VOLUME 28

1958-1959

THE AUSTRALIAN AND NEW ZEALAND

JOURNAL OF SURGERY

Published for the Royal Australasian College of Surgeons

EDITORIAL COMMITTEE: DOUGLAS MILLER, Chairman K: F. RUSSELL, Editor F. D. STEPHENS, Editorial Secretary J. LOEWENTHAL J. W. F. MACKY R. H. ORTON A. ©. McEACHERN JULIAN SMITH H. G. WHEELER

CONTENTS

VOLUME 28 — 1958-59

AUGUST, 1958

The Pathogenesis and Treatment of Primary Hydroceles in Infancy and Childhood Douglas G. McKay, R. Fowler, Jnr., and J. S. Barnett

Thrombosis of the Internal Carotid Artery - John Connell

Carcinoma of the Supra-Aortic Part of the Thoracic Gunde C. S. Yeoh and Y. Cohen

Anatomical Vagaries of Double Ureters _ F. Douglas Stephens

Cervical Lymph Node Metastases from Epithelioma of the — Lips and Mouth Howard H. Eddey

The Bowel Sounds in Cases of Haematemesis and Melaena

G. W. Milton and G. J. A. Clunie

Paget’s Disease of the Nipple occurring in a Young Woman

P. R. Joyce and J. S. Lekias Edward A. Allcock Thomas H. Ackland

N.C. Tan

A. Distin Morgan

_ Rowan Webb

iia A. "McDonald and G. R. McLeish

Spontaneous Perforation of the Oesophagus Chronic Inflammatory Mastitis with Duct Ectasia Traumatic Rupture of the Lung

Anaesthetic Problems in Surgery of the ae we Hydatid Cyst of the Liver __ Cirsoid Aneurysm of the Pelvis ___ Books Reviewed

Book Received

NOVEMBER, 1958

Brief History of Peptic Ulcer Surgery - W. W. Woodward Some Recent Studies on the Physiology of Smooth Snel and the Mechanical Aspects of Gastro-Intestinal Function and some possible implications to Surgical Problems

G. W. Milton Douglas Cohen H. D. O’Brien Stephen Suggit

’ F, Ellis Kenneth R. Cox

A Simple Method for the Oxygenation of Heparinized Venous Blood

Fluothane -

The Surgery of steno ‘ , Closure of Tympanic Membrane Pestecsdinns Cholecystectomy for Acute Cholecystitis __ Fibrosarcoma of the Scrotum Daniel Lane

Percutaneous Prostatic Biopsy D. G. Macleish

Familial Intestinal Polyposis Associated with Further Sheniendins of Growth P. J. Kenny and J. O’Neill

Gall-stone Ileus _. J. J. McCarthy

Advanced Carcinoma of the Gente Uteri with este Beyond Five Years after Total Pelvic Exenteration with Colonic Substitute Bladder __. . Graham Godfrey

Books Reviewed

Page

18 27

A5 50 57 62

71 72 75 80

96 108 110 120 126 128 139 141

145 151

155 157

THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

FEBRUARY, 1959

Page Carcinoma Corporis Uteri __. ies ae A .. Barry Kneale 161 Sporadic Amoebiasis in Victoria _,. oe A. M. Cuthbertson and J. D. Tange 171

Gun for the Attachment of Clips to Small Vessels in Deep Pelvic Surgery D. Fairbanks, A. S. Manson and Graham Godfrey 180

Intact Extrusion of Hydatid Cysts __ nA 7 in _. W.W. Woodward 186

An Experimental Method for the Production of Mitral Incompetence Thomas S. Reeve and lan Monk 191

Pilonidal Sinus of the Axilla ‘eh —_ see a ale E. S. J. King 196 Fatal Complications following Colectomy _. sila ides _. E, S.R. Hughes 202 Thrombosis : poe ran idan = _. V.J. McGovern 215

Blood Volume Studies in _ Men T. S. Reeve, T. H. Oddie, Sheilah Bowman and F. F. Rundle 221

The Administration of Presuren oa ‘ied a oe sibs T. R. Morley 228

Traumatic Intraperitoneal Rupture of the Urinary Bladder = __ ..._ B. Hartley 233

Books Reviewed , - vas a = 238

Proceedings of the Royal Australasian College of Surgeons __. om sont —_ 21 MAY, 1959

Spinal Injuries — A Challenge i one sis oni ._... G. M. Bedbrook 245

The Relationship of Solar Radiation to Melanoblastoma V.J. McGovern and B. S. Mackie 257

