Laparoscopic-assisted Treatment of Abdominoscrotal Hydrocele

This video will demonstrate the role of laparoscopy in the diagnosis and treatment of abdominal scrotal hydroceles. Abdominal scrotal hydroceles represent 0.17 to 3.1% of all hydroceles. They should be considered in any patient with a large hydrocele. Diagnosis can be made by reduction of the scrotal hydrocele while palpating for an abdominal mass or by ultrasound. We begin with a case of a six month old infant. Who presents with a large right-sided hydrocele and palpable lower abdominal mass. Physical examination demonstrates a large hydrocele that appears reducible but immediately refills. As the hydrocele is reduced, the surgeon palpates the abdomen to assess for a lower abdominal mass. Pressure on the abdominal mass causes immediate re-expansion of the scrotal hydrocele as seen in the video. This is known as the spring back ball sign. Ultrasound confirms the diagnosis by demonstrating a dumbbell-shaped fluid-filled mass with scrotal, inguinal, and intraabdominal but extraperitoneal components. There are 3 main theories to explain the pathophysiology of abdominal scrotal hydroceles. The most commonly accepted theory is that first described by Dupetrin in 1834 as a double sacked hydrocele. Dupertrin suggested that the abdominal scrotal hydrocele forms from a regular infantile hydrocele that enlarges over time pushing through the internal ring into the extraperitoneal space. Whatever the etiology at operation, the hydrocele sac is usually large, inflamed, and adherent to the cord. Dissection is often confusing because there are two separate sacs running along the cord at the level of the internal ring. Treatment of abdominal scrotal hydrocele is surgical, as spontaneous resolution is rare, and the long-term effects on testicular development are unknown. There are many different repairs described in the literature, including inguinal, intraperitoneal, laparoscopic, and scrotal approaches. For the past 10 years, we have used laparoscopy to confirm the presence of the abdominal scrotal hydrocele and monitor the repair, which is done through a standard groin incision. This laparoscopic video demonstrates the presence of a left-sided abdominal scrotal hydrocele, which is confirmed by exerting pressure on the scrotal component while observing filling of the intraabdominal sac. Our attention is then turned to the groin dissection. After opening the external oblique upon neurosis, the spermatic cord is exposed. The hydrocele sac is identified and opened anteriorly to allow evacuation of the hydrocele, facilitating further dissection. As the sac is dissected proximally, traction is applied to the cord, allowing delivery of the preperitoneal component and evacuation of the hydrocele. Since the sack is wide, thick, and adherent to cord structures, the Clatworthy technique is required to safely separate the sack from the vase and vessels. With traction and blunt dissection, the sac of the preperitoneal component can be completely removed. The laparoscope monitors the progress and confirms the absence of a breach in the peritoneum. Once the preperitoneal component is removed, the second lumen of the sac, in other words, the patent processes vaginalis or hernia sac, can be examined with an instrument or a finger when it is wide, as in this case. The sac is then secured at the level of the internal ring in the standard fashion. If the sac is wide, as in this case, it can be closed with a running suture. A final look with the laparoscope confirms the repair is adequate. A simple suture or figure of 8 can be used to narrow the widened internal ring. The wound is then closed in the usual fashion. Abdominal scrotal hydroceles represent a difficult surgical problem due to their large size and adherence to surrounding structures. The authors have used laparoscopy to guide the repair of 8 patients with abdominal scrotal hydroceles in the past 10 years. Although laparoscopy is not essential, we have found it to be a useful adjunct to ensure adequate repair and possibly decrease the risk of recurrent hernia.