Overview
Definition:
Hydrocele repair, specifically the Jaboulay procedure (also known as Jaboulay-Proust), is a surgical technique employed to manage hydrocele, a condition characterized by the accumulation of serous fluid within the tunica vaginalis of the testis
This procedure aims to remove the hydrocele sac and prevent fluid reaccumulation.
Epidemiology:
Hydroceles are common in infants, often resolving spontaneously
In adults, they can be primary (idiopathic) or secondary to underlying conditions like trauma, infection (epididymitis, orchitis), or testicular tumors
The incidence increases with age, and they can occur unilaterally or bilaterally.
Clinical Significance:
Significant hydroceles can cause discomfort, heaviness, and cosmetic concerns
Large hydroceles can interfere with physical examination of the testis, potentially masking underlying pathologies like testicular tumors, making timely and effective surgical intervention crucial for accurate diagnosis and patient well-being.
Clinical Presentation
Symptoms:
Painless scrotal swelling, often gradual in onset
Feeling of heaviness or discomfort in the scrotum
Pain may be present if associated with an underlying cause or complication like torsion or infection
Impaired gait due to large swelling.
Signs:
A tense, fluctuant, and smooth swelling in the scrotum, typically transilluminating positively
The swelling may envelop the testis and epididymis
Palpation may reveal that the testis is not directly palpable within the enlarged sac
Vital signs are usually normal unless complicated.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on history and physical examination findings of a smooth, fluctuant, transilluminating scrotal swelling
Ultrasound is used to confirm the diagnosis, differentiate from other scrotal masses (e.g., spermatoceles, hernias, tumors), and assess the testis and epididymis
Aspiration is generally not a diagnostic tool but may be considered in specific cases.
Diagnostic Approach
History Taking:
Inquire about the onset, duration, and progression of swelling
Ask about associated pain, trauma, or recent infections
Assess for any changes in urination or sexual function
Family history of hydroceles or other scrotal conditions is relevant
Red flags include rapid onset, severe pain, recent trauma, or fever, suggestive of complications or secondary causes.
Physical Examination:
A thorough examination of the external genitalia, including palpation of the scrotum, testes, and epididymis
Assess for transillumination
Examine the inguinal region for hernias
Digital rectal examination may be considered if prostate or seminal vesicle pathology is suspected
Thorough examination of the contralateral testis is essential.
Investigations:
Scrotal ultrasound is the primary imaging modality
it differentiates hydrocele from solid masses, confirms the presence of fluid, and visualizes the testis and epididymis, assessing for any abnormalities like tumors or torsion
Doppler ultrasound helps assess testicular vascularity, particularly if torsion is suspected
Urinalysis and urine culture may be performed if infection is suspected
Blood tests (e.g., CBC, inflammatory markers) are generally not required unless systemic infection is present.
Differential Diagnosis:
Inguinal hernia
Spermatocele
Epididymal cyst
Testicular tumor
Hematocele (following trauma)
Varicocele (typically a "bag of worms" superiorly)
Orchitis/Epididymitis (usually painful and associated with fever).
Management
Initial Management:
For asymptomatic, small hydroceles, especially in children, observation may be sufficient as spontaneous resolution is common
For symptomatic or large hydroceles in adults, surgical intervention is typically indicated
Aspiration is generally not recommended due to high recurrence rates and potential for complications.
Medical Management:
Medical management is not the primary treatment for hydroceles
However, if an underlying cause like orchitis or epididymitis is identified, appropriate antibiotic therapy will be initiated
Pain management with NSAIDs may be used for symptomatic relief in some cases.
Surgical Management:
The Jaboulay procedure involves excision of the hydrocele sac
Key steps include: Incision through the scrotal skin, dissection to identify the hydrocele sac, opening the sac to drain fluid, meticulous excision or eversion of the sac wall to obliterate the space and prevent recurrence
Hemostasis is crucial
The tunica vaginalis is then closed in layers
Alternative procedures include Lord procedure (plication) or Jaboulay-Sprengel (partial excision with eversion).
Supportive Care:
Postoperatively, patients require wound care, pain management, and scrotal support (e.g., scrotal suspensory)
Monitoring for signs of infection, bleeding, or hematoma formation is essential
Patients are advised to avoid strenuous activity for several weeks.
Complications
Early Complications:
Bleeding and hematoma formation are the most common early complications
Wound infection
Seroma formation
Testicular injury if not adequately visualized and protected during dissection.
Late Complications:
Recurrence of hydrocele due to incomplete sac excision or failure to obliterate the space
Chronic scrotal pain
Testicular atrophy (rare, usually associated with inadequate vascular preservation)
Formation of adhesions between the testis and the scrotum.
Prevention Strategies:
Meticulous surgical technique with complete excision or effective eversion of the hydrocele sac
Ensuring adequate hemostasis
Using appropriate suture materials for tissue approximation
Proper postoperative scrotal support and activity restrictions.
Prognosis
Factors Affecting Prognosis:
The success of the Jaboulay procedure is generally excellent with low recurrence rates when performed correctly
Prognosis is also dependent on the absence of underlying pathology causing the secondary hydrocele
Pre-existing testicular compromise can affect long-term outcomes.
Outcomes:
Successful surgical repair typically leads to resolution of scrotal swelling and relief of symptoms
Most patients experience good functional and cosmetic outcomes
Recurrence rates are generally low, typically <5%, with modern techniques.
Follow Up:
Routine follow-up is usually scheduled at 1-2 weeks post-operatively to assess wound healing and check for complications
Further follow-up may be arranged at 1-3 months to ensure no recurrence
If a secondary cause was identified, follow-up for that condition is also important.
Key Points
Exam Focus:
Jaboulay procedure involves excision/eversion of the hydrocele sac
Differentiate hydrocele from other scrotal masses using ultrasound and transillumination
Always rule out testicular tumors, especially in secondary hydroceles or hydroceles with palpable testicular abnormalities.
Clinical Pearls:
Ensure adequate exposure and visualization of the testis and tunica vaginalis
Meticulous hemostasis is paramount
Consider the choice of procedure (excision vs
plication) based on sac characteristics and surgeon preference
Postoperative scrotal support significantly aids in recovery.
Common Mistakes:
Incomplete sac excision leading to recurrence
Mistaking a solid testicular tumor for a hydrocele, delaying definitive diagnosis
Inadequate hemostasis leading to significant hematoma
Aggressive dissection causing testicular injury or compromising vascular supply.