Studies of Renal Transplantation in Sheep _.. _ an ot R. M. Mitchell 263 The Genetic Approach to Hereditary Congenital Ptosis __ ni _. B. K. Rank 274 Biceps Cineplasty for Forearm Amputees __. i = si J. T. Hueston 280

Small Bowel Obstruction following Abdomino-Perineal Excision of the Rectum

E. S. R. Hughes 286

Microdissection Study of Late Renal Disease _ = — . Thelma J. Baxter 290 The Diagnosis of Portal Hypertension -.. GG. Berci, E. A. Allcock and M. R. Ewing 301 Contraction in Wounds Made at Short Time Intervals __ .... A. M. Cuthbertson 309 A Modified Technique of Lower Limb Venography __ sn pe ... R. Paton 312 Traumatic Rupture of the Kidney in Christmas Disease __ .... Robert Shannon 316 Books Reviewed ais a wile — don il _ _— ines ... 319 Book Received — : . vas sii = wie ... 319

Proceedings of the Royal Seanietee College of ia es on i .. SD

The Australian and New Zealand JOURNAL OF SURGERY

AUGUST,

Vol. 28 —No. 1

1958

THE PATHOGENESIS AND TREATMENT OF PRIMARY HYDROCELES IN INFANCY AND CHILDHOOD

By Doucias G. McKay

Adelaide

AND

R. Fow.er, JNr., AND J. S. BARNETT

Surgical Research Unit, Royal Children’s Hospital, Melbourne

YDROCELES in infancy and childhood

may be divided into primary hydroceles and those which are secondary to disease of the testis or its adnexae. Primary hydroceles include, firstly, those of congenital origin in which a macroscopically obvious communica- tion with the peritoneal cavity allows free passage of peritoneal fluid into the hydrocele sac, and secondly, the so-called idiopathic hydroceles where no such cause for the fluid accumulation is obvious.

Idiopathic hydrocele is a relatively uncom- mon finding in adolescent or young adult males and yet is occurs with considerable frequency in the younger and older age groups. This curious incidence, which has excited little comment, is a reason for doubt- ing that the idiopathic hydrocele of elderly males has the same pathogenesis as that of idiopathic hydroceles in infancy and child- hood.

Nevertheless the several empiric methods of surgical treatment of the adult condition have been variously and indiscriminately applied to hydroceles in children. These orthodox methods include total excision, partial ex- cision and eversion, or eversion only of the vaginal sac — Jaboulay’s operation. Any of these procedures may be followed by such troublesome sequelae as haemorrhage, in- duration, infection or recurrence, while in

children there is the added risk that extensive procedures in the neighbourhood of the testis may damage its blood supply or the vas deferens. For these reasons it was felt that further attention should be paid to the patho- genesis and surgical treatment of hydroceles in children.

This paper reports our experience of a method of surgical treatment which avoids or minimises such troublesome complications. It ignores altogether the hydrocele sac and strikes directly at the source of the fluid. This method, we believe, has not previously been advocated and has a rational basis in our concept, elaborated in this paper, of the mechanism of origin of childhood hydroceles.

RATIONALE OF RECOMMENDED TREATMENT

The view is put forward here that all primary hydroceles of infancy and childhood have resulted from a persistent patency of the processus vaginalis — not from some abnor- mality of the tunica vaginalis as is more often supposed.

It is logical, therefore, that in preference to those orthodox manoeuvres directed to the hydrocele sac itself, we should recommend as the treatment of choice a simpler procedure directed to the processus vaginalis alone. Permanent cure will result merely from the severance of an obviously patent funicular

2 THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY

process or from division of that strand of tissue running from the peritoneum to the hydrocele, even though no lumen may be demonstrable within it at the time of opera- tion.

The evidence to be presented from this study attests not only the success in practice of the method we advocate but also the validity of the hypothesis on which it is rationally based.

MATERIAL AND METHODS

The above thesis has been preached and practised in Adelaide by one of us (D.G.M.) for the past ten years, and is based upon his personal experience and observation of more than 50 cases so treated without any known recurrence.

