Open Hydrocelectomy for Scrotal Hydrocele

CHAPTER 1

Hi, I am Dr. Joseph Clark, Professor in the Department of Urology here at Penn State Health Milton S. Hershey Medical Center. We have a case of a 50-year-old male who had a left hydrocele. So a hydrocele is a fluid collection around the testicle. And when we're born, everyone had, all males have a little fluid around the testicle. As the testicle descends from the abdomen, it takes a layer of the peritoneum into the scrotum and everyone has a fluid collection. In a hydrocele, there is an imbalance between fluid production and absorption, and it can lead to accumulation of fluid, excess fluid that becomes symptomatic. So the patient that we are going to operate on is a 50-year-old male. He was actually seen two years ago, he had an ultrasound that confirmed the hydrocele and he elected for observation. However, we saw him about six weeks ago and he said that the hydrocele was getting larger and he wanted surgical treatment. Interestingly, despite his young age, he did have a history of myocardial infarction and we actually did his procedure on aspirin. So the surgery started off - after anesthesia, we marked about a five-centimeter horizontal skin incision. We cut through the marking with a scalpel and the key here is to get down to the hydrocele itself without entering it. So we want to just get to the, just the thin layer of the hydrocele sac itself. Once we were at the hydrocele, we bluntly dissected the hydrocele off the inner scrotal wall, and you can see us using our fingers. And once we delivered the hydrocele sac containing the testicle, we used gauze to remove the excess tissue off because we just want the hydrocele sac by itself. Once it was dissected and out of the scrotum, we made an incision on the anterior aspect of the hydrocele sac because the testicle would be on the inferior end. And we actually aspirated about 450 cc of clear yellow fluid, which is a typical fluid color of a hydrocele. Once we made that incision, we extended that incision superiorly and inferiorly and removed the actual hydrocele sac. We actually left about a two-centimeter rim of the hydrocele sac attached to the testicle. We use cautery to obtain hemostasis on the edge of the hydrocele sac. And then additionally, we ran 3-0 chromic suture along that edge for additional hemostasis. Once this is done, we again inspected the testicle. We irrigated it to make sure that the hemostasis was good. We then flipped the edges of the hydrocele sac behind the spermatic cord and we put one chromic suture very loosely behind the two. And that's really to keep the edges from flopping over itself once we put the testicle back in. We also obtained hemostasis on the inner lining of the scrotum where we had dissected the hydrocele sac off. And once we replaced the testicle into the scrotum, we made a drain site. So the drain was placed on the inferior aspect or the dependent portion of the scrotum. We brought in a quarter-inch Penrose drain through the incision and placed the Penrose drain within the scrotum itself. Once that was done, we closed the incision in several layers. The first layer that you'll see is this kind of beefy red layer that is the dartos. And again, we did this patient on his aspirin and we want to make sure that we obtain very good hemostasis. So that was a running suture to close that incision. And then we close the skin also with chromic sutures. These are sutures that will dissolve on their own and that the patient does not need to return to have their sutures removed. Following this, we actually placed additional simple interrupted sutures of chromic in case that running suture of chromic fell apart early and then he would've a skin separation. After that, we cleaned the scrotum and smeared bacitracin ointment over the incision line. Now I did something a little bit different. Sometimes people who do elect to place drains will put a suture that would need to be cut to remove the drain. But I do these as same-day surgery, so the patients go home that same day. And what I elect to to do was pass a suture through the gauze that will be in his scrotum to give compression. And we sew the gauze to the drain itself so that tomorrow morning when he removes the drain, that drain will come out. And he will be left with a little hole at the bottom of his scrotum, which may continue to drain a little bit of old blood and it'll eventually seal. the chromic sutures that we placed on the scrotum will eventually dissolve. I counsel all patients that after the surgery, the scrotum itself will swell up, there'll be some edema and it'll feel very firm, again, and this is all in patient education. So they have expectations on what to expect. The firmness and swelling around the testicle, I tell them will take months for it to slowly resolve.

CHAPTER 2

This patient has a moderately large left hydrocele. This is his right testicle here. Here. And this is his hydrocele, and his testicle is within this fluid-filled cavity. So we're gonna try to deliver the hydrocele sac. So scalpel. That's a big one.

