# Massive Recurrent Chylous Ascites Following Laparoscopic Inguinal Hernia Mesh Repair

## TL;DR

A patient developed severe chylous ascites after hernia mesh surgery, highlighting the need for careful diagnosis to avoid rare but serious complications.

## Contribution

This case presents a novel management approach for chylous ascites caused by lymphatic injury during hernia mesh repair.

## Key findings

- Chylous ascites following laparoscopic hernia repair is rare and can be caused by lymphatic injury.
- Conservative treatments failed, but surgical mesh removal and ligation resolved the condition.
- Accurate preoperative diagnosis is crucial to prevent iatrogenic complications from mimicking pathologies.

## Abstract

Chylous ascites is a rare condition characterized by the accumulation of lipid-rich lymph within the peritoneal cavity. While typically secondary to malignancy or trauma, its occurrence following laparoscopic inguinal hernia repair is exceptional. While clinical findings are usually sufficient to diagnose an inguinal hernia and justify surgical intervention, this case demonstrates that rare lymphatic malformations can closely mimic common pathology. A high index of clinical suspicion and further imaging should be employed when diagnostic ambiguity exists to avoid such devastating iatrogenic complications. This case contributes a novel presentation and management approach to the literature.

A 35-year-old female, initially misdiagnosed with a right inguinal hernia, underwent elective laparoscopic transabdominal preperitoneal (TAPP) repair with mesh placement. Three weeks postoperatively, she developed progressive abdominal distension and weight loss. CT imaging revealed massive free fluid consistent with ascites, and paracentesis yielded 9 L of chylous fluid with elevated triglyceride levels. Conservative management, including a medium-chain triglyceride (MCT) diet and somatostatin analogues, failed to achieve resolution. Lymphography subsequently identified multiple leak sites in the right groin; however, an attempt at percutaneous embolization was unsuccessful. Definitive surgical exploration was performed, during which the mesh was removed, revealing injured lymphatic vessels at the femoral ring. These vessels were ligated, and Tisseel® (Baxter) fibrin sealant was applied. The patient recovered uneventfully, with no recurrence at the three-year follow-up.

This case highlights that lymphatic malformations can mimic inguinal hernias and lead to severe iatrogenic complications if not considered in the differential diagnosis when clinical findings or imaging are ambiguous. When conservative measures fail, surgical intervention, specifically mesh removal and direct ligation, is essential. In this patient, the presence of the mesh likely perpetuated the lymphatic leak. This complex scenario required multidisciplinary management; ultimately, prevention relies on accurate preoperative diagnosis.