For the critical appraisal of these teachings we have undertaken at the Royal Children’s Hospital, Melbourne, since 1955, an elective study of childhood hydrocele and its treat- ment by this simple technique. This study has included observations on the nature, for- mation and reabsorption of hydrocele fluid; the surgical anatomy of the hydrocele sacs; the phenomenon of spontaneous cure; recur- rence after orthodox surgical procedures; and the results of operation by the Adelaide method. The observations made on 58 children with 62* hydroceles supported the foregoing views on the pathogenesis and correct surgical treatment of this condition. Accordingly, these views are now based on the combined Melbourne and Adelaide ex- perience of more than 100 cases. Hereafter, unless otherwise stated the figures quoted in this paper refer to the Melbourne series.

Included in the Melbourne and Adelaide series were 6 recurrences following orthodox surgery which were successfully treated by this simplified method.

The relative infrequency of secondary hydroceles in children can be gauged by the fact that we only encountered one such case during the two years in which this study was in progress.

*Two hydroceles were no longer present at the time of operation so that only 60 hydroceles are represented in the diagrams (Figs. I and II).

EVIDENCE IN SUPPORT OF THE CONGENITAL HyporuHeEsIs

1. Clinical features (a) Right-sided preponderance

The right-sided preponderance typical of childhood hernia and undescended testes (Gross, 1953), is also a feature of hydrocele. Out of 62 hydroceles in this present series 38 were on the right, 16 on the left, and 4 were bilateral; right undescended testes were asso- ciated with two of the bilateral cases and a left undescended testis accompanied one of the left-sided hydroceles. These facts point to a kindred aetiology and suggest that hydro- cele has its genesis in some anomaly of development and closure of the processus vaginalis testis. (b) Postural variation in size

The story was often elicited that the swell- ing, although never completely disappearing, varied in size and was largest towards the end of the day. This is just what would be expected if gravity and any rise in intra- abdominal pressure were helping to fill the tunica vaginalis with peritoneal fluid by way of some communication with the abdominal cavity.

The initial observation leading to the con- genital concept of hydrocele was that in a number of boys seen by one of us (D.G.M.) with the history that an irreducible hydrocele had been aspirated, the swelling had recurred within twenty-four hours. It seemed likely from so rapid a recurrence that these hydro- celes had some communication with the peri- toneal cavity.

(d) Recurrence after operation

The next observation was that recurrence of a hydrocele in childhood could follow orthodox surgical procedures confined to the tunica vaginalis testis. Presumably in such cases a portion of the tunica containing the lower end of a patent funicular process had been left behind. In the ensuing months a new sac formed and likewise became filled with fluid from the peritoneal cavity. When sought for, this patent funicular process could be demonstrated at subsequent opera- tion and its excision resulted in permanent cure,

Se we

oe aes.

THE PATHOGENESIS AND TREATMENT OF PRIMARY HyYDROCELES a

The 6 recurrent hydroceles in this series had all reappeared within twelve months or less from the first operation and were all found to have a patent funicular process not dealt with on that occasion.

However, the usual success of the excision or Jaboulay types of opera- tion should not be wondered at, since in a majority of cases the patent processus will probably have been obliterated in one way or another; this may result from the inflam- matory response to surgical trauma or the unwitting division of the processus by some surgeons: other surgeons intentionally divide the processus by routinely combining hernictomy with an orthodox hydro- cele operation (Gross, 1953), but the latter procedure is thereby rendered unnecessary.

2. Surigcal anatomy (a) Morphological types

The anatomical varieties of hydro- cele sac and their incidence as re- corded in this series are shown in Figs. I and II. It is not suggested that this display exhausts the pos- sible permutations or combinations of sacs and patent funicular pro- cesses, nor is it intended as a basis for erecting any new form of clas- sification. Their variety, however, does serve to show the futility of attempting to classify hydrocele sacs according to the confusing and com- plex nomenclature that has _be- wildered generations of students in

the past (Fig. III). FIG.

between these sacs was demonstrable. From two of tnese macroscopically non-communicat- ing cases the adjacent sac walls were excised and _ sectioned serially (at 15, thickness, mounting and staining every fifth section with

NON-COMMUNICATING HYDROCELES

aye

No. of Cases: 1

Saccular morphology of 12 non-commuricating

hydroceles: (e) represents the “inner sleeve’ arrangement

described in the text and (f) a similar arrangement in which omentum had become invaginated into the lumen of the inner

We have chosen, solely for con- venience in presentation, to divide the cases into non-communicating and communicating hydroceles, but we do not believe there is any funda- mental difference in the pathogenesis of these two types.

