotten cord lipomas. In such cases, performing an open approach and excising the lipoma resolves the issue.

Lipoma in Direct Hernias

As is well known, classical hernia sacs are not present in direct hernias. Instead, a lax and bulging transversalis fascia gives the appearance of a sac. In large direct hernias, once the hernia contents are reduced during laparo-endoscopic surgery, a lipomatous mass is often encountered. This structure is usually preperitoneal fat, often originating from the anterior surface of the bladder. In some cases, the bladder itself may be pulled into the direct hernia defect. Therefore, utmost care must be taken during dissection in this area, and the bladder must always be kept in mind.

Final Word

Cord lipoma is a clinical entity that must not be overlooked — and yes, it is a hernia. Especially during minimally invasive inguinal hernia repairs, its presence should be meticulously assessed. If detected, it should be carefully reduced from the inguinal canal and positioned behind the mesh. Excision is optional, not mandatory. What matters most is a solid repair performed with the correct diagnosis, proper dissection, and full anatomical awareness.

Remember: a missed cord lipoma is the hidden cause behind many cases mistakenly considered as recurrences.