Hydroceles (and hernias)

Adult hydrocelectomy

  1. Position supine, trim hair, prep/drape, give cefazolin or other antibiotic for skin flora
  2. Can make either midline incision along scrotal raphe or transverse incision through rugae
  3. Pick up layers and divide with electrocautery to avoid accidentally entering hydrocele too early, can also push testis anteriorly within scrotum to help identify layers
  4. Once overlying layers freed, can deliver testis + hydrocele into operative field
  5. May have further overlying layers, can bluntly push off with raytec or divide with electrocautery
  6. Once ready, open hydrocele anteriorly in longitudinal fashion to avoid testis and cord structures (epididymis and vas can travel within vaginalis)
  7. Can trim excess sac, obtain hemostasis, then wrap posterior to testis and loosely close posteriorly with running 3-0 vicryl
  8. If desired can pexy testis into scrotum with prolene or PDS (not done frequently)
  9. Replace testis back into scrotum, ensure good placement without torsion
  10. Close dartos with 3-0 vicryl, close skin with chromic or monocryl, then apply bacitracin

Pediatric hydrocelectomy + hernia repair

  1. Place patient supine, prep/drape, no antibiotics if prepubertal, perform ilioinguinal block
  2. Make inguinal incision ~3-5cm length starting just superior to pubic tubercle, dissect layers with electrocautery and bluntly divide with hemostat
  3. Define the inguinal canal then open external ring sharply with tenotomy scissors
  4. Grasp edges of fascia and bluntly pull canal contents off the fascia
  5. Gently grasp contents to identify hernia sac in canal, then push off other contents bluntly to isolate hernia sac
  6. Once hernia sac completely free, clamp with hemostat x2, divide between
  7. Dissect contents off proximal hernia sac, then twist and suture ligate with 3-0 vicryl
  8. Put traction on distal hernia sac, bluntly separating from surrounding scrotal dartos tissue (should eventually deliver testicle into field)
  9. Open hydrocele sac anteriorly to minimize injury to testicular/cord structures, can excise excess sac, pexy posterior to testis without strangulating with 3-0 vicryl interrupted
  10. Pull on scrotum to position testis back in scrotum, should sit comfortably without torsion
  11. Close external fascia with running 3-0 vicryl, close scarpa fascia with 3-0 vicryl interrupted, inject local anesthesia under skin, then close skin with 5-0 monocryl, then apply dermabond

Hydrocele aspiration

  1. Prep scrotum with betadyne, drape with sterile towels
  2. Inject lidocaine subcutaneously (usually 1-2mL sufficient)
  3. Insert large bore angiocath through scrotum, retract needle to leave cannula in place
  4. Aspirate with 50-60mL syringe until hydrocele completely drained
  5. Optional: use extension tubing and 3-way stopcock to make drainage more efficient
  6. Optional sclerotherapy: inject 200mg or 400mg (for > 500mL hydrocele) doxycycline in 10mL 0.5% bupivicaine (usually perform cord block prior due to pain), massage in for 1-2min - can also use alcohol or other chemicals
  7. Can apply dressing, send with pain meds and short course antibiotics