of a

In the first category there were 12 cases in which an extensive hernial sac was present (Fig. I), 10 of which shared a common wall with the hydrocele sac, but no communication

sleeve to form yet another sleeve; (g) was the only example loculated sac encountered; in (i) there was a small blind “daughter sac” arising from the common wall of the hernial and proximal hydrocele sacs; (j) was the only case of abdomino-scrotal hydrocele encountered. The testis was undescended and lay in the inguinal canal. The hernial sac and the upper extent of the hydrocele sac passed upwards in the pro-peritoneal plane for a distance of approximately 2”

above the internal ring.

haematoxylin and eosin). These sections likewise failed to show any communication between the sacs. It must be emphasized, however, that in all the cases studied, whether

4 THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

communicating or non-communicating, a patency of at least the proximal part of the processus vaginalis was present.

the peritoneal cavity. In the second group. a small funnel-like hernial sac was present at the upper limit of this processus. In the third

COMMUNICATING HYDROCELES

Type I without

Typell

associated hernial sac. with short hernial sac.

No. of Cases: 8 2

bu bei

Type Il

with long hernial sac

Weboes

FIG. Il Saccular morphology of 48 communicating hydroceles grouped according to the presence and extent of associated hernial sacs. The distal sac in Type If (d) was obliterated. Type III (a) is virtually a total funicular hernial sac, but these cases presented clinically as hydroceles, and the calibre of their lumen was judged to be too small at the time of operation to admit bowel or omentum. The calibre of the other patent processes is shown, for clarity, to be much wider in proportion to the hydroceles than was

the case at operation.

In 48 cases, by careful dissection, a com- munication between the hydrocele and _peri- toneal sacs was displayed, although in many of these the patent processus was so fine that it would have escaped a mere casual in- spection of the cord for a hernial sac. The mechanism of fluid entry into the hydrocele sacs could therefore be readily accounted for in these 48 cases.

Broadly speaking, the communicating cases could be grouped into three representative types although there were all manner of variations and gradations between these types (Fig. 11). Firstly, there were those in which no hernial sac was present hut a fine patent processus vaginalis joined the hydrocele with

group, there was a rather extensive hernial sac extending for most of the length of the inguinal canal or beyond to communicate by a short, though very fine, processus with the hydroceie sac.

(b) Valvular arrangement

One important point in the surgical anatomy of these hydroceles was that the patent processus often entered the distal vaginal sac below its apex, so as to create a valvular effect (Fig. IV). It is easy to see how this valve would be shut by the firm external pressure of attempted reduction but could permit slow partial emptying of the sac when a recumbent posture was assumed. This arrangement would likewise seem to

THE PATHOGENESIS AND TREATMENT OF PRIMARY HyYDROCELES 5

favour a tendency to spontaneous obliteration at this junction, especially since the valvular effect was often heightened by a dense fascial web binding the processus to the side wall of the sac (Fig. IV).

would often lead to escape of fluid from its proximal end, indicating its communication with the peritoneal cavity. Microscopic sec- tion of these strands anywhere along their length revealed a lumen. It seems probable

HYDROCELES (after LEE M°GREGOR)

hagma/ Congenital Infantile Encysted Mya. of cord

HERNIAS (after LEE MSGREGOR)

L8Y

Funicu/ar

/nfant ile Lncysted

HYDROCELES (after BAILEY and LOVE )

Sus

Vaginal Congenital Infantile Encysted

Hourglass

Bilocular Abdommo-scrota/l

FIG. Ill. Diagrams (modified and redrawn from Bailey and

Love and Lee McGregor) illustrating the confusion existing in

conventional schemes of classification of hernial and hydrocele

sacs. The criteria for the selection and application of the

terms used are by no means clear and the types depicted should

be contrasted with those encountered in the present series (Figs. I and II).

In Adelaide, one of us (D.G.M.) has had experience of cases in which no patent pro- cessus could be demonstrated at operation but in which dissection among the cord structures displayed a tough strand of tissue running from the upper aspect of the tunica along the full iength of the cord, and tension on its upper extremity would pull down a nipple of peritoneum. Division of this upper portion

that in some other such cases a sufficiently careful study would likewise reveal a com- munication between the peritoneal and hydro- cele sacs.

Nevertheless, it seems likely from our own study the evidence of which now follows, that the next phase in the natural history of this condition is the delayed spontaneous oblitera- tion at one level or another of the patent

6 THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

funicular process. If this delayed spon- taneous obliteration is accepted as a corol- lary of the congenital hypothesis then it can readily be pictured from the observed surgical anatomy (Figs. I and IL), how the evolution of the more complex sacs could follow from the simplest type of communicating sac.

