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  • 1. Right Incision
  • 2. Entry into Sac and Primary Drainage
  • 3. Mobilize and Externalize Sac
  • 4. Excise Sac
  • 5. Right Closure
  • 6. Left Incision
  • 7. Entry into Contralateral Sac and Primary Drainage
  • 8. Mobilize and Externalize Sac
  • 9. Excise Sac
  • 10. Left Closure
  • 11. Removal of Subdermal Implants
  • 12. Post-Op Remarks
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Bilateral Simple Hydrocelectomy and Removal of Subdermal Implants


Domingo Alvear, MD1; Lissa Henson, MD2; Jaymie Ang Henry, MD, MPH3

1World Surgical Foundation
2Philippine Society of Pediatric Surgeons
3Florida Atlantic University, G4 Alliance



Yeah. Small. Yeah. Like that. Good. A little bit more, if you want.


Okay. Use the cautery. Just go in with the cautery. And then I'll wait for the splash.

Get the suction ready. Okay. Go ahead.

Just stretch it with a hemostat or something. Make the opening bigger.

It's flooding.

Okay, hemostat.

Pick up the sac.



Push all this with the forceps. Peel it off. Yeah.

Suction. Okay, go ahead. Just peel it off.

You can cauterize all these little vessels when you see them.

Yeah, go ahead.

Here comes the baby.

Okay. Alright, good. Peel off all this gubernaculum. Yeah. Thinned out, yeah. Yeah, we'll excise most of it - of the sac.

You're almost done.


Okay. So you can open the sac. Cauterize it.


Even have compartments in this hydrocele. See? There's a hydrous compartment. It's almost like a cystic hygroma. Yeah. Go ahead, open the compartment. It's multiloculated. So I guess we have to - we didn't communicate with the - tunica, see? It's all different. We'll excise it. Go ahead.

Divide it here. Cauterizing.

Now we can see the testicle, okay.

Yeah, this compartment is - poke it.

Remove it here.

Yeah. Remove that.

Another compartment.

Yeah, we can save that.

Just pop that one, we don't have to take it out. Epididymal cyst or something. That's still part of it. Just poke it.

You can have that.

Okay. This one you remove, and we're all set. There's nothing in there.

That's not part of his testicles, so take it out. Good.


Okay, just put a couple stitches here with a Vicryl. Stitch it. Put that together. And evert.

What we're doing is we're doing a - what they call a bottle procedure, so it’s a - to prevent everting the lining so that the fluid will go in the tissue and it'll be absorbed. It won't reaccumulate.

Okay, tie it. You don't need any more.

There's one bleeding over here. Okay, get cautery. Get this bleeder.

Yep. Looks like we're good. How about that? That edge.

Okay. Put it back in its house and close it.

A bleeder?

You can put your whole - It's there now?


Yeah. Okay. Okay, close it.

Yeah. Maybe that one layer, yeah.

Do the skin.

I find that this incision - less scarring, because if you do the oblique, they somehow scar. Especially dark people. This is a much better incision. They don't scar as much. Yeah, it won't be visible. Yeah. Correct.

This one of the few surgeons who - who uses the needle holder properly. She uses the - the handle of the needle holder, puts her fingers inside rather than palm it, like - a lot of people palm the needle holder. Yeah. They palm it. And this is one of the few to use it properly. She does another thing, another pointer - see, she uses it with her fingers inside the needle holder. That's the way I do it. That's the way it was designed to be, actually. Because the instrument's supposed to be an extension of your fingertips.

So hopefully, she can - Okay. Next one.



Okay. Cauterize.


Okay. Pick it up.





Oh, good. Another compartment.

Yeah, that's testicle there. Yeah.


It was just one compartment when we went in. There's a lot of - multiple cysts.

Okay, there's the tunica.

Here, open this. Yeah. There it is. That where you want to be?

Actually, you can just evert this thing. You can just evert it.

Excise part of it. Open it.

Yeah. Let go of that.

Just sew them. Yeah. Just sew it together. Suture.


Here. To there. That's it. Tie it.

This one cyst, we're going to just puncture. Now pop the cyst. That's it.

Put it back.

There. Going back to his house.

What a difference! Now you can see tickler better.

And a tickler. We didn't - they didn't put that in the diagnosis.

Yeah, removal of foreign body.

Well, we all heard it.

I didn't hear it.

So now, how are we going to take this tickler out? It should just pull out, right? Just take one end and just like that.

It just seems like there are multiple -


Yeah, so, maybe one broke off. Yeah. It looks like this one broke off.

We'll just cut it here, and then we'll remove the foreign body.

Yeah. Make an incision there. Yeah. Get a hemostat in. Try to get the tickler out.

Yeah. Cauterize.

Yeah, it's silicone. Look, a silicone tickler.


There. It's coming out. Like a snake.

Yeah, you just get a cautery. You cauterize it. The adhesions. And just keep pulling it.

Ah, there it comes. Woo!

Go ahead, cauterize that.

Yeah. There.

The beads. The beads of life. How many kids did he have?

Almost got it, there.

Yeah. It slipped.

You got it in the opening. You got an opening.

This is going to bother him more than the operation.

Okay, got you - got you! Okay. This one is harder. That's the one that tickles.

Okay. There's the other one. Now we have to get the other tickler. Oh, the other one came already. So this is the other one. Can we get it through the same hole? No. I doubt it. I think you have to make another incision.

Yeah. Either way.

Yeah. There it comes. Come right out.

He's very interesting.

Put an interrupted stitch, whatever's left.

Interesting. I've never seen it before.

Okay. That's it. Good job.

You can't even see our incisions. Yeah.

You can't even see them, no?

Yeah. It's invisible.

Invisible. Very nice.



This case was seen and they thought it was a hernia, but it turned out to be a hydrocele, both from the physical exam with a light, it transilluminates when we put a light on, and then also the ultrasound made the diagnosis of a hydrocele rather than a hernia. And we also have a foreign body on his penis, which is a silicone that he used while he was still - active sexually, I guess.

And so what we did was, we made an incision - we made an incision above the scrotum, rather than a groin incision, which is painful - we just made it above the scrotum and then pick up the sac, the hydrocele sac, peel it off from the gubernaculum, excise it, and then we everted it behind the testicle. That will prevent reaccumulation of fluid and prevent recurrence of hydrocele. And then after that, we close it. As you can see, it's closed. And it was a bilateral, which means both sides, hydrocele. And this was - the larger one was on the right side.

Okay. Thank you.