Chylous ascites as a diagnostic surprise during inguinal hernia surgery: a case report and review of literature

Chylous ascites is a rare form of ascites characterized by the accumulation of lipid-rich lymphatic fluid in the peritoneal cavity. In children, congenital lymphovascular malformations are the most common cause. However, its intraoperative detection during elective procedures like inguinal hernia repair is exceedingly rare. We report the case of a 5-month-old male infant who presented with a reducible right inguinal hernia. During elective herniotomy milky white fluid was encountered, raising suspicion of chylous ascites. Fluid analysis confirmed the diagnosis with triglyceride levels >9500 mg/dL and positive chylomicrons. Subsequent imaging revealed a cystic lesion in the mesentery and the child underwent exploratory laparotomy with complete excision of the lesion and bowel anastomosis. Histopathology confirmed cystic lymphangioma. Postoperatively the child remain stable and tolerated orals well. At one-year follow-up, the child remains asymptomatic and thriving well. This case highlights the importance of maintaining a high index of suspicion for chylous ascites when atypical intra-abdominal fluid is encountered during surgery. Prompt evaluation, appropriate dietary and pharmacologic interventions, and surgical management based on the underlying etiology can lead to excellent outcomes. Ruptured cystic lymphangioma presenting as chylous ascites encountered during hernia surgery is a very rare phenomena. Reporting such rare intraoperative findings adds valuable insight into the spectrum and management of pediatric chylous ascites.