3. Spontaneous abliteration

Obliteration of a patent funi- cular process has been observed to occur as a delayed spontaneous event. It is not very rare to find that a hydrocele present in the first few weeks of life has dis- appeared during the next few months, and it is believed that this kind of spontaneous cure is prob- ably permanent.

Direct evidence of spontaneous obliteration of a patent processus vaginalis was obtained in two patients. Since the findings in these two cases are important in regard to the evolutionary changes which we believe can take place in hydroceles, their clinical his- tories are given at some length.

A boy aged two years was admitted with the history that bilateral scrotal swelling had been present since birth and had varied occasionally in size. The clinical diagnosis of bilateral hydro- cele was first made at the age of eight months and had been confirmed on three subsequent visits. At operation, however, no hydrocele was found on either side. Instead, a white fibrous strand of tissue, clearly demarcated, was present on both sides in the place where the processus vaginalis would be expected, joining the peritoneum to a normal sized tunica vaginalis testis. Each fibrous strand was excised but in histological section only vascular fibrous tissue without any lumen was seen.

The second child (Fig. Il, Type Ild) was referred to hospital at the age of four months with an irre- ducible swelling in the right groin of twenty-four hours’ duration. The clinical diagnosis of hydrocele of the right spermatic cord was later substantiated by several observers and five weeks prior to operation the lump measured 2” x 14”. One week prior to operation the hydrocele had disappeared but there was a palpable thickening of the cord. At operation, dissection of the cord revealed a very fine patent processus extending from the peritoneal cavity to a point about half-way down the inguinal canal, where

it expanded into a small fusiform sac (Fig. Il, Type IId). Immediately below this little sac, and with no apparent communication with it, was a small blind sac containing virtually no fluid and measuring 1” x 3”. This sac had thick vascular walls, adhering to each other, which could not be readily dissected from the remaining cord structures. A distance of half an inch separated it from a normal tunica vaginalis testis.

FIG. IV. An example of the often encountered valvular arrange- ment of a patent funicular process. A cough fascial web holds the terminal processus to the side wall of the hydrocele. The beaded appearance of this communicating strand, once it has been distended with fluid, is characteristic.

A — internal inguinal ring; B— fine patent processus;

C — external ring; D fascial web; E — valvular junction

of processus and sac wall; F —hydrocele sac.

Our concept of the sequence of events in this case is that the fine patent processus initially supplying a hydrocele of the cord underwent spontaneous obliteration close to its junction with that sac. What then followed was a reabsorption of fluid from the distal sac and a gradual distension of the now blind end of the proximal processus to form the beginnings of a new hydrocele of the cord.

THE PATHOGENESIS AND TREATMENT OF PRIMARY HyYDROCELES rj

It can be readily pictured how this sequence multiplied several times could lead to the complex non-communicating sac formations in Fig. I.

Much of the remaining evidence in support of the congenital hypothesis will show more convincingly that the existence of a non- communicating hydrocele intimately associ- ated with a hernial sac is still compatible with the congenital theory of its origin.

1. Other evidence (a) Hydrocele fluid

Unless those cases without macroscopic communication are to be explained on the basis of a sometime persistent patency of the processus vaginalis, then the origin of the fluid demands some other explanation. It could be an inflammatory exudate, but section of the walls of such sacs revealed no inflam- matory change, nor did the fluid aspirated from these hydroceles suggest an inflam- matory origin. On the contrary, the fluid obtained from either communicating or non- communicating hydroceles was indistinguish- able from the peritoneal fluid which can be aspirated from a hernial sac. The following observations were recorded in Adelaide from a recent case of non-communicating hydrocele associated with a narrow hernial sac. White cell counts on the hydrocele and peritoneal fluid were respectively 223 and 216 cells per cubic millimetre; in both fluids the cells were predominantly lymphocytes, together with a few large endothelial cells but no_poly- morphs. Similar contents were found in Melbourne in the fluid from four other child- hood hydroceles, one with, and three without, demonstrable peritoneal communications.

The protein content of the fluid from the non-communicating hydroceles ranged from 3.3 to 4.4 gms per cent. and that of the fluid from the communicating hydrocele was 3.8 gms per cent. The fluid from either source had an electrophoretic pattern which was qualitatively the same as normal serum, again suggesting a non-inflammatory origin.

