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13 Hernia Surgery in Australasia
133
rounding complications for transvaginal mesh
placement for treatment of urinary stress
incontinence.
References
1. McMahon AJ, etal. Bile duct injury and bile leak-
age in laparoscopic cholecystectomy. Br J Surg.
1995;82:307–13.
2. Schultz L, et al. Laser laparoscopic herniorrhaphy: a
clinical trial preliminary results. J Laparoendosc Surg.
1990;1(1):41–5.
3. Fielding GA. Laparoscopic inguinal hernia repair.
Aust N Z J Surg. 1995;65:304–7.
4. Bellis CA.Laparoscopic inguinal herniorrhaphy is not
a valid procedure. Aust N Z J Surg. 1994;64:295–6.
5. Liam MSL.The learning curve of totally extraperito-
neal laparoscopic inguinal hernia repair. Am J Surg.
1996;171(2):281–5.
6. Kockerling F, etal. Do we need antibiotic prophylaxis
in endoscopic inguinal hernia repair? Results of the
Herniamed Registry. Surg Endosc. 2015;29:3741–9.
7. Update on serious complications associated with
transvaginal placement of surgical mesh for pelvic
organ prolapse: FDA Safety Communication 2011.
8. Tongaonkar R, etal. Preliminary multicentric trial of
cheap indigenous mosquito-net cloth for tension-free
hernia repair Indian. J Surg. 2003;65(1).
9. Grant A, EU hernia Trialists Collaboration.
Laparoscopic versus open groin hernia repair: metaanalysis of randomised trials based on individual
patient data. Hernia. 2002;6(1):2–10.
10. Sajid MS, etal. A systematic review and meta-analysis evaluating the effectiveness of lightweight mesh
against heavyweight mesh in inuencing the incidence of groin pain following laparoscopic inguinal
hernia repair. Am J Surg. 2013;205(6):726–36.
11. Andrew C, et al. Lightweight versus heavyweight
mesh in laparoscopic inguinal hernia repair: a metaanalysis. Surg Endosc. 2012;26(8):2126–8.
12. Akolekar D, et al. Comparison of recurrence with
lightweight mesh composite polypropylene mesh and
heavyweight mesh in laparoscopic totally extraperitoneal inguinal hernia repair: an audit of 1,232 repairs.
Hernia. 2008;12(1):39–43.
13. Burgmans JP, et al. Long-term results of a randomised double-blinded prospective trial of a
lightweight (Ultrapro) versus a heavyweight mesh
(Prolene) in laparoscopic total extraperitoneal
inguinal hernia repair (TULP trial). Ann Surg. 2016;
263(5):862–6.
Hernia Surgery inAfrica
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F.Abi, M.Aboulalaa, M.Mehhane, M.Moumen,
F.El Farès, J.Obama, M.El Akkad, M.J.Moosa,
M.M.Noori, andD.Maggiore
14
14.1 Summary
The AMEHS was founded on September 2009in
Geneva for my will and other African and Middle
East colleagues. The reason why we want to join
Africa and Middle East is connected to the concept of “Africa as the cradle of humankind.” In
fact the most ancient nds were found in subSaharan Africa. The Sahara was an important element in the historical evolution of the continent
as well as the Arabic language. These are the two
crucial points on which the idea of the AMEHS
(Afro Middle East Hernia Society) was based.
From here we can understand how the Middle
East, irrespective of the social development over
the last 100years, is linked to Africa for better or
for worse. Often the people of Middle East, full
F. Abi · M. Aboulalaa · M. Mehhane
M. Moumen · F. El Farès
Department of Surgery, University Hospital Ibn
Rochd, Casablanca, Morocco
J. Obama
Ministry of Health, Malabo, Equatorial Guinea
M. El Akkad
Department of Surgery, Al Wakra Hospital,
Doha, Qatar
M. J. Moosa · M. M. Noori
Department of Surgery, Al-Yarmouk Teaching
Hospital, Baghdad, Iraq
e-mail: maggiore@amehs.net
D. Maggiore (*)
Department of Surgery, Nouvelle Clinique Vert Pre,
Geneve, Switzerland
of their oil discoveries with the consequent power
of evolution, don’t like to be considered African
brothers, but the root is the same. AMEHS understood it and is following that way.
