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| CASE REPORTS |
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| Year : 2022 | Volume
: 5
| Issue : 2 | Page : 100-102 |
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A rare complication of giant pseudocyst after femoral hernia repair with mesh: A case report
Jasmine Bhinder, Boris Borges, Weidun Alan Guo
Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| Date of Submission | 28-Sep-2021 |
| Date of Decision | 22-Oct-2021 |
| Date of Acceptance | 23-Nov-2021 |
| Date of Web Publication | 19-May-2022 |
Correspondence Address:
Dr. Jasmine Bhinder
Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, 1001 Main Street, Buffalo, NY 14203.
USA
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijawhs.ijawhs_67_21
Hernia repair is one of the most common procedures performed by general surgeons worldwide. Rates of recurrence have significantly decreased with the use of mesh; however, this foreign material has its own inherent complications. We present a rare and unusual complication of giant pseudocyst formation after femoral hernia repair. Pseudocysts have mostly been described after incisional hernia repairs and there are only a handful of cases reported after groin hernia repair in the literature. To the best of our knowledge, this is the first reported case of pseudocyst after femoral hernia repair. Keywords: Femoral hernia, mesh, pseudocyst
How to cite this article:
Bhinder J, Borges B, Guo WA. A rare complication of giant pseudocyst after femoral hernia repair with mesh: A case report. Int J Abdom Wall Hernia Surg 2022;5:100-2 |
| Introduction | |  |
Groin hernias constitute one of the most common procedures performed by general surgeons in the United States with over 800,000 repaired annually.[1],[2] The most common complications following hernia repair include infection, hematoma, inguinodynia, and recurrence. The use of mesh has significantly reduced the incidence of recurrence; however, there have been some reports of unusual complications such as pseudocyst formation. This occurrence has primarily been described following incisional hernia repairs with only a few cases described after inguinal hernia repair.[3],[4],[5],[6],[7] To the best of our knowledge, this case is the first to be described following femoral hernia repair.
| Case Report | | |
An 89-year-old female with a body mass index of 21 and past medical history significant for atrial fibrillation, hypertension, hyperlipidemia, and gastroesophageal reflux disease presented to the emergency room (ER) with right groin pain. She denied any history of allergic reactions and has no allergies to medications. She was found to have an incarcerated right femoral hernia on physical exam and computed tomography (CT) scan. The hernia was reduced at bedside and the following day she subsequently underwent robotic-assisted repair with 3D Max light mesh (comprising polypropylene light-weight monofilament with large pore size; 7.9 cm × 13.4 cm). Patient did well and was discharged home on postoperative day 2.
Five months after her operation she presented to the ER with abdominal pain and fullness associated with urinary incontinence. CT scan at the time showed a large cystic mass in the pelvis measuring 16.5 cm × 10.7 cm × 11 cm with a portion of the cystic lesion protruding into the right femoral space [Figure 1] and [Figure 2]; this was compared to CT imaging prior to hernia repair which did not reveal any cystic structures. This was initially thought to be a cystic ovarian/adnexal neoplasm and gynecology consultation was recommended. She was seen a week later at a comprehensive cancer care center. The gynecology team had low suspicion for a malignant process and ultrasound-guided drainage was performed with return of 1,250 ml of fluid. Cytology showed predominantly chronic inflammatory cells and cellular debris. No malignant cells were identified. Shortly after, she underwent two further drainage procedures due to recurrent and worsening urinary incontinence. During the third procedure, a percutaneous catheter was kept in place and doxyclycline was administered twice prior to removal. | Figure 1: Axial computed tomography of giant fluid-filled cyst evidently compressing bladder (arrow)
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 | Figure 2: Sagittal computed tomography showing gigantic fluid-filled cyst
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She was then referred to an alternate general surgeon for elective resection of the cyst due to rapid re-accumulation and persistence of symptoms. A preoperative CT scan was performed which showed similar pelvic cyst measuring 15 cm × 12 cm × 17 cm with extension into the right femoral space. She was taken to the operating room and initially underwent diagnostic laparoscopy. The cyst was noted to be very large and adherent to the anterior abdominal wall. We subsequently converted to an open laparotomy. The cyst was within Retzius space and noted to extend into the right femoral canal and left obturator space. The cystic lesion was dissected free using a combination of electrocautery and blunt dissection. Unintentional entry into the cyst occurred and 950 ml of straw-colored fluid was suctioned out. The bladder was adherent to the posterior surface of the cyst and inadvertent injury to the bladder occurred which was repaired with running and imbricated Vicryl suture. Once the cyst was removed, the femoral space was closed with 0-Polydioxanone (PDS) suture by bringing coopers ligament to the shelving edge of the inguinal ligament. The left obturator space was also closed using 0-PDS. On gross examination, it was noted that the mesh was incorporated within the cyst wall and was not in its initial location [Figure 3]. The patient recovered well from the operation and was discharged home on postoperative day three. Histopathology showed that the cystic wall was comprised of chronic inflammatory tissue which was devoid of any epithelial lining, confirming the diagnosis of a pseudocyst. | Figure 3: Gross specimen of pseudocyst showing incorporation of mesh with the cyst wall
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| Discussion | | |
Hernia repair is one of the most common procedures performed by general surgeons worldwide. Early complications include seroma, hematoma, and wound infections and approximately 10% of patients will experience chronic postoperative pain.[3] Rates of recurrence have significantly decreased with the use of mesh in hernia repairs. However, the use of foreign and prosthetic materials has led to its own inherent complications.
