Inguinal hernia is a common and prevalent disease mainly presented as inguinal or scrotal mass . It is not complicated to diagnosis an inguinal hernia, but we must pay attention to some special types of inguinal hernia and special hernia contents. For example, sliding hernia that caecum, sigmoid colon or bladder become part of the hernia sac wall, and these organs can be easily damaged when the hernia sac wall is incised without caution [5–6]. Sometimes the hernia contents extending from the abdominal cavity are not part of the normal tissues, but are retroperitoneal or intraperitoneal tumors such as liposarcoma or neurofibroma from the retroperitoneum, and lymphoma from the small intestine [2, 7]. Special hernia content should be considered, if a huge inguinal or scrotal mass is irreducible without signs of abdominal pain or intestinal obstruction. This patient consulted at the outpatient for his football-sized scrotal mass, and we immediately send him to the radiology department for an abdominal CT scan to rule out other abdominal abnormalities. From the reported literatures, three cases were misdiagnosed preoperatively as mere inguinal hernia and needed reoperation [8–10]. Reoperation would increase the mortality and recurrence of those patients. Sometimes, non-inguinal hernia disease presents as an inguinoscrotal mass also should be cautious. These diseases or disorders are testicular or spermatic hydrocele, varicocele, enlarged lymph nodes in the groin, spermatic cord lipoma or liposarcoma, undescended testis, and cold abscess of the psoas muscle et al [11–12]. Hence, potential pitfalls should be avoided when diagnosis of inguinal masses.
Retroperitoneal liposarcoma presenting with inguinal hernia is extremely rare and only eleven cases have been reported in the world up to this point (supplementary table 1). Histologically, the majority of these liposarcoma were well-differentiated. The majority of the cases perform surgical resection and have favorable prognosis. Hence, radical resection remains the mainstay of therapy particularly for the well-differentiated subtype . But the operation can be a big challenge for the huge tumor with a wide distribution, the surrounding organs are compressed and deformed, and the anatomical adjacent relationship is changed. It is important to radical resect the tumor and preserve the vital organs or vessels. Intraoperatively, bilateral ureteral intubation should be first performed to protect the ureter. The pulsation of important blood vessels should always be touched and the tumor should be dissected more than 1 cm away from the arteriopalmus, so as to avoid damage to the large blood vessels. Large retroperitoneal tumors often have serious adhesion with surrounding tissues and organs, or even completely wrap around some organ tissues. At this time, the choice of combined resection of the viscera can avoid local residual tumor and the spread of tumor cells, which ensure negative surgical margin . For patients with cardiopulmonary insufficiency, multidisciplinary cooperation must be sought. Serdar Yol et al. successfully cured a patient with dyspnea and cachexia by respiratory support in the early postoperative period . In our case, the massive operation was performed under the escort of cardiologist, anesthetist, and intensive care physician. There are still debates about the postoperative radio-chemotherapy of the well differentiated liposarcomas . We did not undergo adjuvant therapy inconsideration of the radical resection and the low risk of recurrence for the well-differentiated subtype.
In conclusion, careful distinction for inguinoscrotal mass is essential to minimize complications and improve patient prognosis. Further imaging examination is mandatory to screen for other intraabdominal abnormalities, if a huge inguinal or scrotal mass is irreducible without signs of abdominal pain or intestinal obstruction. The prime principle to treat well differential retroperitoneal liposarcomas is radical resection with protection of vital organs and vessels. Since radical resection is a challenge for a retroperitoneal mass protruding into inguinoscrotal area, interdisciplinary discussion must be considered.