weekly_question 19/9/2021

[Admin]

A 6-month old boy presents with enlarging bilateral hydroceles. A plan for bilateral open inguinal hydrocele repair is decided upon. At the time of surgery, after induction of general anesthesia, a previously unrecognized left-sided abdominal mass is palpated. Compression of the left scrotal hydrocele seems to increase the size of the mass slightly; release of compression causes the hydrocele to feel tense again. At this point the surgeon should

A Laparoscopically evaluate in conjunction with an inguinal exploration

B Cancel the surgery and obtain a VCUG (voiding cystourethrogram)

C Scrotal hydrocelectomy

D Open laparotomy for the abdominal mass

E Cancel the surgery and obtain an abdominal CT scan

[Admin]

correct answer

A Laparoscopically evaluate in conjunction with an inguinal exploration

The child presents with an abdominoscrotal hydrocele. He has a "springing back ball sign", present in about 90% of infants with an abdominoscrotal hydrocele (ASH), wherein the palpable mass moves back and forth via the internal inguinal ring with compression.

Abdominoscrotal hydrocele (ASH) was first described as a "hydrocele en bisac" by Dupuytren in 1834. ASH is an hourglass hydrocele that originates in the scrotum and extends via the inguinal canal and internal ring into the extraperitoneal cavity. Although some feel a tiny patent processus vaginalis is present, it is usually impossible to identify. The theories of origin include: (a) high obliteration of the processus vaginalis; (b) cephalad extension of a scrotal hydrocele due to overdistension; and (c) a flap valve mechanism from a patent processus vaginalis. This is a rare anomaly that is not commonly reported in the literature. A recent systematic review found 18 case series describing 116 patients with 146 hydroceles.

Ultrasound may be used for diagnosis, with some authors recommending a dynamic ultrasound study: compressing the scrotal hydrocele while observing the intra-abdominal component with the probe. Cryptorchidism or atrophic testis are associated with ASH in some cases. In this case, with the patient asleep in the OR, a diagnostic laparoscopy can help with making the diagnosis as well as assist with operative resection of the intra-abdominal component.


Surgical resection has been recommended, but the complication rate can be high. The sac is often inflamed and densely adherent to the spermatic cord structures making the dissection very difficult. In one series of 29 children, 9 (30%) underwent operation with an 80% complication rate. The remaining twenty patients (70%) were initially managed expectantly. Sixteen (80%) had resolution of their abdominal component, twelve (60%) of which went on to have full resolution of ASH. Four patients (20%) in this group required operative management of ASH. The surgical management usually consists of an inguinal incision and high ligation of the sac, with a distal hydrocele procedure (e.g. Lord procedure with plication of the tunica) and an abdominal (or more commonly, laparoscopic) component with partial resection of the sac. Observation has been reported but there is potential for compressive effects on surrounding structures with sequelae to include lower extremity edema, hydronephrosis, torsion, and hemorrhage. Testicular dysmorphism, specifically a fusiform testis, is a common intraoperative finding with uncertain significance and etiology occurring in 28.1% of hydroceles in our included studies. There has been one case report of mesothelioma developing in the abdominal component of an ASH in a 14-year-old boy.


In this child, confirmation can be obtained by laparoscopy and therefore further imaging (CT scan or VCUG) are not necessary. While some authors note the use of needle aspiration, it is not definitive management in this case. While some authors do advocate for an open approach to the abdominal portion, there is still a need to address the inguinal portion of the hydrocele.

[Mohamed ahmed Abd elsalam]

A

[Dr.Aftab]

This is a abdominoscrotal hydrocele and can approached through extending same inguinal incision.

[Admin]

correct answer

A Laparoscopically evaluate in conjunction with an inguinal exploration

The child presents with an abdominoscrotal hydrocele. He has a "springing back ball sign", present in about 90% of infants with an abdominoscrotal hydrocele (ASH), wherein the palpable mass moves back and forth via the internal inguinal ring with compression.

Abdominoscrotal hydrocele (ASH) was first described as a "hydrocele en bisac" by Dupuytren in 1834. ASH is an hourglass hydrocele that originates in the scrotum and extends via the inguinal canal and internal ring into the extraperitoneal cavity. Although some feel a tiny patent processus vaginalis is present, it is usually impossible to identify. The theories of origin include: (a) high obliteration of the processus vaginalis; (b) cephalad extension of a scrotal hydrocele due to overdistension; and (c) a flap valve mechanism from a patent processus vaginalis. This is a rare anomaly that is not commonly reported in the literature. A recent systematic review found 18 case series describing 116 patients with 146 hydroceles.

Ultrasound may be used for diagnosis, with some authors recommending a dynamic ultrasound study: compressing the scrotal hydrocele while observing the intra-abdominal component with the probe. Cryptorchidism or atrophic testis are associated with ASH in some cases. In this case, with the patient asleep in the OR, a diagnostic laparoscopy can help with making the diagnosis as well as assist with operative resection of the intra-abdominal component.


Surgical resection has been recommended, but the complication rate can be high. The sac is often inflamed and densely adherent to the spermatic cord structures making the dissection very difficult. In one series of 29 children, 9 (30%) underwent operation with an 80% complication rate. The remaining twenty patients (70%) were initially managed expectantly. Sixteen (80%) had resolution of their abdominal component, twelve (60%) of which went on to have full resolution of ASH. Four patients (20%) in this group required operative management of ASH. The surgical management usually consists of an inguinal incision and high ligation of the sac, with a distal hydrocele procedure (e.g. Lord procedure with plication of the tunica) and an abdominal (or more commonly, laparoscopic) component with partial resection of the sac. Observation has been reported but there is potential for compressive effects on surrounding structures with sequelae to include lower extremity edema, hydronephrosis, torsion, and hemorrhage. Testicular dysmorphism, specifically a fusiform testis, is a common intraoperative finding with uncertain significance and etiology occurring in 28.1% of hydroceles in our included studies. There has been one case report of mesothelioma developing in the abdominal component of an ASH in a 14-year-old boy.


In this child, confirmation can be obtained by laparoscopy and therefore further imaging (CT scan or VCUG) are not necessary. While some authors note the use of needle aspiration, it is not definitive management in this case. While some authors do advocate for an open approach to the abdominal portion, there is still a need to address the inguinal portion of the hydrocele.

[Admin]

operative video

https://pediatricsurgery.club/forum/pediatric-surgery-discussions-ac/inguinoscrotal-diseases/5622-lap-management-of-abdomino-scrotal-bilocular-hydrocele