A small fluid collection or seroma after hernia repair is not uncommon; however, these generally resolve without any intervention. Pseudocyst after incisional hernia repair has been well documented in over 35 case reports with some case series reporting an incidence of 0.8%.[4] This complication has also been reported in a handful of inguinal hernia repairs.[3],[4],[5],[6],[7] This report is the first to outline this rare complication after femoral hernia repair.
Pseudocysts are distinguished from cysts due to a lack of a true epithelial lining. The etiology and pathophysiology after hernia repair remains uncertain. Some authors have proposed this occurs secondary to long-standing seromas or hematomas.[5] In addition, during dissection of the pelvic floor there may have been unrecognized injury to lymphatic vessels creating a large lymphocele, which is a well-known complication after laparoscopic radical prostatectomy.[8] Therefore, it is recommended not to touch the fatty tissue in front of the iliac vessels which may contain a lot of lymph nodes and vessels. The formation of pseudocysts can possibly be considered an inflammatory response secondary to chronic fluid collections. As our patient’s hemoglobin remained stable, the likely etiology of pseudocyst formation was secondary to a long-standing seroma. This seroma was large enough to displace the mesh and extend into the inguinal canal.
Using tetracycline as sclerotherapy is an effective mechanism for certain cysts such as ovarian or renal; however, the efficacy of tetracycline is based on its ability to disrupt the endothelial lining of cysts, which causes an inflammatory reaction and subsequent fibrosis. This therapy was attempted in our patient; however, due to the lack of a true epithelial lining, it was unsuccessful. Pseudocysts are generally not responsive to aspiration and have a high rate of recurrence once aspirated. The primary definitive treatment is cyst excision. In cases of pseudocyst secondary to incisional hernia repair, some authors have reported partial excision of the cyst wall and leaving the portion of cyst adherent to mesh in place.[6] Another author successfully treated the pseudocyst with laparoscopic fenestration.[7] In our case, the pseudocyst and adherent mesh was completely excised from the surrounding tissues and removed. The mesh was incorporated into the pseudocyst which extended into the femoral canal.
Postoperative pseudocyst after groin hernia repairs is a rare complication that most surgeons are unaware of. The etiology is possibly a result of chronic seroma or hematoma formation. Attempted aspirations and sclerotherapy are generally not effective and can result in further complications such as infection. On the basis of our personal experience and the reported literature, the definitive treatment is surgical excision.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | HerniaSurge Group. International guidelines for groin hernia management. Hernia 2018;22:1-165.  |
| 2. | Hammoud M, Gerken J Inguinal hernia. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513332/. [Last accessed on 2020 Sep 8]. |
| 3. | Fitzgibbons RJ Jr, Forse RA Clinical practice: Groin hernias in adults. N Engl J Med 2015;372:756-63. |
| 4. | Ielpo B, Cabeza J, Jimenez D, Delgado I, Torres AJ Abdominal pseudocyst complicating incisional hernia repair: Our experience and literature review. Hernia 2011;15:233-7. |
| 5. | Arya N, Batey NR Pseudocyst formation after mesh repair of incisional hernia. J R Soc Med 1998;91:647-9. |
| 6. | Mantelou AG, Georgiou GK, Harissis HV Giant pseudocyst of the anterior abdominal wall after incisional hernia mesh repair: A rare case report. Hernia 2014;18:141-4. |
| 7. | van Loon YT, Ibelings MS Laparoscopic fenestration of a giant pseudocyst after totally extra peritoneal inguinal hernia repair. Case Rep Surg 2016;2016:9867645. |
| 8. | Horovitz D, Lu X, Feng C, Messing EM, Joseph JV Rate of symptomatic lymphocele formation after extraperitoneal vs transperitoneal robot-assisted radical prostatectomy and bilateral pelvic lymphadenectomy. J Endourol 2017;31:1037-43. |
[Figure 1], [Figure 2], [Figure 3]
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