Plate 222

A hydrocele of the tunica vaginalis occurring within the first year of life seldom requires operation, since it will often disappear without treatment. Hydroceles that persist after the first year or appear later in life usually require treatment, since they show little tendency toward spontaneous regression. All symptomatic hydroceles in adults or in children older than 2 years should be removed. Most hydroceles are painless, and symptoms arise only from the inconvenience caused by their size or weight. The long-continued presence of a hydrocele infrequently causes atrophy of the testicle. Open operation is the method of choice for removing the hydrocele. Aspiration of the hydrocele contents and injection with sclerosing agents are generally regarded as unsatisfactory treatment because of the high incidence of recurrences and the frequent necessity for repetition of the procedure. Occasionally, severe infection can be introduced by aspiration. Simple aspiration, however, often may be used as a temporary measure in those cases where surgery is contraindicated or must be postponed.

The accuracy of the diagnosis must be ascertained. Great care must be taken to differentiate a hydrocele from a scrotal hernia or tumor of the testicle. Ultrasound imaging can be very useful in these cases. A hernia usually can be reduced, transmits a cough impulse, and is not translucent. A hydrocele cannot be reduced into the inguinal canal and gives no impulse on coughing unless a hernia is also present. In young children, a hydrocele is often associated with a complete congenital type of hernial sac.

Either spinal or general anesthesia is satisfactory in adults. General anesthesia is the choice in children. Local infiltration anesthesia is generally unsatisfactory because it fails to abolish abdominal pain produced by traction on the spermatic cord. Uncomplicated hydroceles may be excised as an ambulatory surgical procedure.

The patient is placed on his back on a level table with his legs slightly separated. The surgeon stands on the side of the table nearest the operative site.

The skin is prepared routinely, with particular care given to scrubbing the scrotal area. Iodine should be avoided for preparation of the scrotal skin, since it will cause severe excoriation. The area is draped as for any other operation on the scrotum.

The relationship of the hydrocele of the tunica vaginalis testis to the testicle, epididymis, spermatic cord, and covering layers of the scrotum is shown in Figure 1. If the hydrocele is associated with an inguinal hernia, separate incisions are made. If just a hydrocele is present, then after the mass is grasped firmly in one hand so as to stretch the scrotal skin and to fix the hydrocele, an incision 6 to 10 cm long is made on the anterior surface of the scrotum, over the most prominent part of the hydrocele, well away from the testicle that lies inferiorly and posteriorly (Figure 2). The skin, dartos muscle, and thin cremasteric fascia are incised and reflected back together as a single layer from the underlying parietal layer of the tunica vaginalis, which is the outer wall of the hydrocele (Figures 3 and 4).

When the hydrocele is well separated laterally and medially from the overlying layers, its wall is grasped with two Allis forceps, and a trocar attached to a suction tube is thrust into it to evacuate the fluid (Figure 5). With a finger in the opening of the sac acting as a guide and providing traction, the surgeon completely separates the wall of the hydrocele from the scrotum so that the spermatic cord and testicle with attached hydrocele sac lie entirely free in the operative field (Figures 6, 7, and 8). The hydrocele sac then is opened completely (Figure 9). Some surgeons prefer to delay emptying the hydrocele until it has been dissected completely free from the surrounding tissues and delivered outside the scrotum.

In younger men particularly, the testicle is carefully inspected and palpated, since hydrocele has been known to occur in the presence of testicular neoplasm.

The relationship of the testicle to the tunica vaginalis is shown in Figure 10. With the walls of the hydrocele sac completely freed and completely opened, the redundant sac wall is trimmed with scissors, leaving only a margin of about 2 cm around the testicle, epididymis, and spermatic cord (Figure 10, A and B). Great care must be taken to obtain absolute hemostasis, since the smallest bleeding point left uncontrolled is likely to ooze slowly into the loose scrotal tissues, producing a massive scrotal hematoma. Large and painful hematomas that are slowly absorbed after surgery may occur if there is not careful and complete hemostasis.

When the redundant portions of the sac have been excised, the edges are sewed behind the testicle and spermatic cord with interrupted fine suture, thus everting the retained portion of the old hydrocele sac (Figures 11 and 12). Some surgeons prefer not to evert the sac but to place a continuous fine absorbable hemostatic suture along its margin. In children especially, the contents of the upper portion of the cord should be inspected for a possible hernia sac.

The testicle and spermatic cord are replaced carefully in the scrotum, care being taken that no abnormal rotation of the cord has occurred. The testicle may be anchored to the bottom of the wall of the scrotum with one or two absorbable sutures to prevent torsion of the cord (Figure 13). The dartos fascia is closed with interrupted absorbable sutures (Figure 14). A small Penrose drain may be brought out through a small stab wound at the most dependent portion of the scrotum. This allows escape of blood and prevents hematoma. The skin is closed with a subcutaneous absorbable suture.

The scrotum should be supported by a suspensory for 1 to 2 weeks postoperatively. Ice bags should be placed under the scrotum for the first 24 hours. The dressing should be changed daily. The drain is removed in 24 to 48 hours, depending on the amount of drainage. Significant pain or swelling may signal a hematoma or torsion, which can be differentiated with duplex ultrasound scanning. Plain absorbable skin sutures will fall out as they disintegrate. The patient may be ambulatory immediately after surgery.