Ambulatory Surgery for Hydrocoele : A Review of 300 Cases
Parag A Shah*, Bhavik M Patel**

Introduction

In today’s world, where time is valuable,
all patients demand a speedy recovery from their ailments with minimal pain and discomfort. To keep pace with these and cope up with our patients’ demands while at the same time not compromising on patient care, we started to undertake ambulatory hydrocoele surgery.
Performing surgery on patient’s on an out patient basis is not a new concept. However, the rediscovery, refinement and extension of ambulatory surgery have come about only in the last two decades.
Ambulatory surgery should be performed for well-selected surgical problems, which can be managed on elective basis. The surgical procedure should not last long, with a maximum duration of 1 hour and the surgical technique used should involve minimal dissection, thereby minimizing intra operative haemorrhage and postoperative tissue oedema. These are usually responsible for postoperative pain and discomfort and rendering the patient non-ambulatory and bed ridden.
It has been a routine for hydrocoele surgery to involve bulky scrotal dressings and post operative hospitalization for a minimum period of 72 hours for early detection of post operative scrotal oedema/haematoma.
In order to assess whether hydrocoele surgery could be performed on an ambulatory basis, we undertook a prospective study of 300 cases, performed in outpatient operating theatre with a post operative observation period of 2 hours.1 Lords repair2 was performed under local anaesthesia involving the spermatic cord block. We have found the procedure to be safe, simple, cost effective and highly acceptable to patients. We also used a modified, simple and elastic compression dressing, which was effective in providing support and assisting ambulation.

Material and Methods
Three hundred patients between the ages of 16 and 68 years were selected. The criteria for selection were acceptance of local anaesthesia for the procedure, absence of any concurrent untreated medical illness (especially diabetes mellitus), absence of any local infection, presence of translucent hydrocoele indicating clear fluid within a thin pliable sac and absence of any co-existing pathology of the inguinoscrotal region, such as epididymo-orchitis, hernia or varicocoele.
Laboratory investigations included a complete haemogram to rule out anaemia and eosinophilia (filariasis being the most common cause of hydrocoele in our country). Routine Urine analysis was also performed to exclude urinary tract infection and diabetes. In case of eosinophilia, empirical treatment with diethyl carbamazine citrate for a period of three weeks was given prior to surgery. If urinary tract infection was present it was treated with suitable antibiotics as per urine culture report before surgery.

Surgical Procedure
The patients were asked to fast for 12 hours prior to surgery. Written, valid consent for the procedure was taken and the scrotum shaved. Pre medication with oral atropine 0.6 mg was given. Before taking patients into the operation theare they were asked to evacuate their bladder.
After cleaning and draping, 5 ml of 2% lignocaine was injected into the cord at the root of the scrotum and another 5 ml was injected into the layers of the scrotum at the chosen site if incision after grasping the scrotum and tensing the hydrocoele.
An incision of 5 cm in length was made parallel to the the median raphe. The incision was deepened in layers to the tunica vaginalis parietalis. The sac was opened in the same line of that of the incision. No plane of cleavage was created between the layers of the scrotum and haemostasis at the site of incision was obtained using fine haemostats. On opening the sac, hydrocoele fluid was drained and the testis was delivered. Plicating sutures were taken on the inner aspect of the tunica vaginalis parietalis to draw it up into a cuff around the testis. Five to six sutures were usually required. The wound was irrigated with 1% povidone-iodine and the testis was repositioned back into the scrotum. The wound was closed in two layers, dartos muscle layer with chronic catgut and skin with black silk. No drain was used.
Benzoin tincture was applied over the scrotum and lower abdominal wall over an area 5 cm lateral to the symphysis pubis on either side. A 15 cm length of Elastoplast was divided longitudinally for two thirds of its length. After protecting the incision with a gauze piece, the broad uncut portion of the adhesive plaster was applied to the scrotum ensuring that the cut edge was at the base of the penis. The scrotum was than pulled over the pubic symphysis and the cut portions of the elastoplast were stretched and applied to the lower abdominal wall. Another 15 cm length of elastoplast was divided longitudinally along its entire length and each piece was applied laterally to cover the scrotum and give additional support (Fig. 1). During the application of benzoin tincture as well as the adhesive plaster, care was taken to avoid the inguinal ligament, and the medial aspect of the thigh, to prevent discomfort during ambulation (Fig. 2).
After 2 hours of postoperative observation, the patients were discharged on oral analgesics for three days. One antibiotic was given intramuscularly on prophylactic basis. Patients were asked to report on next day to the out patients department for examination. If no pain or tenderness was reported and the wound devoid of soakage, which was usually the case, it was left undisturbed and patient was advised to return for follow up after seven days for removal of sutures.