Spermatic cord lipomas are a common incidental finding during surgical treatment for inguinal hernias. They appear to arise from the retroperitoneal tissue and bulge through the internal ring of the inguinal canal and can be clinically indistinguishable from hernias. The importance of spermatic cord lipomas is poorly understood; therefore, we aimed to determine whether they should be excised when found during groin hernia surgery and if a mesh should be inserted. This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Data sources were literature searches in PubMed, Embase, and The Cochrane Library. We included original studies with patients undergoing groin hernia surgery reporting findings of cord lipomas. Two researchers assessed eligibility and risk of bias independently. Eight of 426 screened studies were eligible for inclusion. The total cohort consisted of 4,140 patients. Of these, 469 lipomas and 4,618 hernias were found during either open or laparoscopic repair. Among the 4,140 patients, cord lipomas had an occurrence of 17%, while 2.3% had a cord lipoma with no associated hernia sac. Three studies reported 66 symptomatic patients where the only pathological finding was a cord lipoma, and after removal, 63 patients (95%) had resolution of symptoms. In conclusion, cord lipomas can be the source of symptoms that clinically resemble groin hernias and removal of the lipoma seems to alleviate symptoms in most patients. Therefore, the surgeon should always consider removing cord lipomas when they are encountered perioperatively. Whether to insert a mesh when no hernial sac is encountered is still unclear.