Hydrocele surgery

A hydrocele is fluid-filled swelling (sac) that forms around the testicle in the scrotum (the pouch that holds the testicles). It is categorised as congenital (in babies) or acquired (in adults). Hydroceles are a cause of concern primarily due to their enlarged size in a sensitive location of the body.

A hydrocele usually resolves on its own without any intervention. However, in some cases, the swelling may increase accompanied by several symptoms. The condition then needs to be treated surgically. Removal or repair of a hydrocele is known as hydrocelectomy or hydrocele surgery.

Based on the age of the patient, there are two techniques to perform the procedure:

• Hydrocele surgery in babies
• Hydrocele surgery in adults

A hydrocele is usually asymptomatic. However, surgery is indicated in the following conditions:

• In babies greater than 1 year of age: congenital hydroceles (present from birth) usually disappear without any intervention by one year of age. However, if the swelling persists thereafter or is increasing in size it needs to be resected.
• In adults, surgery is needed if any of the following symptoms are present:
  • Abnormal size of the swelling leading to cosmetic discomfort
  • A sudden increase in the size of the swelling
  • Pain and tenderness of the hydrocele, suggestive of testicular torsion (the blood supply to the testis is suddenly blocked due to twisting of the testis). This is a medical emergency.
  • Infection in the swelling which is presented by fever, tenderness and warmth around the swelling (due to collection of pus)
  • Ulceration of the scrotum, resulting in bleeding or pus discharge due to trauma or infection to the genital area

(Read more: Homeopathic treatment of Hydrocele)

The surgery is associated with minimal risks. However, in patients with pre-existing conditions such as diabetes or heart disease, the risks associated with anaesthesia and infection post-surgery are increased. Hence, it is to be ensured that these conditions are under control before opting for surgery.

Hydrocele in babies may be a result of premature delivery. Hence, the risks of surgery are to be weighed by ruling out other conditions in the baby, before opting for this surgery.

The procedure is either done by a general surgeon or a paediatric surgeon depending on the age of the patient. The technique of the surgery along with the associated risks are explained to the patient/their parents or guardian.

A detailed medical history of the patient is taken which involves the symptoms, birth history (in case of babies), pre-existing conditions (comorbidities) if any and medications history. In babies, this history is given by the parents/guardian.

A physical examination of the patient is done to assess the hydrocele and rule out any other pathologies. Investigations that are done prior to the surgery include:

• Routine blood tests
• Chest X-ray
• ECG
• Ultrasound of the abdomen and ultrasound of the pelvis. This investigation is useful to:
  • confirm the size of the hydrocele
  • understand the type of fluid present within
  • to identify any associated abnormalities (occasionally a part of the intestine may also be present – also known as an inguinal hernia). (Read more: Inguinal Hernia Surgery)
  • visualise the other contents of the scrotum, including the blood supply to the testis
  • assess the other testis and see whether it is normal

The surgery is done via day-care admission (the patient is admitted in the morning and discharged by the evening). The patient is advised to arrange for a ride back home since after the surgery, the patient will have difficulty driving.

Prior to the day of the surgery, the patient is told to fast overnight. For babies, fasting for at least four hours before surgery is required.

On the day of the surgery, the patient arrives at the hospital with all the relevant investigations and documents and is admitted. The patient is changed into the hospital attire and a final review of the patient is done by the surgeon and nurses before clearing for surgery.

Written consent is taken from the patient (or the parents/guardian in case the patient is a baby) after the surgeon has explained the technique of the surgery and the associated risks and complications. Hair, if present, is shaved off from the area of the surgery. Thereafter, the patient is shifted into the operation theatre (OT).

The patient is made to lie down supine (on their back). A monitor is attached to track the vitals (heart rate, blood pressure and oxygen saturation). An IV cannula is inserted through which medications required for the procedure will be administered.

The patient will be administered general anaesthesia so that the patient is asleep throughout the procedure.

Depending on the age of the patient, the procedure can be carried out in one of the following two ways:

• In babies: the cause of hydrocele is addressed, which is usually a weakened abdominal wall/ defect in the wall that results in the hydrocele. The surgeon makes a small incision in the fold of the groin and drains the fluid present in the hydrocele. Then the surgeon may either remove the sac or push the sac back into the abdomen through the abdominal wall defect. The surgeon then strengthens the abdominal wall (hernia repair) by using sutures (stitches).
• In adults: an incision is made on the scrotum and the fluid in the sac is drained. Thereafter, the sac is excised. In some cases, a hernia may also be present and, hence, hernia repair surgery may also be done. The incision is then closed using sutures. In large hydrocele, sometimes a drain may be placed that prevents the pooling of fluid in the scrotum.

A more modern approach is laparoscopy, which uses smaller incisions and special instruments along with a video camera that helps assist the surgery.

The entire procedure usually takes 30 minutes. After applying sutures, the area is bandaged heavily to prevent bleeding.

Complications of the surgery are minimal. Some of the risks involved are:

• Excessive bleeding
• Injury to the spermatic cord, testicular artery
• Injury to the testis
• Infection
• Occurrence of hernia
• Recurrence of the hydrocele
• Complications due to anaesthesia

After the procedure, the patient is shifted from the OT and kept under observation for a few hours. Pain at the site of surgery is managed by analgesics. An ice pack may be given to the patient to apply locally to reduce the inflammation.

A discharge summary is prepared by the doctor which includes relevant medications and advice on wound care. These typically include:

• Continue medications for pre-existing conditions, if any.
• Antibiotics and analgesics to prevent infection and pain, respectively. For children, these medications will be available in the form of syrups.
• Remove the bandage after two days
• Manage any post-surgery swelling by applying an ice pack or cold compress for no more than 15 minutes at a time for a couple of days.  
• A jockstrap may be advised to be worn to help prevent injury.
• While bathing, wash the area carefully and pat dry
• The patient will be able to perform normal activities after the bandage is removed, i.e., after two days.
• Avoid doing strenuous activities such as aerobic exercises or weight training for at least two weeks
• Avoid indulging in sexual activities for at least two weeks
• Avoid applying any creams or powder to the area until the wound heals completely
• After using the toilet, wipe the area clean to prevent infection. In babies, change the diapers regularly to prevent infection from urine/faeces

Notify the doctor if any of the following symptoms arise/persist:

• Excessive bleeding or soakage of the dressing from the wound
• Pus discharge from the wound
• Excessive pain and tenderness at the wound site
• Sudden swelling at the wound site
• Fever
• Ulceration at the incision site

The wound takes about two weeks for complete healing. The first follow up will be after two weeks to remove the stitches and drain (if present). Further follow-ups are as per the patient's requirements.

Hydrocelectomy is a surgical procedure used to treat hydroceles when they are symptomatic and of cosmetic discomfort. It is a short surgery with minimal complications. Newer methods such as laparoscopy have a shorter recovery period. Postoperative care is usually uneventful and the patient can resume normal activities within two days. Despite a good success rate of the surgery, recurrence is known to happen.