AMEHS has started to walk in small steps over
the years, pointing to the world of “Pathologies of
Abdominal Wall” distinguishing itself for its own
identity during the various congresses.
It wasn’t so easy to present ourselves to the
world, as Africa is a continent and Middle East
already has its clear identity. But we are working
with our well-dened identity over the years to nd
space into social and scientic society, presenting
ourselves with our scientic knowledge about the
health status in each country. Moreover, it is difcult to follow a clear and unique line to everyone as
Africa and Middle East are agglomerations of
completely different situations, economically, politically, socially, and from the point of view of health
status. More specically, North Africa is welldened and very “westernized,” Central Africa is
suffering from many serious problems connected
to the poverty, but it is full of highly performing
and willing colleagues and surgeons, Middle East
is clearly evolved for welfare, and South Africa is
inuenced by the Western countries. Therefore it is
not so easy for AMEHS to coordinate and be able
to bring our work to one voice. We are trying to do
it. Today, 8years after the foundation, we are preparing to select the best substitute of the General
Secretary who will be able to make this ower
blossom in a clear way, this ower that is already
growing well. A special thanks to the friend of all
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_14
135
136
F. Abi et al.
of us, Giampiero Campanelli, our honorary president, who has guided us in the right development
that we desire with the Congress of Milan on 2015
and future plans.
According to the Preface of the chapter,
AMEHS is a young society with many spirits
within itself, so it is more than a continent. Slowly
and with many efforts, we are trying to make
understand the value of joint nature, democracy,
and collaboration to achieve an objective, which
is not an individual objective but a shared one
including a social value and above all, especially
in this case, a scientic value of mutual growth,
considering the exchanges among researchers,
clinicians, and healthcare professionals on the
eld and in rst line. We are convinced that all
these steps are slowly leading to the awareness
that the present line is appropriate and correct for
everyone. The story of other continents is an
example: Europe, America, Asia, and Oceania.
In this sense we wanted to gather the efforts of
those who had given courageously their contribution for this fundamental text which will leave a
trace in the whole world about the pathology of
abdominal hernia.
Prof. Abi, a famous woman surgeon from
Morocco, brought us her experience that, even if
dated, makes us understand the importance of
hernia pathology in her country and the treatment
she had performed with a TEP.
From July 1998 to December 2001, 117
patients were admitted for inguinal hernia to the
surgery department 2 of the Ibn Rochd University
Hospital in Casablanca. Of these, 48 had a totally
extraperitoneal (TEP) approach (29.62%), 6
transabdominopreperitoneal (TAPP) approach,
21 (12.96%) had mesh by conventional surgery, 2
Lichtenstein procedures, 83 Shouldice procedures (51.23%), 2 Mac Vay procedures, and 1
Bassini technique. Thirteen of them were not
operated for various reasons. We reviewed the
outcome of 59 inguinal hernias in 48 patients
who underwent laparoscopic totally extraperitoneal (TEP) approach by 4 surgeons between July
1998 and December 2001. Patient demographics,
hernia characteristics, operative parameters, and
clinical outcomes were evaluated. The selection
criteria were age of more than 45years and the
absence of contraindication to general anesthesia
and retro-pneumo-peritoneum. Mean age of 47
men and 1 woman undergoing 59 inguinal hernia
TEP repairs was 62.9 years (range 45–85).
