Scrotal Hydrocelectomy Made Simple During a Surgical Mission

Case overview

A hydrocele is a condition characterized by the abnormal accumulation of serous fluid between the layers of the tunica vaginalis in the scrotum. It is a relatively common condition, occurring in approximately 1% of adult males and up to 5% of newborn males.^1,2

The etiology of hydroceles is multifactorial, with contributing factors including congenital anomalies, inflammation, trauma, and malignancy. In newborns and infants, hydroceles are often attributed to the failure of the processus vaginalis to close properly during fetal development. In adults, hydroceles may result from testicular torsion, epididymitis, or trauma to the scrotal region.^3,4

While most hydroceles are typically asymptomatic or subclinical, larger ones can cause discomfort, heaviness, and cosmetic concerns. The diagnosis of a hydrocele is typically made through a combination of physical examination and imaging modalities, such as ultrasonography or transillumination. Treatment options for hydroceles range from conservative management (observation, sclerotherapy, or aspiration) to surgical intervention, with the latter being the preferred approach for recurrent or symptomatic cases.^5–7

The surgical management of hydroceles aims to alleviate symptoms, improve cosmetic appearance, and prevent potential complications associated with untreated hydroceles, such as testicular ischemia or chronic pain. The choice of surgical technique depends on various factors, including the type of hydrocele (communicating or non-communicating), the patient's age, and the presence of additional comorbidities or complications.^8,9

Communicating hydroceles have a patent processus vaginalis, allowing for the free flow of fluid between the peritoneal cavity and the tunica vaginalis. For communicating hydroceles, the inguinal approach allows for the identification and ligation of the patent processus vaginalis, effectively disconnecting the communication between the peritoneal cavity and the tunica vaginalis sac. This procedure may be combined with excision or plication of the redundant sac to reduce the risk of recurrence. On the other hand, non-communicating hydroceles are characterized by a closed tunica vaginalis sac, resulting in a localized fluid collection without communication with the peritoneal cavity. For these cases, the surgical treatment of choice is a scrotal approach, which is considered the simplest and most direct method.¹⁰ 

The video presented here shows a step-by-step guide to the surgical treatment of giant bilateral non-communicating hydroceles in a 70-year-old male patient. The procedure starts with a 3–4-cm incision made on the scrotum, adhering to anatomical landmarks to ensure optimal access to the hydrocele sac. The incision site is carefully chosen to minimize postoperative discomfort and scarring while providing adequate exposure for subsequent steps in the procedure. A cautery device is methodically employed to penetrate the hydrocele sac, with precise control maintained to avoid injury to surrounding tissues. Following the successful entry into the sac, attention is given to preparing the suction apparatus for efficient drainage of fluid, ensuring optimal visualization and access for subsequent manipulations.

Using delicate forceps, the hydrocele sac is gently mobilized to facilitate its externalization from the scrotum. Care is taken to handle the sac with precision and finesse, minimizing trauma to surrounding structures (testicular vessels, epididymis, or ductus deferens) while ensuring thorough exposure for subsequent excision. The hydrocele sac is carefully inspected for any compartments or adhesions. Utilizing a combination of sharp dissection and cautery, all identified cystic structures within the sac are removed.

Following the excision of the hydrocele sac, the right-sided incision is methodically closed using absorbable sutures. Special care is taken to evert the edges of the incision, promoting optimal wound healing and minimizing the risk of postoperative complications.

The same steps performed on the right side are performed on the left side of the scrotum. The entry into the contralateral hydrocele sac is achieved with precision. It is mobilized and manipulated as on the right side. Thorough dissection and cauterization ensured the complete removal of all cystic structures within the hydrocele sac while preserving surrounding anatomical structures. Following thorough excision, the incisions are closed using precise suturing techniques, focusing on tissue approximation and hemostasis to facilitate proper healing and reduce postoperative complications.

During the procedure, the subcutaneous penile implants (SPIs), are removed from the patient's penile shaft. These implants are typically inserted beneath the skin of the penile shaft and are designed to alter or enhance sensations during sexual activity. However, their use is controversial and associated with potential risks and complications, necessitating their removal in this case.¹¹ SPIs are identified and removed. Special care is taken to ensure the complete removal of all foreign bodies while minimizing trauma to surrounding tissues, with an emphasis on attaining optimal hemostasis and wound closure.

The surgical procedure is concluded with a comprehensive postoperative assessment conducted, with special attention given to monitoring for any signs of postoperative complications and providing appropriate postoperative care instructions. In the postoperative period, the wound was prepped with povidone-iodine solution, and dressings were changed. The stitches were removed on postoperative day 7. The patient was advised to wear scrotal support or, if unavailable, tight underwear for 5 days. NSAIDs were administered intravenously to control postoperative pain, and the patient received ciprofloxacin 500 mg BID intravenously for 5 days to prevent SSIs.

This video highlights the surgeon's expertise and attention to detail, ensuring a thorough and meticulous surgical technique. The step-by-step approach and clear communication with the surgical team facilitate a smooth and efficient procedure. The importance of this surgical technique extends beyond the individual patient. Providing a simplified and effective treatment option for hydroceles has the potential to improve patient outcomes and reduce the burden on healthcare systems, particularly in resource-limited settings or during surgical missions. Overall, the video serves as a valuable educational resource for surgical trainees and practitioners, demonstrating a simplified and effective approach to the treatment of scrotal hydroceles.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.