(b) Reabsorption of hydrocele fluid

Further evidence for the congenital hy- pothesis and for the rationale of non-inter- ference with the hydrocele itself comes from the reabsorption of hydrocele fluid which follows the spontaneous or operative ablation of a patent funicular process.

(i) Reabsorption after spontaneous oblite- ration.

Direct evidence from 2 patients has already been presented that reabsorption of hydrocele fluid follows spontaneous\ obliteration of a patent funicular process. The reabsorption of fluid resulting from these experiments of nature can be mimicked surgically by the deliberate imprisonment of fluid in a hydro- cele sac below a ligated funicular process.

(ii) Post-operative reabsorption of hydro- cele fluid.

If even the finest patency of the processus vaginalis has been demonstrated and divided, it is not absolutely necessary to empty the fluid from the hydrocele sac, because this will absorb spontaneously. This has been demon- strated in 12 such cases by deliberate ligation of the distal cut end of the processus, with fluid still imprisoned in the vaginal sac. Follow-up of these cases has shown complete reabsorption of the fluid within periods vary- ing from two weeks to six months.

(i) History.

Seven out of 12 such cases were distin- guished by a story that the hydrocele had at some stage varied intermittently in size. This suggests that a communication of these hydro- celes with the peritoneal cavity had been present at one stage in their life history.

(ii) Reabsorption after herniotomy alone.

Furthermore, in 4 of the 12 apparently non-communicating hydroceles simple liga- tion and division of the proximal hernial sac was performed. This was followed by the reabsorption of imprisoned fluid from the hydrocele sac in periods varying from three weeks to six months. Unless the peritoneal cavity had been the original source of this fluid then these hydroceles should have per- sisted. In support of this contention are the observations on the remaining eight cases of apparently non-communicating hydroceles.

(iii) Herniotomy combined with evacua- tion of the hydrocele.

Seven of these 8 hydroceles were treated by simple herniotomy, at the same time emptying the hydrocele of its fluid. In 5 of the 7 cases this was achieved by needle aspiration or minimal stab incision. In 2 of the 7 cases a relatively small portion of the sac wall was

lala) a)

excised for microscopic study. In the eighth case a considerable amount of redundant sac had to be excised to permit of concurrent orchidopexy.

In all of the above 7 cases, herniotomy alone sufficed to prevent reaccumulation of the fluid. The small deficiencies in these sac walls should have rapidly healed and retained any fluid formed by purely local disturbances of fluid exchange across the hydrocele wall, so that unless the abdominal cavity was the original source of their fluid these hydroceles should have recurred.

These observations raise the question of why the fluid in these non-communicating sacs had not reabsorbed prior to operation, once they had lost communication with the peri- toneal cavity. It may be that in some a micro- scopic patency had persisted undetected but this explanation cannot serve for those two cases from whch serial sections were made. Alternatively the fluid in the hydrocele might be a peritoneal transudate from the hernial sac through their common wall; however, in spite of the presence of an adjacent proximal sac this hypothetical mechanism did not pre- vent the reabsorption of fluid from the case of hydrocele of the cord described earlier (Fig. I, Type Id).

The most likely explanation is that spon- taneous obliteration of their peritoneal com- munications had occurred too recently for the fluid to have been absorbed, such absorption sometimes taking several months as has been shown in this study. The presence of a large hernial sac may even impede the reabsorption of hydrocele fluid along the lymphatic and venous channels of the cord.

DiscussIOoN

The foregoing evidence leads us to a con- cept of the congenital origin of all these hydroceles, their evolution beginning with simple patency of the processus vaginalis testis and its gradual distension by peritoneal fluid. If delayed spontaneous obliteration of the entire processus should occur then spon- taneous cure will result and the fluid will be reabsorbed. If, however, a fine processus

should become obliterated only at its junction with the hydrocele, the next evolutionary

THE AUSTRALIAN AND New ZEALAND JOURNAL OF SURGERY

change would be the dilatation of that portion of the processus immediately above the distal sac. In this way, the stage would be set, by repetition of the earlier changes, for just such a series of complicated sacs as are seen in some of the cases illustrated in Fig. 1. When the communicating processus is wide, and has a valvular communication with a distal sac, progressive enlargement of the hydrocele might take place upwards into the cavity of the hernial sac above, producing the rather bizarre “inner sleeve” arrangements pictured in Fig. 1. These, we believe, have not been reported before and were certainly confusing when first encountered.

