Early View Article: Online published version of an accepted article before publication in the final form.

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1 Early View Article: Online published version of an accepted article before publication in the final form. Journal Name: Journal of Case Reports and Images in Surgery Type of Article: Clinical Images Title: Computerized Radiography of Incarcerated Fatty Hernia Authors: Robert W. Ikard doi: To be assigned Early view version published: January 28, 2016 How to cite the article: Ikard R W. Computerized Radiography of Incarcerated Fatty Hernia. Journal of Case Reports and Images in Surgery. Forthcoming Disclaimer: This manuscript has been accepted for publication. This is a pdf file of the Early View Article. The Early View Article is an online published version of an accepted article before publication in the final form. The proof of this manuscript will be sent to the authors for corrections after which this manuscript will undergo content check, copyediting/proofreading and content formatting to conform to journal s requirements. Please note that during the above publication processes errors in content or presentation may be discovered which will be rectified during manuscript processing. These errors may affect the contents of this manuscript and final published version of this manuscript may be extensively different in content and layout than this Early View Article. Page 1 of 6

2 TYPE OF ARTICLE: Clinical Images TITLE: Computerized Radiography of Incarcerated Fatty Hernia AUTHORS: Robert W. Ikard 1 AFFILIATIONS: Sunnyside Drive, Nashville, Tennessee 37205, USA CORRESPONDING AUTHOR DETAILS Robert W. Ikard, M.D. 308 Sunnyside Drive, Nashville, Tennessee 37205, USA Phonee number: Fax: bnkikard@comcast.net Short Running Title: NOT GIVEN Guarantor of Submission: The corresponding author is the guarantor of submission Page 2 of 6

3 TITLE: Computerized Radiography of Incarcerated Fatty Hernia CASE REPORT A seventy-one year old man 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, nontender 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. Computerized tomography showed a six by eight centimeter fatcontaining hernia extending into the scrotum. The left kidney was ptotic. (Figure 1, 2) Because the hernia was very broad-based, its contents did not seem to be at risk for strangulation. For this reason and the patient s high operative risk, surgical therapy was not recommended. DISCUSSION 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 thirty-three percent of a clinical study and seventy-five percent 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 Page 3 of 6

4 retroperitoneal structures into the groin can be with ( para-peritoneal ) 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. CONCLUSION Fatty hernias are rare. Computerized tomography reliably demonstrates their anatomy. If surgical treatment is chosen, the anatomic course of the ureter should be delineated preoperatively. CONFLICT OF INTEREST NOT GIVEN AUTHOR S CONTRIBUTIONS NOT GIVEN REFERENCES 1. Bondevik H. Inguinal prolapse of the retroperitoneal fat ( Fatty Hernia ): report of a case involving the ureter. Acta Chir Scand. 1966; 131: Fawcett AN, Rooney PS. Inguinal cord lipomas. Br J Surg. 1997; 84: Heller CA, Marcucci DD, Dunn T, et al. Inguinal canal lipoma. Clin Anat. 2002; 15: Giuly J, Francois GF, Giuly D, et al. Intrascrotal hernia of the ureter and fatty hernia. Hernia. 2003; 7: FIGURE LEGENDS Figure 1: Coronal section of computerized tomogram with contrast showing ptotic left kidney and large amount of retroperitoneal fat extending into inguinal canal Page 4 of 6

94 95 96 97 Figure 2: Coronal section of computerized tomogram with contrast showing incarcerated fatty hernia.

5 Figure 2: Coronal section of computerized tomogram with contrast showing incarcerated fatty hernia. FIGURE Figure 1: Coronal section of computerized tomogram with contrast showing ptotic left kidney and large amount of retroperitoneal fat extending into inguinal canal Page 5 of 6

107 108 109 110 Figure 2: Coronal section of computerized

6 Figure 2: Coronal section of computerized tomogram with contrast showing incarcerated fatty hernia. Page 6 of 6

Early View Article: Online published version of an accepted article before publication in the final form.

Early View Article: Online published version of an accepted article before publication in the final form. : Online published version of an accepted article before publication in the final form. Journal Name: Journal of Case Reports and Images in Surgery doi: To be assigned Early view version published: November