CHAPTER 3

Yeah, I'm putting traction so that once the incision is made, the skin edges separate. Okay. Incision. And after this we're gonna take a couple of Adsons. Yep, make it, keep on going, and just make it a little bit bigger. Longer. Longer. Yep. Make it a little bit bigger, 'cause I think we're gonna end up extending it anyway. All right, we can start now, I'll take one pickup. Alright, we're gonna pick up the tissue inside. Pick up opposite me. Okay, you're - I can change. All right, so we're gonna go down with a cautery until we get just to the hydrocele sac itself. Okay, and let's just go the length of this incision. So grab, yeah. Okay. Yep. All right, and let's go down here. Okay. And I think we're probably gonna have to make the incision, use a cut and make it a little bit bigger. Alright, good. And we're not quite at the hydrocele sac, so... Okay, and then let's grab here. All right, so gimme just a little... Again, we're just trying to get just to the hydrocele sac itself. And are we good? That might be good enough. So lemme just see if we can... So again, this is just the hydrocele sac itself, and I think you can go ahead and put your fingers in there and try to dissect around it. So we're gonna try to deliver this hydrocele sac. Yep. Mm-hmm. All right, I am gonna deliver. All right, there's still a little bit of... There we go. I think the Ray-Tech can kinda swipe the overlying tissue. On this side that has it almost. So can we also have a Penrose drain? We can get one. What Size do you want? Like a quarter-inch will be fine. Can I get a quarter-inch Penrose? And we have a lot of 3-0 chromics? Yeah. All right. Yeah, so just... All right, so we wanna just get just to the hydrocele sac itself. And get right in here. I think that's fine, 'cause that's like the cord structure. So typically on a hydrocele, the testicle is posterior. So this is just fluid here. And this is the spermatic cord.

CHAPTER 4

I think what we're gonna do is we'll take two hemostats. And are we, can we zero the suction container so that we know how much... Yep, you're good. Can try to get a little bit. All right, so... It's popped. Yeah, make an incision quick. All right, so we're gonna make an incision. Bigger incision. All right, so we zeroed it and we just document how much fluid actually is in here. This is typical hydrocele fluid, which is clear yellow. You can grab the edge so that, you know, I mean with the hemostat, so... Alright, so far, 200. But again, I think we lost a little bit. Yeah. All right, so 400 so far, but we'll see what more comes out.

CHAPTER 5

All right, so in a hydrocele there's a, this is an adult, so this is not a communicating hydrocele like in the pediatric population. So what we're gonna do is we're just gonna open up the hydrocele sac. So use the cautery. And yeah, go - open it up that way. All right. A little bit more so I can get two fingers in there. All right, good. And I'm gonna put two fingers. All right, and just follow my fingers. So we're open up the hydrocele sac, okay. And maybe just a little bit more, just a tad more. Okay, good. And then let's go down.

CHAPTER 6

All right, so this is the testicle and it appears normal. This is the epididymis, which has actually been a little bit splayed out, it looks like. And this is the inferior aspect of the testicle. So the testicle will return this way.

CHAPTER 7

So what we're gonna do is now we're just gonna excise the wall or the majority of this. You have a couple of Allises? And clamp up there, and clamp maybe another one there actually. Yeah, I'll get it here. You can just hold those and I'll just use my thumb as a guide. So I think you can just go right on the edge of my thumb. Yeah, and here. Alright, so we're excising the wall of this hydrocele sac. So we can call it a actually a hydrocelectomy. Okay. And then here we're getting to the tail of the epidermis. We're gonna give a little extra room so we keep on buzzing. Alright, so that's a segment of the hydrocele sac. And just buzz the edges while we see it. It's kind of bleeding right there. We're gonna oversew this edge with suture for additional hemostasis, but we're getting a little hemostasis right now. Now the other side, we'll take the Allises again. You can just grab the... Yep. Yep, and maybe grab another. Alright, lemme just put the lights, so... All right, so I'm gonna just maybe start here where my, the edge of my finger is. Okay, keep coming down. Come down. Yep. Mm-hmm. Yep. Okay, and then let's see where we are. Yeah, I think you can just kind of go straight and lop it off. All right, so segment of hydrocele sac. And actually we'll take the Allis again.