Twenty-seven (56.25%) of our patients were professionally active, and 21 (43.75%) were sedentary. Six had cardiovascular and endocrine
disruptions, respiratory risk factors were present
in 20 patients (41.66%), and urinary for 19
(39.58%). Strenuous activity was reported by 19
patients (39.58%). Two patients complained of
chronic constipation. Inguinal hernias were unilateral (n = 30) 27 right inguinal hernia (RIH)
(56.23%)? left inguinal hernia (LIH), 13 (27.08%)
and bilateral (BIH) (n = 8) (16.66%), indirect
hernia 37 (77.08%), direct hernia 11 (22.91%), 8
defects (16.66%) were recurrent. Surgery was
programmed in all patients (100%), and general
anesthesia was performed in the 48 patients
(100%). Antibiotic prophylaxis has been systematic in all patients (100%). The rst patients beneted from an antibiotic prophylaxis (based on
Penicillin A+inhibitor of B lactamase) and the
latter from a second-generation cephalosporin.
Intraoperative diagnosis showed indirect hernia
in 38 patients (79.16%), direct hernia in 8 patients
(16.66%), and pantaloon hernia in 2 patients
(4.16%). Our patients were classied according
to the NYHUS classication to type 2, 24 cases
(50%) (18 patients (37.5%) classied as stage 2
had associated risk factors); type 3a, 3 cases
(25%); type 3b, 13 cases (27.08%); and type 4b,
8 cases (16.66%). The conversion into open surgery was necessary in 26 patients (54.16%). The
reasons for conversion were the difculty of
reducing the hernia sac in 7 patients (26.92%),
the difculty of dissecting the hernia sac in 5
patients (16.23%), hypercapnia with subcutaneous emphysema in 5 patients (19.23%), persistence of a large pre-hernia lipoma after reduction
of the sac in 4 patients (15.38%), pneumoperitoneum in 2 patients (7.69%), the introduction of
the trocar directly intra-abdominal in 1 patient
(3.84%), a technical problem in 1 patient (3.84%),
and difculty to unfold the mesh in 1 patient
(3.84%). The types of mesh used in patients operated only under laparoscopy were Parietex in 2
patients (9.9%), Mersilene in 5 patients (22.72%),
14 Hernia Surgery inAfrica
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137
Prolene in 14 patients (63.63%), and Hi-tec in 1
patient (4.54%). The size of the prostheses is on
average 15/14cm (range 12/10–17/15 for unilateral hernias and 15.5/29 for bilateral hernias).
The suture xation with slow resorbable wire
knots for ve patients (one Hi-tec and four
Mersilene prostheses) and tack xation for the
other three meshes: two Parietex and one
Mersilene. One patient out of the 22 completed
under laparoscopy had drainage. Of the 26
patients requiring conversion, 15 patients underwent mesh implantation: 13 according to the
Stoppa procedure by Pfannenstiel incision, 1
according to the Rives technique, and 1 by the
Lichtenstein technique. Eleven patients had a
Shouldice operation. The operative complication
rate was 0%. Postoperatively the migration of an
unattached mesh was seen in one patient. The latter was operated again on a postoperative day 3
by the same approach with replacing the mesh
with good outcome. There were no complications
in all the other patients, treated entirely by laparoscopy and converts. There was not any postoperative death. The average hospital stay was
3.54 days (range, 2–7 days). At the outpatient
surveillance, two patients had scrotal edema
(9.09%) that responded perfectly to anti-inammatory treatment and two others (9.09%) showed
an induration of the inguinal region which disappeared at the following control without treatment. One patient had moderate pain at the groin
that responded perfectly to anti-inammatory
treatment. The follow-up was nil for 4/22 patients
(18.18%); however, the remaining 18 patients
(81.81%) had a follow-up average of 5months
and 21 days (range 6 days–38.5 months). No
patient in our study showed recurrence.
Endoscopic inguinal herniorrhaphy has become
an established approach to groin hernia. The use
of a totally extraperitoneal (TEP) approach
allows a tension-free, preperitoneal approach
with potentially less discomfort and morbidity
than to classic repairs. Concerns have been raised
regarding excessive cost, need for general anesthesia, and an extensive learning curve for the
surgeon. The need for a long and difcult learning of this technique is at the origin of a high conversion rate observed during the rst ten
interventions. Some reports have listed specic
indications for laparoscopy over open repair,
including recurrent hernias, bilateral hernias, and
the need for earlier return to full activities.
