operative steps - eversion of sac and circumcision

1. OPERATIVES #02
EVERSION OF SAC
CIRCUMCISION
BY:
DR. MOHAMMAD MASOOM PARWEZ
ACADEMIC RESIDENT,
GENERAL SURGERY, AIIMS BHOPAL

2. EVERSION OF SAC

3. Introduction
Hydrocele is collection of fluid between the parietal and visceral layers of tunica vaginalis sac
Depending upon the cause, Two types: primary and secondary
Primary hydrocele: idiopathic; due to defective absorption of secreted fluid or defective
lymphatic drainage
Secondary hydrocele: testicular etiology / epididymal origin (epididymo-orchitis, tumor, torsion,
trauma)

4. Types of hydrocele
 Congenital/communicating: patent processus
vaginalis
 Funicular: deep inguinal ring to upper pole of testis
 Infantile: extends from tunica vaginalis upto the
inguinal canal but not beyond the deep inguinal ring
 Encysted hydrocele of cord: fluid in intermediate
segment of processus vaginalis
 Vaginal hydrocele: fluid in tunica vaginalis in scrotum
 Bilocular/Hydrocele en bisac: prolongation of tunica
vaginalis sac into the inguinal canal; cross fluctuation
+ve
 Hydrocele of hernial sac: fluid in distal part of hernial
sac

5. Operative procedure
Antiseptic dressing and draping
Anesthesia: operation is done under local anesthesia.
The spermatic cord is infiltrated with 2% lignocaine hydrochloride. The scrotal skin along the line
of incision is also infiltrated
Skin incision: A vertical incision parallel to the median raphe of the scrotum
Incising the layers of scrotum: Incision deepened to cut the dartos muscle, scrotal fascia and to
expose the hydrocele sac lined by the parietal layer of the tunica vaginalis

6. Operative procedure
Incising the parietal layer of tunica vaginalis: sac is separated from the dartos muscle layer by
finger dissection
Stab incision is made over the tunica vaginalis in an avascular area anteriorly, away from the
cord, testis and epididymis
Straw colored fluid is drained in a kidney tray
This incision is then extended and testis is delivered out of the sac
Eversion of sac: The cut margin of sac is everted around the testis
Suturing the cut margins of tunica vaginalis: stitched behined the testis with 1-0 chromic catgut
sutures

7. Operative procedure
Hemostasis is secured and the testis with the
everted sac placed back into the scrotal sac
Closure: dartos muscle stitched with 1-0
continuous chromic catgut sutures
Skin is sutured with interrupted monofilament
polyamide suture
Coconut bandage is then applied

8. Complications of hydrocele
If untreated:
Infection- pyocele
Trauma- hematocele
Atrophy of testis
Rupture
Calcification of sac
Hernia of the sac

9. CIRCUMCISION

10. INDICATIONS
Congenital phimosis
Acquired phimosis: lichen sclerosus, recurrent balanoposthitis
Religious and cultural reasons
Circumcision has now been shown to be an effective measure for reducing the incidence of HIV
infection

11. Preputial adhesions v/s Phimosis
In the infant the foreskin does not retract due to physiological glanulo-preputial adhesions
In the young child, a non-retractile foreskin may be due either to a phimosis or persistence of
these adhesions
Congenital adhesions usually separate spontaneously in the absence of infection, and a
circumcision is not required

12. Anaesthesia
GA preferable in children, LA (penile ring block)/regional anaesthesia (caudal/subpubic block)
Never use adrenaline
Penile ring block: dose according to patient’s body weight. Good bolus injection just under
pubic symphysis to block dorsal nerves, further drugs around base of the penis in a ring

13. Operative procedure
1. Retract the foreskin to clean the glans, place an artery through the preputial opening and
open to widen it, for severe phimosis
2. Tight bands can be incised with tissue scissors
3. Define the coronal margin. Antiseptic wash to thoroughly clean the glans and remove
inspissated smegma
4. Replace the foreskin
5. Apply 2 hemostats in the midline on the dorsal aspect of foreskin and divide the tissue in
between with scissors. Take care not to injure the glans with the inner blade
6. Continue this incision until about 0.5cm short of corona, leaving a cuff of tissue just around
the corona

14. (A) application of
artery forceps
(B) the
dorsal slit
(C) dorsal slit completed;

15. Operative procedure
7. Cut laterally around the base of the glans creating an even cuff of tissue all the way round to
the frenulum on one side and then the other
8. Use bipolar diathermy to achieve hemostasis. The small artery of the frenulum may need to
be tied
9. Reconstruct the frenulum with a fine absorbable suture. Place the second suture on the
dorsal side in the midline (stay sutures)
10. Two layers of the foreskin can be opposed with fine absorbable interrupted sutures

16. (D) resection of prepuce (E) reconstruction of frenulum (F) the completed circumcision.

17. Complications
Early:
Bleeding
Pain
Infection
Chordee
Glanular necrosis and amputation

18. Complications
Late:
Epidermal inclusion cyst
Suture sinus tracts
Redudant foreskin
Penile adhesions
Meatal stenosis
Urethrocutaneous fistula

19. Thank you