Article

The tip of the iceberg: a giant pelvic atypical lipoma presenting as a sciatic hernia

Department of General Surgery, St, John's Hospital at Howden, Livingston, NHS Lothian-University Hospitals Division, UK.
World Journal of Surgical Oncology (Impact Factor: 1.2). 02/2006; 4:33. DOI: 10.1186/1477-7819-4-33
Source: PubMed

ABSTRACT This case report highlights two unusual surgical phenomena: lipoma-like well-differentiated liposarcomas and sciatic hernias. It illustrates the need to be aware that hernias may not always simply contain intra-abdominal viscera.
A 36 year old woman presented with an expanding, yet reducible, right gluteal mass, indicative of a sciatic hernia. However, magnetic resonance imaging demonstrated a large intra- and extra-pelvic fatty mass traversing the greater sciatic foramen. The tumour was surgically removed through an abdomino-perineal approach. Subsequent pathological examination revealed an atypical lipomatous tumour (synonym: lipoma-like well-differentiated liposarcoma). The patient remains free from recurrence two years following her surgery.
The presence of a gluteal mass should always suggest the possibility of a sciatic hernia. However, in this case, the hernia consisted of an atypical lipoma spanning the greater sciatic foramen. Although lipoma-like well-differentiated liposarcomas have only a low potential for recurrence, the variable nature of fatty tumours demands that patients require regular clinical and radiological review.

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    ABSTRACT: INTRODUCTION Few reports detail adequate surgical management of giant pelvic tumors that traverse the sciatic foramen. PRESENTATION OF CASE We present a case of a giant retroperitoneal pelvic lipoma that presented with a dumbbell shape on imaging, occupying the entire lesser pelvis and protruding to the gluteus through the sciatic foramen. Surgery was performed for en bloc resection of the tumor. DISCUSSION A parasacral approach with the patient in the prone position was necessary to dissect the tumor in the buttock, manipulate around the sciatic foramen and preserve collateral blood flow for the gluteal muscle. An abdominal approach was also essential to ligate the internal iliac vessels involved in the tumor. Accordingly changings the position of the patient during the operation were required. Division of the sacrotuberous and sacrospinous ligaments and packing of the soft tumor into a plastic bag were useful to pass the buttock portion through the foramen without the tumor breaking off. CONCLUSION The asynchronous abdomino-parasacral approach with several turnings of the patient's body and plastic bag packing of the tumor were advantageous to manage en bloc resection of the giant pelvic lipoma presented in this case study.
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    ABSTRACT: Sciatic hernias are considered the rarest pelvic floor hernias, with a very limited number of published reports worldwide. The condition has received limited attention in the surgical literature. The data reported herein are based on a literature review including MEDLINE and CURRENT CONTENTS computerized database searches. The existing bibliographies on sciatic hernia were explored for articles pertaining to the review. Finally, the Internet was searched for articles not listed in the available medical databases. Sciatic hernia is unusual, and can present the physician with diagnostic and treatment dilemmas. The hernia may present with obscure pelvic pain, intestinal obstruction, life-threatening gluteal sepsis, or as an asymptomatic, reducible mass that distorts the gluteal fold. Small sciatic hernia can remain hidden behind the gluteus maximus muscle. The diagnosis requires imaging studies in such cases. Treatment of sciatic hernia is always surgical and requires prosthetic reinforcement for the best result.
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