CASE REPORT – OPEN ACCESS

International Journal of Surgery Case Reports 66 (2020) 215–217

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International Journal of Surgery Case Reports

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Inguinal tumorous mass – an uncommon late manifestation of

chronic organized hematoma after laparoscopic transabdominal
preperitoneal inguinal hernia repair: Two cases report
Petr Chmatal ∗ , Radan Keil
Institute of Aviation Medicine Prague, Generala Piky 1, 160 00 Praha 6, Czech Republic

a r t i c l e i n f o a b s t r a c t

Article history: BACKGROUND: Hematoma is a common complication following inguinal hernia repair. It is usually
Received 24 October 2019 diagnosed early after surgical procedure and is spontaneously, or after evacuation, resorbed. Chronic
Received in revised form 8 December 2019 organized hematoma is rare surgery complication, there is no relevant article after laparoscopic hernia
Accepted 11 December 2019
repair in literature.
Available online 17 December 2019
CASES PRESENTATION: 62- and 54-year-old men presented a groin palpable tumorous mass several month
after uncomplicated laparoscopic transabdominal preperitoneal inguinal hernia repair. Their dominant
Keywords:
complaints were mechanical restrictions. The ultrasound showed a solid formation subcutaneously. The
Transabdominal preperitoneal inguinal
hernia repair
removal and histopathology examination confirmed a chronic organized hematoma and at the same time,
Chronic hematoma this ended the patients ‘problems.
Tumour CONCLUSION: Both patients represent uncommon cases of late postoperative difficulties, uncharacteristic
TAPP localization of chronic organized hematoma and the need for surgical reintervention to exclude neoplasm.
Rare disease © 2019 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open
access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

1. Background 2. Cases presentation

Inguinal hernia repair is one of the most frequent surgical pro- 2.1. Case report
cedures in general surgery around the world. For male patients
with primary unilateral inguinal hernia a laparoscopic technique A 62-year old white man had a left inguinal hernia, 5 × 2 cm in
is suggested [1]. Postoperative complications are watched and size, which lasted for two years. He was suffering from pain and
evaluated. The incidence of hematoma after laparoscopic trans- pressure in the groin. With regard to additional diseases, there was
abdominal preperitoneal inguinal hernia repair (TAPP) is reported only hypertension treated with angiotensin blockers. Clinical find-
from 3 to 8%. The latest published meta-analysis puts the incidence ing apart from hernia was physiological, ASA classification II. TAPP
at 3,4% on average [2]. The risk of hematoma is increased by par- procedure lasted 60 min without any complications. We identified
tially absorbable mesh, chronic anticoagulation, recurrent hernia direct hernia. The inguinal defect was covered using polypropy-
procedure, mesh fixation, larger hernia defect and medial defect len non-absorbable mesh which was fixed with ProTack (5 mm) on
localization [3–5]. Hematomas commonly manifest themselves Cooper’s ligament and transverse abdominal muscle. The patient
early after the surgical procedure and imaging examinations show a was discharged to home care the next morning. The stitches were
fluid collection. Although hematoma as a fluid collection after TAPP removed after 8 days. The last follow-up was after 4 weeks without
is not unusual, the finding of chronic organized hematoma (COH) any complaints and with normal postoperative status. The patient
as a hard inguinal mass causes mechanical problems and solid for- returned to surgery four month later with a palpable tumour in
mation image on ultrasound is rare. This work has been reported the groin, 4 × 6 cm in diameter. The ultrasound picture repeat-
in line with the SCARE criteria [6]. edly showed an uncharacteristic formation, presumably of solid
hematoma or tumorous lymphatic node subcutaneously (Fig. 1).
The puncture was unsuccessful. The tumour was removed eight
months after the TAPP from anterior access (Fig. 2). The inguinal
Abbreviations: TAPP, transabdominal preperitoneal inguinal hernia repair; COH, channel was firm and intact. The patient was discharged same day
chronic organized hematoma; ASA, American Society of Anesthesiologist; CEH, and postoperative course was without any complications. Macro-
chronic expanding hematoma. scopic and histopathology findings confirmed COH (Fig. 3). The
∗ Corresponding author.
patient is constantly without problems.
E-mail addresses: [email protected] (P. Chmatal), [email protected]
(R. Keil).

