Operations for hydrocele

General principles of surgical treatment

Surgical treatment is strictly indicated for patients diagnosed with a large hydrocele. Regardless of the surgical tactics chosen subsequently, the basic conditions for performing the intervention remain unchanged. The patient is placed on the operating table in a standard supine position. Local anesthesia is used as the optimal method of pain management. This ensures adequate loss of sensitivity in the intervention area while minimizing systemic risks to the patient's body. The main goal of either operation is the reliable elimination of the cavity where fluid pathologically accumulates.

Surgical access and wound topography

To fully expose the operative field, the surgeon makes a linear incision approximately eight centimeters long. The line of this incision begins slightly above the inguinal crease and then smoothly continues downward, extending directly onto the base of the scrotum.

During access, tissues are dissected strictly layer by layer. The surgeon sequentially passes through the following anatomical structures:

• Skin and underlying subcutaneous tissue.
• Superficial fascia, followed by the spermatic fascia.
• Cremaster muscle (m. cremaster).
• Internal spermatic fascia (fascia spermatica interna).

After all listed layers are dissected, the hydrocele sac must be carefully delivered into the surgical wound. To achieve this, the physician applies gentle pressure to the lower pole of the formation directly through the scrotal tissues.

Winckelmann procedure

This surgical method is based on the principle of plasty of the native tunics without their radical removal.

1. Evacuation of the cavity: After successfully delivering the sac into the wound, the accumulated fluid inside must be removed. To do this, the tunica vaginalis is punctured with a specialized surgical instrument—a trocar.
2. Incision: The serous membrane is incised with a scalpel in a strictly longitudinal direction.
3. Plasty: This is the key and most specific stage of the operation. The incised tunic is completely turned inside out, wrapping it tightly around the testis itself and the structures of the spermatic cord.
4. Fixation: The everted edges are securely sutured behind the testis. Classic interrupted sutures made of catgut are used for this purpose.
5. Completion: After thorough hemostasis, the testis is gently placed back into the scrotal cavity. The wound is closed layer by layer and tightly. To prevent blood accumulation, a rubber drain is placed for 24 hours.

Bergmann procedure

The Bergmann technique is used by surgeons in the presence of a specific, clear indication: markedly thickened testicular tunics. Under such conditions, their plasty and eversion become technically impractical or entirely impossible.

• Initial stage: Exactly as in the previous case, a puncture is performed first, followed by a longitudinal incision of the tunica vaginalis.
• Tissue resection: The pathologically altered and thickened tunic is carefully separated exclusively by blunt dissection. After complete isolation, it is excised and removed from the wound.
• Suturing of remnants: A neat continuous catgut suture is applied to the small fragments of the tunica vaginalis that inevitably remain after resection.
• Final steps: The treated testis is returned to the natural scrotal cavity, after which the surgical wound is closed layer by layer.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Topographic anatomy of the fasciae and muscles of the scrotum (layered structure)
• Technique of blunt tissue dissection in operative surgery
• Features of applying continuous and interrupted catgut sutures
• Methods for achieving thorough hemostasis during testicular surgeries
• Rules for wound drainage with a rubber drain

Other topics in the section «Pelvic and Perineal Surgery»

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