CHAPTER 8

You wanna send these together? Yeah. And why don't we just buzz this edge here, it looks... Yes. Hydrocele sac. Mm-hmm. Yep. And then again, I just wanna make sure when we close this, that, or we run the suture, and we get both layers. Anything else? Yeah, just buzz that. And there's 550 cc so far that was removed. It is probably a little bit more 'cause we lost a little bit upon entry. All righty. All right, I think that's good. You have one more Allis? All right, so we'll take the 3-0 chromic. What we're gonna do is put a running suture along this edge because this can bleed. So this is for additional hemostasis other than the cautery we just used. Suture scissors, you can kind of cut the tail. Actually, actually make it a little bit shorter. Yep. Right below her... Alright, good. So I'll take this and we're just gonna run and we can maybe lock every other one. Pull, pull, pull, pull, pull. Great. Now we want this one. Pull, pull, pull, pull, pull. Okay. Is it this? And we'll lock this one. Yeah, this one right here. Alright. So we'll do this for the other side as well. And then we'll flip these edges back on itself to decrease recurrence rate of hydroceles. Mm-hmm. Do we have the bacitracin ointment already up? We have it up here. Yeah, we can a little squirt out. I can run this suture through the ointment. And we'll take some fluffs and support at the, for the end of the case. Okay, locking. We're almost halfway down this suture line. Oh, there's a little bleeder there. Just keep on pulling and pulling, and that itself makes it hemostasis, yep. We'll lock this one. All right, and lemme just pinch a little bacitracin ointment to select things up. All right. All right, only like a few more centimeters to go on this side. All right, we're almost at the end on this side. And again, this is just for hemostasis. Alright, maybe one more throw and then we'll tie. Do you want me to go through here? Oh yeah, I think that'd be fine. Get a good bite, so that... So up top there? Well you can go closer to the suture here so that we... All right, and then just tie this. Alright, it says 540 so far is what we got. Yep, that's more than I thought, that's for sure. I think, I guessed... I think I guessed... Was it 300 or, I don't know. Four hundred? Yeah. 400 I think, I guessed, wasn't really. Alright, we'll take another 3-0 chromic. So now we're gonna run the other side similar. Let's see. Yeah, take the... Got another Allis? Let's see, well I guess we can maybe run this way. Actually, lemme get a little bit closer. All right. I can take that. Okay. All righty. So at the end of this we'll partake a little saline in the Asepto and a kidney basin. Locking it. All right, so this one won't be locking, and then this one will be locking. All right, let me just grab a little bit more of the edge. All right. Are we near anything structurally? Nope, I think we're good. We're not near the epididymis. And we left a generous rim of tissue. Okay, let me get a little bit more. Just a little floppy tissue there. You wanna lock this? You wanna lock this? Can't keep track of lock, unlock. Just tie that. I mean the instrument tie and we just restart or maybe pull through. All right, so let's see, how much more do we have? So we got a little bit. Grab this edge. Not locking. Okay. Locking. Okay. All right. Regular, or not locking. All right, we're gonna lock this one. We just locked the last one. Oh, okay, then we won't lock this one. All right, let's see, how much more do we need to climb up? Maybe up to here. Yeah. Lock. Lock. Not lock, and I'll lock the last one. I'll do one more after this one. Okay. This is the last one on this side. Yep. Something is squirting. Hopefully I tied it off. And we'll take the kidney basin. Oh, this will do. I thought a kidney basin comes in this set. It usually comes in the double basin, but they gave us a single basin. All right, we're just gonna irrigate this area. All right. Get that. And actually, so 540 is what we got. And we're just gonna get hemostasis, make sure there's nothing oozing. So we can see that we excised the hydrocele sac. There was the incision line and we ran suture on either side. And before we put the testicle back in, we wanna make sure that there's no bleeding. So we're gonna just look at this and see if there's anything that might be bleeding. And so right here, pick up. All right, and let's look at the other side. And it looks like it's pretty good. I'm gonna evert the scrotum and see if there's anything here. So maybe right here. Okay. Pull this one. I think what we'll do is we'll take that Asepto, we'll irrigate this area and we'll look one more time. And a Ray-Tech. Yep, yep, go ahead. Yep. You can put the sucker in there.

