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Hydrocele

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Definition—collection of fluid in the sac of tunica vaginalis.

 

Classification—

Primary hydrocele—when there is no definitive cause / idiopathic.

Secondary hydrocele—diseases of testis

1.  TB of epididymis

2.  Epididymal orchitis

3.  Syphilitic orchitis

4.  Testicular tumours (seminoma—5th decade of life and onwards, teratoma—1st and 2nd decades of life, sertoli cell tumours, leydig cell tumours, lymphoma)

5.  Orchitis arising by virus

6.  Trauma

 

Difference between primary and secondary hydrocele—

Primary

Secondary

Big and tense

Small and loose, lax

Testis cannot be felt

Testis can be felt

No definitive history

Definitive history of the disease

 

Difference between hernia and hydrocele—

Hernia

Hydrocele

Inguino-scrotal swelling

Scrotal swelling

Cannot get above the swelling

Can get above the swelling

Cough impulse is positive

Negative cough impulse

Fluctuation test negative

Fluctuation test positive

May or may not be reducible

Never reducible

 

Classification depending on the extension—

Vaginal—sac at the level of the epididymis and not covering the epididymis.

Infantile—sac extends upto the deep inguinal ring. Treatment is eversion of the sac.

Encysted hydrocele of the cord—the sac has no communication with the peritoneal cavity, patient complains of 3 testis. Testis traction test is done to detect that it is attached with the cord. Treatment is excision of the sac.

Congenital/communicating hydrocele—the sac has communication with the peritoneal cavity. Patient complains of swelling of the scrotum in the evening and becomes normal at morning. It doesn’t disappear by squeezing. As it has communication with the peritoneal cavity, water is trickling down. Because of narrow neck water cant come out when squeezed, this is called Bottle-Neck effect. Treatment is done by incising the skin over the inguinal canal at its medial end, the cord is isolated and the neck is separated from the sac. Herniotomy is done. Inguinal approach is due to hernia.

 

Treatment of Primary vaginal hydrocele—Eversion of the Hydrocele sac.

 

If treatment is not done then—

·   Size will be increasing which will cause mechanical disturbance.

·   Scrotum comes to the knee and there is difficulty in walking.

·   Social disturbance—cant wear pants.

·   Skin ulceration—due to friction of sac with floor while seating.

·   Calcification of sac (thickening of the sac).

·   Herniation through the layers of the scrotum.

·   Testicular atrophy due to pressure.

·   Penis can be buried in the scrotal skin.

·   Haemorrhage, haematocele.

·   Infection—clear fluid turns into pus (pyocele).

 

Counseling—

1.  Must tell that it is curable

2.  Complication can occur if not treated

3.  No loss of sexual function and no sterility

 

Procedure—

 

Anaesthesia—Spinal anaesthesia in the subarachnoid space. Xylocaine (30 min/5ml), Bupivacaine (>30 min).

 

Cleaning—6 times rubbing with 10% Povidone Iodine causes 98% disinfection, kills almost all commensals within 30 seconds. 95% ethyl alcohol (spirit) can cause 92-93% disinfection. Dilute Savlon and Hibitane may be also used.

 

Draping—with surgical cover.

 

Screening is done in the chest and the scrotal wall is inched with a tooth forceps to see if the patient is anaesthetized or not.

 

Surgical procedure—

Incision—

In single hydrocele longitudinal incision parallel to the median raphe, 1 inch lateral to it.

In bilateral hydrocele transverse incision, so that both can be approached.

 

Layers of the scrotum—

·   Skin

·   Dartose muscle

·   External spermatic fascia

·   Creamesteric spermatic fascia

·   Internal spermatic fascia

·   Tunica vaginalis.

 

Steps—

1.     Layers of the scrotum incised except Tunica vaginalis.

2.     By finger dissection, hydrocele sac is separated from scrotum.

3.     Put a stab incision on the anterior part of the sac.

4.     Water is sucked out with suction.

5.     Enlarge the incision upwards and downwards.

6.     ………………

7.     Secure any bleeding points.

8.     Must put a drainage tube through a separate wound to drain the bleeding to prevent haematoma.

9.     Close the scrotum with silk suture. (must not twist the testis while putting them back)

10. Must apply a coconut bandage to prevent haematoma.

 

*** after operation the swelling may not subside due to reactionary oedema. Assure the patient that it’ll be reduced but it’ll take time.

 

Other surgery—

1.     Lord’s operation / Lord’s plication

2.     Shworma and Jawhan’s operation

 

Complications—

Per-operative—haemorrhage, torsion due to negligence

Post operative—scrotal haematoma, infection

 

*** no chance of recurrence unless operation is done properly.