A 71-year-old male reported the presence of a left scrotal mass for "two to three years." Chronic systemic problems included diabetes mellitus II, gastric reflux, obesity, obstructive pulmonary disease, congestive heart failure, and groin lymphedema. Physical examination showed an obese man (BMI 40.1) who moved with difficulty and had exertional dyspnea. Penile and left scrotal skin were swollen. A large, soft, non-tender mass filled his left inguinal canal and scrotum. This could be partially reduced with the patient supine.

Ultrasound examination of his groin showed groin skin edema and a soft tissue mass in the scrotum. Computed tomography showed a 6x8 cm fat-containing hernia extending into the scrotum. The left kidney was ptotic (Figure 1) and (Figure 2). The hernia's contents did not seem to be at risk for strangulation because the hernia was very broad-based. For this reason and the patient's high operative risk, surgical therapy was not recommended.

A hernia is the protrusion of an organ or structure through an abnormal opening. An indirect inguinal hernia does not always have a sac, once considered a fundamental feature of that disorder. A lipoma is a discrete, encapsulated portion of fat and can occasionally be found in the spermatic cord. However, most so-called cord lipomas are extrusions of retroperitoneal fat alongside the cord. Thus they are hernias [1] [2].

Such fatty cord masses are common. They were noted in 33% of a clinical study and 75% of a cadaver study [2] [3]. They can be large and cause symptoms. On physical examination, they can be confused with a saccular hernia and are rarely diagnosed preoperatively.

Bondevik presented a case of massive prolapse of retroperitoneal fat and ureter into the scrotum. After considering various terms, the author dubbed this a "fatty hernia." It is rare, his case being the fifth reported in four patients [1]. Prolapse of retroperitoneal structures into the groin can be with ("paraperitoneal") or without ("extraperitoneal") a sac. All reported cases have been in obese patients. Renal ptosis is characteristic. Ureteral herniation can be caused by gravitational pull of the attached mass of fat [4]. When feasible, treatment consists of excision or reduction of herniated fat and closure of the abdominal inguinal ring defect. The potential for ureteral injury must be considered.

Fatty hernias are rare. Computed tomography reliably demonstrates their anatomy. If surgical treatment is chosen, the anatomic course of the ureter should be delineated preoperatively.

Keywords: Fatty hernia, Lipoma of cord, Obesity, Ptotic kidney, Ptotic ureter

1. Bondevik H. Inguinal prolapse of retroperitoneal fat ("fatty hernia"). Report of a case also involving the ureter. Acta Chir Scand 1966 May;131(5):492–6.   [Pubmed]    
2. Fawcett AN, Rooney PS. Inguinal cord lipoma. Br J Surg 1997 Aug;84(8):1169.   [CrossRef]   [Pubmed]    
3. Heller CA, Marucci DD, Dunn T, Barr EM, Houang M, Dos Remedios C. Inguinal canal "lipoma". Clin Anat 2002 Jun;15(4):280–5.   [CrossRef]   [Pubmed]    
4. Giuly J, François GF, Giuly D, Leroux C, Nguyen-Cat RR. Intrascrotal hernia of the ureter and fatty hernia. Hernia 2003 Mar;7(1):47–9.   [Pubmed]