Although the actual hospital costs of laparoscopic repairs are higher than those of open
repairs, the increased cost may be offset by the
societal benets of earlier return to full
activities.
Prof. Obama, surgeon from Equatorial Guinea,
already a Minister of State for Health in his country, conrms that, according to statistics updated
to 2016, upon 7800 operations in Equatorial
Guinea, e.g., Spanish colony, with a population
of 1,222,442 inhabitants on a surface of
28,051km, the abdominal wall hernia is one of
the rst and most common conditions for surgery
in Equatorial Guinea; the hernia repair represents
more than 45% of all surgery performed at
national level. The surgeons observed all varieties of hernia, but the most frequent type is the
inguinal.
More than 90% of hernia repair practiced at
national level is performed through the open
method and approximately 5% of repair they
used is mesh. The most frequent technic used is
the Lichtenstein.
In 2016 only 57 laparoscopic hernia repairs
were performed, and all were done by foreign
medical staff.
In Qatar, part of the Middle East and thus participating in AMEHS, Prof. M. El Akkad
describes the work on the hernia pathology at the
Al Wakra Hospital which is a Hamad Medical
Corporation hospital opened in December 2012.
Prof. El Akkad describes:
We started during the rst year doing routine
hernia surgery with repair of inguinal hernia
using Lichtenstein repair with prolene mesh and
laparoscopic TAPP. For ventral hernia we were
doing only anatomical closure and on lay prolene
mesh. After one year we decided to develop the
hernia service with dedicated team and we started
doing laparoscopic TAPP and UHS for open
inguinal hernia, where TAPP was standard and
open are done due to contraindication to lap or
patient preference. For Ventral hernia we shifted
mainly to lap repair with high or ultra-light
138
F. Abi et al.
meshes. Our rate jumped to 250 cases per year.
Then it applied for accreditation by SRC as a
center of excellence for hernia. As cases increased
we started to deal with ventral hernias differently.
We started doing anterior and position component separation. We did lot of TAR and Carbonelli
repair for large abdominal defects. We were using
different kinds of meshes but mainly light weight.
In 2015 we were accredited as center of excellence and it was the rst and only one in the
Middle East. This increased our work load from
referrals from other centers and growth of our
hospital. We reached 450 that year. In 2016 we
had the Davinci Robot and we started our robotic
assisted hernia repair. We started with inguinal
and then moved to ventral and divarication of
recti. Laparoscopic hernias are now done robotic
using Davinci. We have done now 110 cases
robotic assisted. All through the development we
sought help and advice by travelling to hernia
centers in Europe or inviting experts to come and
work with us on regular intervals. So now we
exceeded 750 cases per year. Our practice now
includes (1) Robotic assisted repair of all inguinal hernia and ventral hernia with small to moderate defect for which we close the defect and
apply mesh with suturing all around with no clipping; (2) Carbonelli on TAR in large abdominal
defects with light weight mesh applied; (3) We
did a lot of rare hernia that present every now and
then like lumbar hernia, Spegillian hernia all by
lap or robotic. We did apply biological mesh for
4 cases. One of them was a case presented in the
last Tokyo conference. The patient presented to
us with recurrent brosarcoma in his rectus abdomen muscle. He already did the left one before.
So we resected his Rectus muscle, he was left
with no recti and big defect which we closed with
biological mesh and reinforced by another light
weight mesh. We followed him for 3 years now
and no recurrence. The meshes we are using are:
Prolene, UHS, PVP, Ultrapro, Progrip.
