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Recurrent Inguinal Hernia vs. Malgaigne’s Bulge vs. Preperitoneal Lipoma regrowth
Good evening!
I have a question whether recurrent inguinal hernias generally present themselves as Malgaigne’s bulge (“phantom hernia”) or preperitoneal lipoma or preperitoneal fat tag in early stages? Or whether – herniating fat must always enter through the wall of the inguinal canal directly or indirectly (through the deep ring) to be a hernia?
To be more specific. 35 y.o. male, history of lots of lipomas and IBS/constipation. I had right indirect inguinal plug and patch propylene anterior repair 2 years ago. During the repair a posterior wall of the inguinal canal was deemed to be week but no direct hernia was palpated. Recovery was uneventful and I hardly felt any pain or anything at all down there due to a prophylactic neurectomy.
Now, three months ago, I started feeling pain in inguinal area that started spontaneously. The intensity of pain decreased over time and I am feeling much better now, although certain things make it more painful (full bladder, full colon, prolonged sitting, but walking is fine).
There is also a small bulge/lump is palpated on Valsalva lateral from the pubic tub. right between the mid-inguinal point and the ileus/hip area. It is located in the lateral 1/3 of the old inguinal line incision, right under it and below it, so I assume that this bulge is pressing against the area where the deep (internal) inguinal ring with the plug is and where the mesh patch cord flaps cover the deep ring and the plug. It also extends a little further laterally from the end of the incision line, so I assume that part of the bulge is under the area not covered under mesh.
The bulge or lump is not visible upon cough or Valsalva only palpable when the hand presses on that area. So, it is not really expansile. The bulge is also very palpable on the raised head test but, again, not visible. It is not painful but certain positions refer pain to the hip.
The hernia center specialist that I am seeing ordered pelvic MRI and Valsalva Ultra Sound. MRI was normal, Ultrasound showed some fat herniation pushing up against the wall of the inguinal canal.
Because I lack the usual expansile visible bulge, the surgeon does not think it is a recurrent hernia but preperitoneal fat (“lipoma” regrowth) with pronounced cough impulse in my groin. The pain may be connected to the mesh plug, not the herniating fat, which the surgeon would be happy to remove through TAPP if pain gets worse.
I am obviously very interested in what in the world that lump is and I was wondering if you have ever seen anything like that before or can offer any ideas.
I have .gif files and jpeg files of the ultrasound videos. If the forum system allows it, I will try to attach one of the videos in the next follow up message – it is almost 12 MB and is playable by Quickplayer (other programs too). I can attach more close-up ultrasound videos of Right Inguinal and Femoral later as well.
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4 Replies
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Recurrent Inguinal Hernia vs. Malgaigne’s Bulge vs. Preperitoneal Lipoma regrowth
In some patients, the mesh plug may be palpable. That alone is not an indication for mesh removal. That decision should be based upon symptoms, such as pain or hernia recurrence.
If pain is due to meshoma, mesh balling up, or the mesh plug, surgery is the only option.
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Recurrent Inguinal Hernia vs. Malgaigne’s Bulge vs. Preperitoneal Lipoma regrowth
Thank you so much!
The MRI radiologist did not find a hernia but the Ultrasound radiologist did diagnose this as a recurrent hernia.
The surgeon whom I am seeing at our research Hernia Center disagrees – from looking at the videos it does not appear that the pre peritoneal fat “bulge” enters into inguinal canal. It is pushing against the posterior wall of the canal in the area of the deep internal ring – so where the plug is.
The most up to date hypothesis on the source of the lump is that the lump is actually the mesh plug felt under my skin. The most up to date hypothesis on the source of my pain in the hip and inguinal area is the scarification of the mesh plug pushing on the nerve that has regrown after neurectomy.
Have you ever seen patients who present with the feeling of the bulge that just turns out to be as simple as a mesh plug pushed by fat? Is this common?
The plan is to proceed with conservative measures and if that fails – laparoscopic removal of the plug is in order.
Anyway, I will refer this website to my surgeon, who may know about it already through friends at UCLA. I really appreciate that this forum exists: not for the purpose of obtaining the diagnoses, but for theoretical discussions about various nuanced problems of hernialogy that cannot be answered by “regular” general surgeons.
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Recurrent Inguinal Hernia vs. Malgaigne’s Bulge vs. Preperitoneal Lipoma regrowth
Here are my thoughts:
– preperitoneal fat through the inguinal canal is a hernia.
РMalgaign̩ refers to a bulging without defect or protrusion of contents
– inguinal hernias are best repaired if symptomatic of increasing in size.
– MRI pelvis may be misread or under diagnosed by the radiologist for a hernia recurrence, especially given the ultrasound finding.
– laparoscopic surgery would be my recommendation if recurrent hernia requires surgery. -
Recurrent Inguinal Hernia vs. Malgaigne’s Bulge vs. Preperitoneal Lipoma regrowth
I could not attach the video to the message but I can send it via Google Docs here –
https://drive.google.com/file/d/0B6VD41DUDgAZZVZHNnNrRTVKU3M/view?usp=sharing
Hopefully, it works.
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