Chylous ascites as an unexpected intraoperative finding in a child with an incarcerated inguinal hernia: a case report

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Introduction Chylous ascites due to an incarcerated inguinal hernia is a rare condition. The factors that typically lead to chylous ascites include trauma (surgical or otherwise), congenital lymphatic anomalies, infectious diseases, liver cirrhosis, heart failure, tumors, and metabolic disorders. Case presentation A four-year-old boy with no history of chronic disease underwent emergency surgery for an incarcerated right inguinal hernia. The incarcerated mass reduced spontaneously during skin preparation. Through a 4 cm incision parallel to the right inguinal canal the hernial sac was opened, and milky fluid was seen draining from the sac and from the abdominal cavity. A lymphatic injury was suspected, and a midline diagnostic laparotomy was therefore performed; it showed no intestinal malrotation, no damaged lymph nodes in the previously incarcerated segment, and no identifiable source of lymphatic leakage. The hernia was repaired and a drain was left on the right side. Biochemical analysis of the fluid confirmed chyle (triglycerides 148 mg/dL, total protein 32.6 g/L, LDH 1102 U/L, total cholesterol 4.8 mmol/L). The workup performed to exclude an underlying cause consisted of tumour markers, abdominal ultrasound, chest radiography, a laboratory panel (electrolytes, renal and liver function tests, albumin, total protein, thyroid function, uric acid, immunoglobulins), urinalysis, a plasma amino acid profile and urinary succinylacetone; all results were normal. Drain output fell from 400 mL on the first postoperative day to 15 mL, the drain was removed on postoperative day 4, and the child was discharged on day 5 on a medium-chain triglyceride diet. Serial ultrasound examinations over one year showed no recurrence of ascites; the child successfully transitioned back to a normal diet and has remained asymptomatic since. Conclusion Chylous ascites can occur in children with an incarcerated inguinal hernia due to obstruction and/or trauma of the mesenteric lymphatic vessels of the incarcerated bowel loops.