Surgical Treatment of Hydrocele & Hernia

Dept. of Urology, Masan Samsung Hospital, Sungkyunkwan Univ. School of Medicine

Dong Soo Ryu, M.D.

The 11th Catholic International Urology Symposium, 2009

짝 불 알 ?

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PathophysiologyPathophysiology

• As the testis descends into the scrotum from its abdominal position, it carries with it a tongue of peritoneum (processus vaginalis)

• During the embryologic processes, the processus vaginalis did not closure and obliteration of the processus (patent processus vaginalis), that can result in commonly seen inguinal or scrotal pathology.

Anomalous closure of the processus vaginalis

DiagnosisDiagnosis

• History– Vacillates in size (usually related to activity)

• Phys. Exam– Soft or tense scrotal swelling– Bluish hue through thin scrotal skin– Fluid shift– Transillumination

• USG– Small intestine, omentum, bladder,

or genital contents

Transillumination test

Hydrocele in cord

Abdomino-scrotal Hydrocele

Late-onset communicating hydrocele

• Communicating hydrocele: congenital by definition

• Manifestate for the first time in older child or adolescent

• Many of cases are found to be omental hernia (descent of a plug of omentum through the internal inguinal ring)

• Palpable thickening in the inguinal canal (suggestive of entrapped omentum)

Management OptionsManagement Options

• Observation– most hydrocele resolve during the first 2 years of life

• Contraindications– Aspiration– Sclerotherapy

• Surgery (high ligation of PPV)

Surgical TechniqueSurgical Technique

A case of hydrocele (5 y-o)

Incision line along Langer’s lines in a skin crease

Kogan BA. Communicating hydrocele/hernia repair in children. BJU Int 2007;100:703-13

Incise the aponeurosis of external oblique along the course of its fiber

Ilioinguinal nerve

The patent PV is seen anteromedial to the rest of the cord structures

Cremasteric m. fiber

Use of Methylene Blue

• Moderate but not tense hydrocele: the blue dye flows upwards into the inguinal canal → clearly outlines the PV

• Tense scrotal hydrocele: delineation of the loculated area

Dissection of PV: direct isolation or open on anterior wall of PV

Omentum or bowel in the hernia sac

Separation of the PV from the cord structures up to and above the internal

ring

High ligation of the hernia sac

Removal of distal sac (large &/or tense hydrocele):Incision, unroofing or aspiration

Closure

Consideration IssuesConsideration Issues

• Purpose of Surgery

• Exploration of contralateral inguinal canal

• Incision: inguinal or scrotal

Purpose of HerniorrhaphyPurpose of Herniorrhaphy

• Testicular atrophy• Incarceration• Calculi• Torsion of hernia sac• Epididymitis

Contralateral ExplorationContralateral Exploration

• Indication– Any past or present history of contralateral inguinal

or scrotal pathology– Child with V-P shunt – Other source of increased intraperitoneal fluid (e.

g., peritoneal dialysis)

• No consensus about technique or age– Incidence of contralateral manifestation– A number of unnecessary procedure– Risk of bilateral testicular trauma

Contralateral Manifestation after the Repair of UnilaContralateral Manifestation after the Repair of Unilateral Inguinal Hernia / Hydroceleteral Inguinal Hernia / Hydrocele

Incidence• 7% (6 of 89) 6 to 15 months (median 12) postoperatively

Lym L, et al. J Urol 1999;162:1169-71

• Inguinal hernia: 11.7% (76 of 647); 13.1% (≤ 1yr), 13.7 (≤ 2yr)

Hydrocele: 7.6% (8 of 105); 11.1% (≤ 1yr), 9.4 (≤ 2yr) Kemmotsu H, et al. J Pediatr Surg 1998;33:1099-103

• 29% at some time in their lives; if first repair was on the left, the child’s chance of contralateral involvement was 41%.

McGregor DB, et al. J Pediatr Surg 1980;15:313-7

Inguinal Hernia and Hernia in Infants and Children

• Do you explore the contralateral side after operating on a unilateral hydrocele? Yes, 43%

• In a boy with a clinically apparent unilateral inguinal hernia, do you explore the other sides? Yes, 80%

• If you routinely explore the opposite side, is age a factor? Yes, 100%

• Up to what age do you routinely explore the contralateral side of the clinically apparent hernia? → 3 mo. (3%), 6 mo. (7%), 2 yrs (31%), 3 yrs (7%), 4 yrs (7%), 5 yrs (10%), 6 yrs (3%), 7 yrs (7%), 10 yrs (7%), 12 yrs (3%), 15 yrs (14%)

Rowe MI, Marchildon MB. Surg Clin North Am 1981;61:1137-45

Hernia Survey of the Section on Surgery of AAP

Frequency of contralateral exploration with unilateral IH according to Age

Wiener ES, et al. J Pediatr Surg 1996;31:1166-9

Age (yr)

1 2 3 4 AllOthe

rNeve

r

Males 28 35 4 19 4 8 2

Females 10 14 7 52 9 7 1

Males, left-sided 24 36 6 22 5 6 1

Females, left-sided

8 14 8 53 8 8 1

Former preemie 27 34 6 24 4 4 1

Hydrocele 25 35 4 20 3 5 8

NOTE. Data are expressed as percentages.

Laparoscopic evaluation of contralateral IH

• Laparoscopic evaluation performed by only 6% of responders, 40% of whom use the open ipsilateral sac for introduction of the scope.

Wiener ES, et al. J Pediatr Surg 1996;31:1166-9

Laparoscopic variability of the internal inguinal ring

Nixon RG, et al. J Urol 2002;167:1818-20

Normal internal inguinal ring

male female

Before traction on testicle

After mild traction on testicle

Laparoscopic variability of the internal inguinal ring

Nixon RG, et al. J Urol 2002;167:1818-20

Wide open sac consistent with patent PV Recurrent inguinal hernia (before & after hernia repair)

Vein of peritoneum over internal ring

Contralateral ExplorationContralateral Exploration

• Perform it as indicated – history of contralateral communication – child with source of increased intraperitoneal fluid

• In boys with clinically apparent inguinal hernia under 1 or 2 years of age (?)

• Informed consent to parents about risk of contralateral manifestation after repair of unilateral hydrocele/IH

• Laparoscopic evaluation with use the open ipsilateral sac for introduction of the scope

Inguinal or Scrotal approach ?Inguinal or Scrotal approach ?

• Advantage of scrotal approach• Cosmesis• No risk of ilioinguinal N. injury

• Scrotal approach• Single scrotal incision orchiopexy for the palpable undescend

ed testicle (Caruso AP, et al. J Urol 2000;164:156-9)

• Scrotal exploration (ipsilateral oblique upper scrotal incision) for unilat. nonpalpable testis

(Snodgrass WT, et al. J Urol 2007;178:1718-21)

Adult type Hydrocele / Hydrocelectomy

• Excision technique– Simple excision– Jaboulay’s bottleneck technique

• Plication technique– Lord’s plication technique

• Sclerotherapy

Inguinal or Scrotal approach ?

SUMMARYSUMMARY

• Hydrocele surgery in children can be simple or remarkably complex, depending on the child’s anatomy and the surgeon’s experience.

• Importantly, a hydrocele in a child is most frequently a communicating hydrocele, with a patent processus vaginalis.

• In these cases the critical step in the operation is a high ligation of the hernia sac (the patent processus vaginalis). Dealing with the hydrocele itself is secondary and often unnecessary.

Thank you for your attention !

The 11th Catholic International Urology Symposium, 2009