Everted plication--a modified technique in hydrocoele surgery.OP Rohondia, SS Kowli
Dept. of Surgery, KB Bhabha Hospital, Bandra, Bombay, Maharashtra.
In the present article, a new technique of surgery for hydrocoele is described. This technique involves combination of plication and eversion of tunica vaginalis sac. This surgical method was compared with the standard operative procedures-Jabouley's and Lord's (25 patients in each group). Our technique required less suture material (average knots required were 4). The risk of injury to epididymis or testis appeared to be less and time required for surgery was 10 min. Thus the technique appeared to be simple and safe, even when carried out by junior surgeon.
Keywords: Comparative Study, Follow-Up Studies, Human, Hydrocele, surgery,Male, Surgical Procedures, Operative, methods,
The fluid in between two layers of tunica vaginalis, sac (TVS) is secreted by tunica vaginafis visceralis JVV) and is absorbed by tunica vaginalis parietalis (TVP) and the lymphatics of the scrotal wall. Excess of hydrocele fluid collection can occur in tunica vaginalis sac if there is an excess production of hydrocele fluid as in cases of inflammatory or neoplastic condition of the testis or by defective absorption by TVP,.
The principle of surgical treatment of hydrocele is to expose the TVV directly to the scrotal wall and its lymphatics by- excision, plication or by eversion.
Jabouley described partial excision with eversion of the sac [Figure:1A] . Lord described plication of the sac to expose TVV to the scrotal wall and its lymphatics [Figure:2B].
We have described in the present article the new technique of dealing with the sac so as to expose TVS to the lymphatics of the scrotal wall. It aims at plication, eversion and obliteration of dead space behind the testis.
A study was carried out. in 75 patients with hydrocoele to compare our modified technique with two standard surgical techniques. They were randomly divided into 3 groups as follows:
Group A (n = 25) - Patients from this group were operated by Jabouley's technique.
Group B (n = 25) - Lord's procedure was carried out in these patients.
Group C (n = 25) - These patients were operated by modified technique. The procedure, in short, is as follows:
In this technique hydrocele sac was reached by standard vertical incision on the scrotum to expose TVP. After reaching the sac it was dissected all around from the scrotal wall. Hydrocele fluid was evacuated and the TVS was incised and everted. A plication suture with 30 chromic catgut was taken starting about 1 cm away from the testicular margin till the edge of the sac, The same stitch was continued on the opposite edge of the sac at the same level from the posterior side of testis till it reached the area approximately 1 cm away from the testicular margin [Figure:2]. Maximum 3 or 4 stitches were taken at different levels at a distance of 1.5 cm from each other [Figure:2].
After plicating the sac, haemostasis was achieved and the testis was reposited into the scrotum and the scrotum was closed in layers in an usual manner.
Record was kept of time required for treating the sac, number of catgut packets required and number of knots applied on the sac. Any immediate or late complications were noted.
After the operation patients were observed for 7 days in the hospital and then followed up in OPID for next 6 months.
[Table - 1]
Our Modified technique is simple and safe. The advantages of this technique is compared with the standard techniques as follows:
While following Jabouley's technique time is lost in partial excision of the sac as well as achieving haemostasis. If the sac is not adequately excised, blood or serum may accumulate behind the testis, predisposing to infection. In our study two patients operated by this technique had wound infection.
The procedure for Lord's plication involves 10-12 radial plication sutures, starting at the margin of the testis and the epididymis. This carries a relative chance of injury to the testis and epididymis, especially when an inexperienced junior resident surgeon is operating.
This risk is minimized in our modified technique wherein we take stiches 1 cm away from the testicular margin. The number of stiches taken are also less 3 to 4 only, thus leaving behind 3-4 knots as compared to 10-12 described in Lord's plication.
Using modified technique, excision of the sac can be avoided. Plication helps in achieving haemostasis and obliteration of dead space behind the testis. This rules out collection of blood, and have infection. This technique thus combines the advantages of Lord's and Jabouley's methods ke plication and eversion both.
The proposed modified technique appears to be simple, safe and less complications, and can be employed routinely for medium viz. vaginal hydrocoele. The time required for the operation is 10 min, the suture material required is also less and the results are comparable with the other standard methods.
[Table - 1]