https://doi.org/10.1016/j.ijscr.2019.12.016
2210-2612/© 2019 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).
 CASE REPORT – OPEN ACCESS
216 P. Chmatal, R. Keil / International Journal of Surgery Case Reports 66 (2020) 215–217

procedure lasted 60 min without any complications. We identi-

fied the indirect hernia sac. The non-absorbable mesh was used
into preperitoneal space which was fixed with ProTack (5 mm) on
Cooper’s ligament and transverse abdominal muscle. The patient
was discharged to home care the next morning. The stitches were
removed after 7 days. The last follow-up after 3 weeks was without
any complaints and with a corresponding postoperative finding.
This patient returned to surgery after 10 weeks with subcutaneous
firm bulk limiting his motion. The ultrasound finding was suspi-
cious of COH. The puncture was unsuccessful. The surgery was done
three months after the TAPP from the anterior access, the inguinal
channel was firm and we removed a tumour, 3 × 2 cm in size. The
patient was discharged same day and postoperative course was
without any complications. Macroscopic and histopathology find-
ings confirmed COH. The patient is constantly without problems.

Fig. 1. Chronic organized hematoma – ultrasound image eight month after TAPP.

3. Discussion and conclusions

The chronic organized hematoma is a rare complication and can

occur in a variety of postoperative or post-traumatic locations. It is
a tough and fibrous tissue mass with an uncharacteristic view on
imaging examinations. The diagnosis is often difficult and it can be
easily mistaken for one of the relatively more frequent malignant
neoplasms. The clear mechanism responsible for the development
of COH remains unclear. After initial bleeding, chronic changes
of hematoma typically start – fibroblasts create inner and outer
membranes during the process of local inflammation – hematoma
encapsulate with a central mass of blood, a wall of granulation
tissue and fibrous tissue at the periphery. In case of COH fibrous
septs grow inside the capsule during the following several weeks
and contain highly fragile neocapillary vessels. Repeated bleeding
from these neocapillars causes irritant effects of blood and self-
expansion of hematoma supports fibroblast activities. It results in
the genesis of fibrous trabecular structure with small lacunas of
Fig. 2. Chronic organized hematoma – macroscopic image.
liquid hematoma inside the membranes or fibrous material slowly
increase in volume, forming a solid hematoma, in which the inner
and outer membranes tend to fuse completely. This process can
continue to deposit calcium to tissue. Macroscopic and microscopic
findings of COH are associated with reactive inflammation and it is
analogous with the chronic expanding hematoma (CEH) described
by Reid in 1980 [7]. There is no consensus on the diagnostic term
of this disease’s entity.
Both our described cases did not presage any complications.
The patients came for the follow-up in long interval after their
uncomplicated TAPP with mechanical problems caused by inguinal
formations, which were outside of postoperative scars and out-
side direct operating space. Though patients were operated on
by different surgeons, the TAPP technique is standardized in our
facility and should not influence the healing process. CT or MRI
examination before reoperations could not bring any additional
information and wasn’t used. Although exists studies which recom-
mend laparoscopy in inguinal hernia reoperations [8], in our cases
a laparoscopic approach couldn’t get to tumour above abdominal
wall.
Fig. 3. Chronic organized hematoma – microscopic image. The COHs in our patients after TAPP occurred out of direct
surgery area, caused mechanical restriction, had uncharacteris-
2.2. Case report tic finding on imaging examinations and remove was needed to
exclude neoplasm. Inguinal channel histopathology changes in men
A 54-year-old white man had a left inguinal hernia, lasting with inguinal hernia was precisely described in studies from Uni-
for fifteen years, 6 × 6 cm in size. The hernia limited him in hard versity of Palermo [9–11]. Postoperative changes are described in
work. He had no additional diseases in history. Clinical finding several studies. We didn’t search any relevant articles concerning
apart from hernia was physiological, ASA classification I. The TAPP COH or CEH after TAPP in the literature.
 CASE REPORT – OPEN ACCESS
P. Chmatal, R. Keil / International Journal of Surgery Case Reports 66 (2020) 215–217 217

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Declaration of Competing Interest

The authors declare that they have no competing interests.

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