Hydrocele

Collection of fluid between the parietal and visceral layers of tunica vaginalis

Can be various types depending on what part of the processes vaginalis obliterates

- complete = 'congenital'

- distal failure to obliterate = 'vaginal

- middle mailure = encysted

- proximal failure = funicular

Congenital: Failure of tunica vaginalis to obliterate in all or part of its length
- may be confied to scrotum; most close within 6m
- may be in cord
- may be completely patent processes.

Acquired: Primary of secondary

—    Primary – usually in older men. Due to defective absorption of fluid.

—    Secondary:

o   Trauma

o   Tumour

o   Torsion

o   epididymo-orchitis.

o   Usually occur in men age 20-40. US to examine underlying cause.

Examination: Balloon-like swelling
Does not usually cause symptoms; painless swelling
Cannot feel testis separately, trans-illuminates, Can get above it.

Indications for surgery are enlargement, discomfort, and patient preference.
- needle aspiration usually --> recurrence.
Discourage surgery in pts wishing to have children
- risk of damage to blood supply

Operative: Open hydrocoele sac

1. Jaboulay procedure

• GA. Supine. IV abx. Heparin. TEDS. SCD. Time out.
• Assistant holds Scrotum so that it is tense. Incision over the anterior aspect of hydrocele parallel to Median Raphe made with back of blade between any visible vessels.
• Dissect through skin, Dartos, external spermatic fascia, Cremasteric fascia, internal spermatic fascia.
• Then take artery forceps and gently bluntly dissect in the plane between internal spermatic fascia and parietal layer of tunica vaginalis. Complete dissection using fingers and deliver the hydrocele intact from the scrotum.
• The hydrocele fluid is drained by a simple stab incision and collected in a bowl. A sample is sent for cytology, microscopy and culture.
• Place two artery forceps on the edges of sac and split the tunica vaginalis to expose the testis taking care not to damage testis or epididymis
• The testis and epididymis is then inspected for any abnormality.
• The parietal layer of the tunica vaginalis is trimmed as required everted and wraped around the testis and sutured to itself around the back of testis and cord using 2/0 Vicryl –Achieve perfect haemostasis of tunica, edges of scrotum.
• Return the testis to the sac created.
• I close the dartos layer using interrupted 2/0 Vicryl and palce a silatic corrugated drain into the sac created by blunt dissection.
• Close skin with interrupted inverted 3/0 Monoctryl
• Apply a scrotal support

• Assistant holds Scrotum so that it is tense. Incision over the anterior aspect of hydrocele parallel to Median Raphe with diathermy between any visible vessels.
• Dissect through skin, Dartos, external spermatic fascia, Cremasteric fascia, internal spermatic fascia and parietal layer of tunica vaginalis is entered.
• The hydrocele fluid is drained and collected in a bowl. A sample is sent for cytology, microscopy and culture.
• The testis is delivered everting the hydrocele behind it
• Use interrupted 3/0 Catgut sutures to plicate and bunch up the sac: Multiple bites are taken of the parietal layer of tunica vaginalis, starting at the cut edge and proceeding towards the testis. Finally a superficial bite is taken of the visceral layer of the tunica vaginalis.
• Four to five placating sutures are placed in clips before tying all of them to obliterate the hydrocele behind the testis.

• I use Lord’s procedure when the hydorcele is small or medium-sized and the wall of the hydrocele is thin. Otherwise the placation leaves an excessive mass.
• Jaboulay is preferable for thick-walled sacs or large hydrocele. However the dissection to create the pocket for the hydrocele increases the risk of haematoma formation. ­­