In the end in Iraq, a country tormented by a
27-year-long war, Prof. Moosa explains that hernia is a common surgical disease. It affects both
gender and all age groups (even if it is more in
third and fourth decades). In a study done by
Moosa in 2015, inguinal hernia forms the majority of cases, and it forms about 65% of all hernia
patients when it affects male more than female,
followed by incisional hernia and then umbilical
hernia which affect female more than male in
both types. Incisional hernia is more in female
following mainly Caesarian section and hysterectomy operations, while it is lower in male in spite
of war injuries in Iraq which affect male soldiers
because Iraqi surgeons built up great experience
in trauma and war surgery. All types of surgery
are done according to the type of hernia, the
experience of surgeon, and the circumstances of
hospital; in spite of that, open surgery is done
more than laparoscopic surgery because of short
resources.
Humanitarian Hernia Surgery:
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Lessons Learned
AlexanderD.Schroeder andCharlesJ.Filipi
15
15.1 Introduction
Almost 10 years ago, Dr. Paul Farmer identied
surgery as the “neglected stepchild of global
health” [1]. This is attributed to communicable diseases dominating global health initiatives.
However, approximately two billion people lack
access to essential surgical care. The impact of
such care in low-income countries (LICs) and lowmiddle-income countries (LMICs) can be estimated
in avertable mortalities and disability-adjusted life
years (DALYs). Providing basic surgical care at the
district hospital level (50–250 beds) is cost-effective and could prevent up to 1.4million deaths and
77.2million DALYs per year [2].
An increasing number of short-term surgical
missions have identied specic challenges.
These include adequate outcomes, appropriate
patient follow-up, a shortage of skilled local staff,
and patient access. In high-income countries
(HICs), elective inguinal hernia repair is considered a basic surgical procedure with low morbidity (0.02–4.5%) and mortality rates (0–0.1%)
[3–5]. However, there have been reports of unacceptable mortality rates in LICs, up to 100 times
higher than in HICs [6, 7]. In the following, the
authors describe lessons learned from service and
training mission trips addressing the inguinal
A. D. Schroeder, M.D. · C. J. Filipi, M.D. (*)
Creighton University School of Medicine,
Omaha, NE, USA
e-mail: alexanderschroeder@creighton.edu
hernia burden of disease and the ability to achieve
HIC results in austere environments.
15.2 Service Missions
15.2.1 Surgeon Selection
To obtain HIC surgical results, successful global
surgical outreach requires recruitment of competent surgeons. There is no universally accepted
denition of surgical competency [8]. Several
tools are available to measure technical competency [9, 10], but there is no objective way to mea-
sure improvisation, communication, leadership,
technical, and teaching skills in the surgical arena.
Additionally, surgeons operating in LMICs are
often confronted with more complicated inguinal
hernias and a higher risk for complication [11]. In
order to produce surgical outcomes comparable
with those in HICs, expert hernia surgeons were
recruited. Our organization has had the good fortune to have access to these experts.
Surgeon leaders of the American Hernia
Society (AHS) and European Hernia Society
(EHS) came as volunteers to the Institute of Latin
American Concern (ILAC) center in Santiago,
Dominican Republic. There, they operated upon
hernia patients for a week, each performing 30–40
operations, and were directly observed for operative technique, leadership, fund of knowledge,
adherence to the organizational mission, and
overall results to determine who was qualied to
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_15
139
140
train the Lichtenstein repair (our standard operation for training) and lead future hernia teams. Of
our nine trainers, four directly and one indirectly
mentored under Dr. Parviz Amid, the surgeon that
popularized the Lichtenstein repair. It has been
demonstrated that deliberate practice and acquisition of expert performance are related to “focused
improvement with immediate feedback, time for
problem solving and evaluation, and repeated performance to rene behavior” [12]. The opportunity to work with true experts and their willingness
to serve the poor plus the catalyzing political and
logistic inuence of past AHS presidents have
been paramount factors for good patient outcomes. Table15.1 lists many of the surgeons that
served patients and trained surgeons. The Hernia
Repair for the Underserved training surgeons are
shown in Figs.15.1, 15.2, 15.3, 15.4, 15.5, 15.6,
15.7, 15.8 and 15.9.