CHAPTER 9

All right, so what we're gonna do is just bring this thing out again. So what we're gonna do is, again, the hydrocele was like this. We excised most of the sac and now we have this rim. And just so that this doesn't flop over itself, we're gonna just put a couple of simple interrupted sutures to loosely approximate these edges behind the testicle. So we'll take chromic. We'll also close skin with chromic. While we're waiting, just get the Bovie, and we'll just do this. Anything else? Here's something. Alright, so again, we're just gonna put very loosely, these two edges. It's not a strength, it's just to prevent it from flopping over once we put the testicle back in. Yep, that's plenty. Yeah, I think that's probably good enough. Again, this is not a strength layer. And this is just in case there's some swelling. I didn't want the cord strangulated.

CHAPTER 10

So we can actually see the anatomic landmarks. There is actually a lateral cleft, this is the epididymis. Usually it's a little bit closer, but this has been splayed out. This is an excess mesoepididymis. And then because it's a lateral cleft and this is the left side, it will go in that way. And again, just make sure there's nothing oozing before we put... What is oozing? Is it like this? Okay, anything else? This is all skin edge. If it's all skin edge, that'll stop when we do the skin closure. All right, so let's actually make that drain hole. So you're gonna put your finger in here and... Okay, so we have that Penrose drain. Yeah, here. Yeah, on the left side in the deep and in position. Just - alright, great. Get your double glove. Yep. So you can use a cut. Yep. Make a generous incision. Maybe just a little bigger. All right, I'm gonna give you this. Put your finger tip and bring it out. Actually, let me open this up. And here you can make the hole a little bit bigger. Okay. So we'll take the Penrose drain. All right, so that's the drain. And we're gonna put this way back in there. Let me take an Allis. Again, this is so that the drain doesn't accidentally come out while we're manipulating everything. Okay, everything looks good. We'll take two Allises.

CHAPTER 11

So we're gonna grab this dartos. This is the beefy red layer that tends to bleed. All right, and then we'll take the chromic. And we're just gonna run this. So you're gonna, so it's toward yourself. So just take it here. Yeah, you can just leave that. So this is the dartos layer, the beefy red layer of the scrotum, and it tends to bleed. So we're gonna close this separately. Next one. Okay. All right, I'll just pause - do this and we can... Okay, and we're gonna be cognizant and make sure we do not put the needle through the drain that is in there. Yep, that. What's that? What's that? What... That. This? I think that's just scrunched up tissue. Yep, big bites of this dartos. Are you sure? That looks like a structure, no? Lemme see. No, I think it's just kind of just scrunched up tissue from... All right, but again, I wanna make sure we don't put a... Nothing on the drain. Yeah. Make sure we don't hit the drain so that the drain will come out tomorrow. All right, so we also have the fluffs, flipped up. Fluffin the fluffs and some kind of mesh shorts or scrotum supporter. Got that. Yes, that'll do. Go in and grab from the inside, yep. Maybe one or two more. Yep, and maybe one more and then you can tie. Okay. All right, and we have another one of these 3-0 chromics? All right, we're gonna be doing a running horizontal for the skin. Take this off. And I'm taking, let's see, I'm taking scissors from your Mayo. I got that one. That one's fine. Sticky. It's not... Yeah. And we will take another 3-0 to make sure there's nothing. Is there something oozing? Yeah, the skin edge we should be able to get with a suture. What's that? Yeah, I think it's the skin. So take a relatively big bites for the running horizontal. All right. All right. Okay. Yeah. Need a little bigger bite. Okay. Because there's still a little bit of dartos kind of poking through. All right. I'll go. Yeah, take a little bigger bite. Maybe even half a centimeter back. Here? Yep. Because that way, we'll for sure get some of that excess dartos that we did not close. Mm-hmm. Let me just... All right, and I'm gonna take a little bit of this, backhanding. All right just... That was very far. I didn't realize how far I went. I went super far. No, I think that that's so - so go in about the same depth or distance. Okay. Yep, and then it's just come across... Yep. I just grab the edge. Try to help you with grabbing the edge. And I'll close with chromic as well, right? Yep, so go in here. And we'll put some simple interrupteds. It's just... Yep. Yep. Mm. Mm-hmm. All right. Okay, we're almost at the end of our incision. All right, gonna tie that. Yeah, you can tie that. And then we can, we have enough for the simple interrupteds in between, just on the chance that, you know, the suture comes off and the whole suture will, or the incision might well unravel. All right, we have just about for like 15 more minutes. We've already closed the skin, so we already have a count that we're good. All right. All right. And now we'll do some simple interrupteds. And at the end we will take a sloppy wet one. So try to get the skin edges, yeah, simple interrupteds in between, yep. And I just do one of those? Yep, you'll do it. Pick up each side separately. Small bite. Well yeah, take a little bigger bite, the same distance. Lemme just run some ointment through. We may put another suture here just for hemostasis, but again, you can just keep on finishing up the incision. Because again, it was the skin edges that were bleeding. Yes. Give yourself a little more of a tail. Preserving suture. So at the end we'll take like a sloppy wet one to clean him off. Yeah, maybe one over there. And then we'll see if there's a little oozing there, so... All right, and then I think right over here, it deserved another suture. Yeah. Squeeze it. Okay, we're just playing a little bit. Yeah, we - take a deep one. Hopefully this will be the last one, but we'll, we'll see. See it? All right, if we decide to put another one, give a new suture. Let's see, is there...? One there? Maybe one, yeah, maybe... I think I might be able to do it. No, no, just get the fresh suture. So put one like here and here, okay. Oh. Mm-hmm. And get another one like right in there. All right, is that... Is that hemostatic? How about one more? One more right in here. Yeah, he kinda had a very thick dartos that was oozing. So probably more suture is better. All right, just make sure to see how much just comes out this drain. So not much. Alright, we'll take the sloppy wet one. And a dry one. And then got the heavy scissors, I'll just cut this drain just a little bit. All right. And we'll take the, was it an 0 PDS? Mm-hmm.

