Surgical Treatment of Hydrocele & Hernia

1. The 11th Catholic International Urology Symposium, 2009 Surgical Treatment of Hydrocele & Hernia Dept. of Urology, Masan Samsung Hospital, Sungkyunkwan Univ. School of Medicine Dong Soo Ryu, M.D.

2. 짝 불 알 ? or

3. Pathophysiology • 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.

4. Anomalous closure of the processus vaginalis

5. Diagnosis • 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

6. Transillumination test

7. Hydrocele in cord

8. Abdomino-scrotal Hydrocele

9. 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)

10. Management Options • Observation • most hydrocele resolve during the first 2 years of life • Contraindications • Aspiration • Sclerotherapy • Surgery (high ligation of PPV)

11. Surgical Technique

12. A case of hydrocele (5 y-o)

13. Incision line along Langer’s lines in a skin crease Kogan BA. Communicating hydrocele/hernia repair in children. BJU Int 2007;100:703-13

14. Incise the aponeurosis of external oblique along the course of its fiber Ilioinguinal nerve

15. The patent PV is seen anteromedial to the rest of the cord structures Cremasteric m. fiber

16. 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

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

18. Omentum or bowel in the hernia sac

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

20. High ligation of the hernia sac

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

22. Closure

23. Consideration Issues • Purpose of Surgery • Exploration of contralateral inguinal canal • Incision: inguinal or scrotal

24. Purpose of Herniorrhaphy • Testicular atrophy • Incarceration • Calculi • Torsion of hernia sac • Epididymitis

25. Contralateral 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

26. Contralateral Manifestation after the Repair of Unilateral 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

27. Inguinal Hernia and Hernia in Infants and Children Rowe MI, Marchildon MB. Surg Clin North Am 1981;61:1137-45 • 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%)

28. Hernia Survey of the Section on Surgery of AAP Wiener ES, et al. J Pediatr Surg 1996;31:1166-9 Frequency of contralateral exploration with unilateral IH according to Age NOTE. Data are expressed as percentages.

29. Laparoscopic evaluation of contralateral IH Wiener ES, et al. J Pediatr Surg 1996;31:1166-9 • Laparoscopic evaluation performed by only 6% of responders, 40% of whom use the open ipsilateral sac for introduction of the scope.

30. 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

31. Laparoscopic variability of the internal inguinal ring Nixon RG, et al. J Urol 2002;167:1818-20 Recurrent inguinal hernia (before & after hernia repair) Wide open sac consistent with patent PV Vein of peritoneum over internal ring

32. Contralateral 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

33. Advantage of scrotal approach Cosmesis No risk of ilioinguinal N. injury Scrotal approach Single scrotal incision orchiopexy for the palpable undescended 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) Inguinal or Scrotal approach ?

34. Adult type Hydrocele / Hydrocelectomy • Excision technique • Simple excision • Jaboulay’s bottleneck technique • Plication technique • Lord’s plication technique • Sclerotherapy

35. Inguinal or Scrotal approach ?

37. SUMMARY • 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.

38. The 11th Catholic International Urology Symposium, 2009 Thank you for your attention !