Table 15.1 Surgeons participating in HRFU missions
Surgeons Country Trainer No. of trips
Carl Boyd US 2
Kevin Buckley US 5
Giampiero Campanelli Italy X 13
Marta Cavalli Italy 12
David Chen US X 8
Robert Cusick US X 14
Robert Fitzgibbons US X 6
Colleen Fitzpatrick US 1
Jarrod Kaufmann US 5
Steven Kern US 1
Oliver Lao US 1
Tommy Lee US 2
Antoine Lout Canada 1
Brent Matthews US X 1
Dwijen Misra US X 4
John Murphy US 2
David Partrick US 4
Steve Raynor US 2
Mark Reiner US 3
Wolfgang Reinpold Germany X 13
Sergio Roll Brazil X 4
Michael Schroeder Germany X 2
Kelly Shine US 1
Lutz Steinmueller Germany 1
Erwin van Geffen US 2
Rob Weinsheimer US 4
Marvin Wexler Canada 4
A. D. Schroeder and C. J. Filipi
Fig. 15.1 Dr. Giampiero Campanelli
Fig. 15.2 Dr. David Chen
Fig. 15.3 Dr. Robert Cusick
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Fig. 15.4 Dr. Robert Fitzgibbons
141
Fig. 15.7 Dr. Wolfgang Reinpold
Fig. 15.5 Dr. Brent Matthews
Fig. 15.6 Dr. Dwijen Misra
Fig. 15.8 Dr. Sergio Roll
Fig. 15.9 Dr. Michael Schroeder
142
Fig. 15.10 Barb Elliott RN
15.2.2 Sta Selection
Volunteers want to go on hernia trips some for the
adventure and novelty, but it is important to select
nurses that are devoted to quality care and have
leadership ability. One such nurse is Barb Elliott
pictured in Fig.15.10. After our rst service trip,
she assumed a leadership role organizing equipment, soliciting in-kind donations, seeking staff
volunteers, and arranging matching grants for
nurse and surgical technician airfare—she ran the
mission. A true charge nurse is invaluable, and
for 15 years she has maintained her passion to
serve the poor in every way possible including
personal and nancial sacrice. Find a Barb
Elliott and your team will prosper.
15.3 Surgical Technique
andEquipment Used
Numerous suture and mesh techniques for inguinal hernia repair have been described. Tensionfree mesh repair as described by Dr. Lichtenstein
and Dr. Amid is the widely accepted treatment for
A. D. Schroeder and C. J. Filipi
inguinal hernia in HICs [3, 13]. Compared to
suture repairs, tension-free mesh repair signicantly decreases recurrence rates. However, in
many LICs and LMICs, surgeons perform only
suture repairs due to the high cost of mesh. Hernia
Repair for the Undeserved aims to provide surgical care to poor patients without any compromise
in outcomes. Therefore, we chose to utilize the
Lichtenstein—Amid technique for service and
training missions. We have been able to obtain an
abundant supply of donated commercial mesh
from industry. Ultimately, we expect market evolution to lower the cost of commercial mesh due
to competition from in-country manufacturers.
Other surgical outreach initiatives have
described the use of mosquito netting for inguinal
hernia repair [14]. A recent randomized controlled
trial by Loefgren etal. demonstrated similar complication and recurrence rates at 1-year follow-up,
when comparing sterilized mosquito mesh to commercial mesh for inguinal hernia repair [15].
However, the authors reported one postoperative
death in the low-cost mesh group due to unclear
causes, and during further follow-up, there was
another death in the low-cost mesh group and
three deaths in the commercial mesh group. It
remains our contention that proven standardized
operative techniques, expert surgeons and anesthesiologists, and uncompromising quality of equipment are essential for good outcomes in developing
countries. Polypropylene mesh is easier to sterilize
and manufacture than polyethylene mesh and
should remain the standard of care until there is
more compelling long-term evidence to the contrary. Low-cost innovative solutions to health care
remain critical, and therefore, further randomized
controlled studies with long-term follow-up are
encouraged.
