Tattooing: more than skin deep

Abstract

In March 2012, an otherwise fit 35-year-old Caucasian male was referred to the surgical outpatient clinic with a history of a left inguinal hernia. This was confirmed on clinical examination and a date was set for an elective Lichtenstein repair under general anaesthetic as a day case procedure. The patient’s groin was reexamined as routine on the day of surgery, marked and informed consent was obtained. Following induction of general anaesthesia his hernia was manually reduced. A routine oblique skin incision along Langer’s lines, 2 cm above the inguinal ligament was made and extended laterally. Whilst retracting the subcutaneous tissues, a firm lump was unexpectedly felt at the level of the inguinal ligament. The subcutaneous tissue was carefully dissected revealing a large rubbery black pigmented superficial inguinal lymph node. The lymph node was excised and an emergency frozen section procedure was requested. Whilst awaiting the pathology report and with the patient still under anaesthetic, the incision was covered and the sterile drapes removed to expose the patient’s torso and lower limbs. A primary melanoma lesion was searched for, however, examination revealed a large tattoo along the outer aspect of his left leg that had not been appreciated preoperatively (Fig. 1). No other abnormality was identified. Emergency pathology reported a lymph node with prominent pigment deposit. No obvious malignancy was seen. Hence, the procedure was resumed and the patient had a Lichtenstein hernia repair in routine fashion using a self adhesive mesh (ParietexProGrip, Covidien, Dublin, Ireland). A subsequent full pathology report of the paraffin embedded specimen confirmed the presence of dense pigment deposit within the lymph node and no evidence of neoplasia (Fig. 2). The node measured 25 9 10 9 5 mm. Body art in western societies has seen a dramatic surge in popularity in recent years. Once the domain of specific subcultures, tattoos are now commonly seen on mainstream male and female celebrities, including athletes and