Hydrocelectomy, Orchiectomy
Hydroceles are collections of fluid between the parietal and visceral layers of the tunica vaginalis. Communicating hydroceles, in which this space communicates with the peritoneal cavity, are often encountered during repair of indirect inguinal hernias. These are simply managed by amputating the distal portion of the hernia sac. In noncommunicating hydroceles, the balance between fluid generation and absorption in this space becomes uneven and fluid accumulates.
A variety of conditions can cause noncommunicating hydroceles. The most important thing is to exclude testicular malignancy. High-resolution scrotal ultrasound can help exclude malignancy.
As with most cancers, testicular malignancy is most appropriately treated by an experienced multidisciplinary team. The surgical treatment of testicular malignancy consists of radical orchiectomy through an inguinal approach. This chapter describes two common procedures for hydrocelectomy as well as inguinal orchiectomy. The precautions used in cases of possible malignancy are also described.
SCORE™, the Surgical Council on Resident Education, did not classify hydrocelectomy and orchiectomy but included hydroceles and testicular tumors in the recommended curriculum under the “Broad” and “Focused” categories, respectively.
STEPS IN PROCEDURE
Inguinal incision
Identify and protect ilioinguinal nerve
Identify spermatic cord at external ring
Surround spermatic cord with Penrose drain
Place noncrushing clamp on cord, if malignancy suspected
Deliver testis and cord into surgical field
Identify vas, epididymis, and vessels
Hydrocelectomy
Open hydrocele in an area remote from testis and supporting structures
Biopsy and obtain frozen section of any suspicious areas
If negative, release clamp
If positive, consult urology or proceed with orchiectomy (below)
For simple excision:
Excise redundant tissue of hydrocele, leaving cuff around testis (one fingerbreadth)
Oversew the cut edge of hydrocele with running lock stitch, absorbable suture
For bottle operation:
Excise redundant tissue of hydrocele, leaving generous cuff around testis
Invert tissue around testis and suture cuff to itself, leaving loose closure at top to allow exit of cord structures
Return cord and testis to scrotum
Check hemostasis and close inguinal incision
Orchiectomy
Individually clamp and tie vas and vessels
Ligate remaining structures
Remove cord and testis together
Release clamp
Check hemostasis and close inguinal incision
HALLMARK ANATOMIC COMPLICATIONS
Ischemic orchitis
Injury to vas
Failure to identify malignancy
LIST OF STRUCTURES
Camper and Scarpa fasciae
External oblique aponeurosis
Ilioinguinal nerve
Spermatic cord
Processus vaginalis
Tunica vaginalis
Vas deferens
Epididymis
Testis
Testicular artery
Pampiniform plexus
The testis lies posterior in the scrotum as shown in Figure 117.1A. Anterior to the testis there is a potential space lined by tunica vaginalis (termed visceral, where it is adherent to the testis; and parietal, where it is adherent to the scrotum). This space covers approximately the anterior two-thirds of the testis. When fluid accumulates in this space, it is termed a hydrocele. Figure 117.1B shows the situation when the processus vaginalis seals off distally, but does not completely seal proximally, and an indirect inguinal hernia forms (see Chapter 115). When the processus vaginalis does not seal off at all, a communicating hydrocele (Fig. 117.1C) forms. This type of hydrocele is generally encountered and repaired during management of the associated inguinal hernia. Related situations are shown in Figure 117.1D and F. These are primarily encountered in infants and children.
The most common type of hydrocele requiring intervention in adults is the noncommunicating hydrocele (Fig. 117.1E).
The fluid may accumulate for a variety of reasons, and it is important to exclude malignancy as a possible cause.
The fluid may accumulate for a variety of reasons, and it is important to exclude malignancy as a possible cause.
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