The congenital aetiology of all primary childhood hydroceles has not been categoric- ally stated previously, although suggested by the writings of Gross (1953) and Keeley (1954), who both stress the frequent associa- tion of hydroceles and hernias. At the Children’s Hospital, Boston, for instance, 15 per cent. of patients operated upon with in- guinal hernia had associated hydroceles (Gross, 1953). However, the type of hydro- cele pictured by Keeley and in most surgical texts as the commonest variety is a hydrocele sac with nothing but a solid cord of tissue between it and the peritoneal cavity. This anatomical variety was not encountered in this present study and would require in explana- tion of its origin some theory of disturbed fluid exchange through the wall of the hydro- cele itself.

A disturbance of the normal fluid exchange across the wall of the tunica could result from either an increased production of fluid, such as by inflammation, or from decreased re- absorption due to deficient venous or lym- phatic drainage, or to thickening of the sac wall. These local mechanisms are advanced in explanation of idiopathic adult hydroceles (Ozdilek, 1957) but have been excluded as the prime cause of childhood hydroceles by the evidence from this study.

Impaired lymphatic or venous drainage could conceivably play a secondary role in delaying reabsorption from a non-communi- cating hydrocele association with a large her- nial sac, or might sometime be responsible for a secondary hydrocele developing after herniotomy or herniorrhaphy in childhood.

ee ———

“ F SS oe

THE PATHOGENESIS AND TREATMENT OF PRIMARY HyYDROCELES 9

In regard to our concept of the congenital aetiology of childhood hydroceles, it may be wondered in view of the rapid absorption of fluid which takes place from the pleural or peritoneal sacs, why the rate of entry of peri- toneal fluid into a hydrocele sac should not be balanced by a commensurate absorption through the wall of the sac. Experimental evidence indicates that the normal tunica vaginalis testis is peculiar in this regard and has the slowest absorption characteristics of any of the serous sacs in the body, whereas from the sacs of chronic hydroceles absorp- tion is even more prolonged (Allen and Rinker, 1946; Huggins and Entz, 1931). In line with these experimental findings are our own observations that fluid imprisoned in a hydrocele sac may take from weeks to months to be completely reabsorbed.

Finally, the conventional classifications of hydrocele to be found in textbooks, founded as they are on muddled criteria, are unneces- sarily confusing (Fig. III). They become almost meaningless when considered in rela- tion to similar classifications and descriptive terms applied to hernias (Fig. III). How in- appropriate such terminology is when applied to hernias has been admirably discussed years ago by Hamilton Russell (1923).

Logically, childhood hydroceles may be classified according to the following criteria, established by operative in preference to clinical findings: communicating or non-com- municating, according to the particular stage in their life history at which they present; simple or loculated according to shape; scrotal, funicular, inguino-scrotal, or ab- domino-scrotal, according to their extent; and single or multiple according to the number of sacs present. Useful as such descriptive terms may be, they are not indicative of varying pathogenctic types nor do they possess any practical significance in regard to the treat- ment which should be adopted.

SurGicaAL TREATMENT

(a) Principles

Two important principles have emerged from the present study which influence the surgical treatment of this condition. Firstly, the accumulation of hydrocele fluid should be prevented at its source. We have found that simple herniotomy with transfixion, liga- tion and division of any patent derivative or

strand of the processus vaginalis will cure the condition. Secondly, it is not necessary, and indeed may be harmful, to remove the hydrocele sac itself. Ignoring the sac in this fashion avoids those complications enumerated earlier, which so often follow the orthodox surgical procedures.

Furthermore, these orthodox procedures may fail to prevent recurrence, and our joint experience of six recurrences of this type has already been related. These cases should be explored again, when careful dissection will reveal a fine strand or patent processus vagi- nalis bringing the hydrocele into communica- tion with the peritoneal cavity. Severance of this processus will cure these hydroceles.

(b) Considerations in technique

Under certain circumstances the surgical technique required may present two problems which differ from those encountered in a simple routine herniotomy—one arising when the hydrocele sac is very big, and the other when the communicating processus is very small.

The problem of finding a very fine proxi- mal processus will often be solved by the application of manual pressure either to the abdomen or to the hydrocele sac. In either case it may be possible to force a few drops of fluid along the processus, in which case it will assume a characteristic distended, beaded, opalescent appearance (Fig. IV). It can then be isolated as a separate structure entirely free from the other cord tissues. However, pressure on the hydrocele may not succeed until after the division of fascial bands at the valvular junction of the pro- cessus with the hydrocele wall (Fig. IV). It is often easier to trece the fine processus downwards from the internal ring where there is frequently a “tenting” or funnel-like expansion of the processus at its junction with the peritoneum. For this reason we have chosen as a routine to split the external oblique aponeurosis because of the better ex- posure and control thereby secured.