CHAPTER 12

Alright, so take this and just put it through, through... So this is a a technique where we're gonna suture the drain to the gauze, so that tomorrow morning when he removes the gauze, the drain would just come on out. All right, can you be just big air knot. And we'll take some additional gauze as well. Yeah, another boat. No, I have this in my wrong hand. Yeah, yep, flip your hands if you're used to tying the other way. Yeah. Yeah, that's good enough. It doesn't have to be tight. And one more through and I'll cut that. All right, we're gonna smear a little bacitracin ointment on the incision site itself. Yep. And we'll put more gauze. I'm gonna take this Allis that's been keeping that in place so we didn't accidentally lose it during the case. Alright, we'll take more of this. Yep, put that on there. Alright, we'll take the drapes off. And we have, let's see, we already did the counts. There's no sharps here on the drapes. And then the scrotal support is Tetra Athletic Supporter. Large. Alrighty. I think we're good. Can we get something to wipe his perineum? There's a little bit of blood that dripped. So we have his legs there. And what I'm gonna do is I'm gonna just roll him towards me. So just kind of cinch up his... All right, so that's the hydrocelectomy.

CHAPTER 13

So the patients are counseled to wear the scrotal support for at least a week. They are given post-op discharge instructions, which specifically says that they can take quick showers starting the next day. The sutures that we put will dissolve much faster if there is immersion. So we tell them no tub bathing, jacuzzi, swimming. And again, I will see them in a few weeks to inspect the incision and reassure them about the swelling. Again, they should just really take it easy for the next week or two. The scrotum may end up bruising. And again, that is an expectation from the surgery itself. With the drain in place, again, the risk of a hematoma is much less. Again, and the surgery went very well as expected. The surgeon assisting me was Dr. Jenny Kane, and she just finished her internship in urology and this is her second year of training. And she did very well performing steps of the procedure. Some of the things that could have been different is if we had gotten to the hydrocele sac and we actually made an incision into the hydrocele sac, then there would be early fluid that we would have to remove. And again, we can actually then grab the edges of the sac after most of the fluid is drained and we can dissect the dartos layer off that sac. So that's something that could have been done if we had made an early entry into the hydrocele sac. But again, I think it's a lot easier to deliver and remove the excess tissue off the hydrocele sac if it's intact. The other things to be important and to be cognizant is the core structures and the epididymis, especially inferiorly. Sometimes when you're actually excising the hydrocele sac, you can get very close to the epididymis. So I teach all of the residents to look at the testicle itself, see where the epididymis is, and to give a lot of room when they're excising the sac to be about maybe two centimeters away from the epididymis.