15.3.1 Procedures toClosely Monitor
intheAustere Operating
Room Environment
Hydrocele is one of the most common comorbidities encountered during preoperative assessment
of inguinal hernia patients. Non-communicating
hydrocele, due to lymphatic lariasis (Wuchereria
bancrofti, a mosquito-borne worm), is endemic in
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143
Southeast Asia and Sub-Saharan Africa [11]. It is
also one of the most common urologic pathologies encountered in Haiti, comprising up to one
third of urologic procedures performed at the district hospital level [16]. The biological predilection of the adult larial worms to live and
reproduce in lymphatic channels of the scrotum
means that greater than 50% of infected men will,
with age, develop a chronic hydrocele. In
untrained hands, large hydroceles should be
avoided during inguinal hernia campaigns due to
infection rates of up to 60% and overall high
recurrence rates [17]. Beard etal. point out that in
some cases simple hydrocelectomy is contraindicated, and reconstructive surgery is necessary
[11]. Specic procedures for large hydroceles
condition are followed by our organization.
15.3.2 HRFU Hydrocele Protocol
andGuidelines [11, 18, 19]
Aspiration is generally unsuccessful due to rapid
uid re-accumulation. Indications for surgical
management are pain, disturbing size, and sensation of heaviness. Surgical repair should not be
performed in infants under age 2, but for older
patients a persistent hydrocele suggests a concomitant inguinal hernia, and repair should be
considered.
The surgical repair appropriate for most
hydroceles is the Lord’s technique. An incision is
made in the scrotum lateral to the median raphae.
The dartos fascia is divided until the hydrocele
sac (tunica vaginalis) is identied. The sac is
bluntly dissected free of surrounding tissue and
delivered through the incision, if possible. A
small incision is then made to drain the uid. The
sac is opened proximally, everted around the testicle and spermatic cord, and the cut edges are
sutured with a running locking closely spaced for
hemostasis, absorbable suture. Care must be
taken to ensure that the testicle is not twisted
prior to placing it back in the scrotum. A pexy
suture should be placed from the testicle to the
scrotal wall to maintain its anatomical position.
For hydroceles with large dissection beds, a drain
may be left in place. A variation on this procedure
involves subtotal excision of the sac. This technique is gaining favor in treating larial hydrocele due to its associated lower recurrence rate.
Complication rates after hydrocelectomy are
as high as 20%, even in HICs. The complications
include hydrocele recurrence, hematoma, infection, and testicular infarction. Repair of larial
hydrocele may have complication rates up to
30%, because the scrotal skin and lymphatics are
damaged by the parasitic infection, leading to
increased inammation in the operative eld and
poor wound healing.
Guidelines
• All patients are examined by the operating
surgeon prior to entering the operating room.
• A presumptive diagnosis of hydrocele man-
dates transillumination during the preopera-
tive assessment.
• The groin and scrotum must be prepped thor-
oughly—i.e., all folds should be attened
when prepped, and the prep should include the
contralateral scrotal side and the penis. A ster-
ile towel is placed under the scrotum/over
both thighs, and the operative site is carefully
draped with towel clips used to secure them,
as the towels often move and expose the
unprepared skin.
• Extra consideration is warranted for any mas-
sive hydrocele, hematocele, acute hydrocele,
or suspected lymphatic lariasis hydrocele. If
hospital admission or signicant postopera-
tive care is expected, the patient should be
referred to a tertiary care center.
• The decision to operate on a larger compli-
cated hydrocele should depend on surgeon
experience and the local surgeons’ postopera-
tive availability and ability to manage
complications.
• Preoperative intravenous antibiotics are
administered for large hydrocele patients.
• Postoperative care
– A sterile dressing should be maintained
over the external portion of the drain if
used. If the patient is unlikely to be compliant or lives in a very disadvantaged
circumstance, they should be kept in the
hospital overnight.
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