In the case of a very large tense sac the hydrocele may extend right up to the internal ring, overlapping the communicating sac. Attempts to dissect around such a_ tense bulging hydrocele might result in the fine patent communication being avulsed and missed completely. If this occurred close to

10 THE AUSTRALIAN AND New ZEALAND JOURNAL OF SURGERY

the peritoneum, spontaneous cure might result, but if a processus of any length is left, the stage could be set for recurrence of a hydrocele. Preliminary needle aspiration of the hydrocele through the scrotal coverings, until it is slack, will enable the dissection to proceed with greater facility. If aspiration is attempted through the exposed sac, the fluid may all be lost through the puncture hole thus preventing its subsequent use should it be needed to display the processus.

In the one case of abdomino-scrotal hydro- cele encountered (Fig. 1) adherence to the above principles and technique enabled us to operate successfully by the inguinal route, without recourse to the more cranially placed or multiple incisions which have sometimes been used for this uncommon condition (Prather, 1942).

(d) Procedures on the hydrocele sac

Once the processus is dealt with, the ques- tion arises as to what to do with the hydro- cele itself. The fear that a hydrocele will result from leaving the distal part of a total funicular sac should be dispelled by our observations on the reabsorption of fluid from such sacs. When a hydrocele occurs following herniorrhaphy or herniotomy it is probably due to interference with the pampiniform plexus or to damage to the lym- phatic vessels in the spermatic cord (Obney, 1956).

Although we have shown that the fluid will reabsorb in time, we nevertheless recommend that the hydrocele should be emptied by simple aspiration or minimal stab incision. This is the procedure of choice for all cases in order to save the child’s parents from an anxious period of waiting.

(e) Management in infants

In view of the strong tendency towards spontaneous cure, surgical interference is not indicated during the first year of life for the hydrocele itself. Surgery may be required,

however, for the distress or complications of an associated hernia, the principles of sur- gical intervention and the management of infant hernia being admirably discussed by Sloman and Mylius (1958).

SUMMARY AND CONCLUSIONS

This paper is based on the combined ex- perience in two children’s surgical centres of more than one hundred childhood hydroceles.

A wide variety of saccular morphology was encountered, with all intervening gradations between the simplest communicating type of sac and the most complex non-communicating and multiple saccular formations. It is emphasized that, whether communicating or non-communicating, such hydroceles were always associated with an abnormal patency of at least the proximal part of the processus vaginalis testis. From the succession of types observed it is possible to picture the natural history of evolution of the various forms and a congenital aetiology for all of them is en- visaged. On the concept of their congenital origin, by distension of a patent processus with peritoneal fluid, is based the simplified method of surgical treatment advocated in this paper.

The following additional evidence from our study supports this congenital hypothesis :—

1. The right-sided preponderance typical of hernias and undescended testes was like- wise found for these hydroceles.

2. A history was usually elicited, even in the apparently non-communicating cases, of intermittent variation in the size of the hydrocele at some stage in its life history.

3. The fluid from both communicating and non-communicating hydroceles was micro- scopically and chemically indistinguish- able from peritoneal fluid.

1. Imprisoned hydrocele fluid was shown to be reabsorbed from both communicating and non-communicating cases after simple operative ablation of a patent funicular process.

5. If the hydrocele sac was left behind, emptied of its fluid, with only a needle puncture or minute incision in its walls, reaccumulation of such hydrocele fluid did not occur after severance of the funicular process or strand.

6. Recurrent childhood hydroceles, in our experience, were always associated with a fine patent processus which had been over- looked at the original operation. Sever- ance of this fine processus cured the con- dition.

a ee Me

THE PATHOGENESIS AND TREATMENT OF PRIMARY HyYDROCELES 11

Difficulties can arise in locating and deal- ing with a very fine patent procesus or a very large hydrocele sac, and the appropriate points in surgical technique are discussed.

In infants, the management of hydroceles should be expectant because of the tendency to spontaneous cure.

The conventional terminology and clas- sifications of hydrocele are critically reviewed and shown to be confusing. Variations in saccular morphology are no basis for an aetiological classification and the treatment of election is unrelated to whatever descriptive terms of convenience may be used.

The