RANDOMISED PROSPECTIVE COMPARATIVE STUDY ON ...

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RANDOMISED PROSPECTIVE COMPARATIVE STUDY

ON THE EFFICACY OF SHARMA JHAWER’S

OPERATION WITH LORD’S PLICATION AND

JABOULEY’S OPERATION IN THE TREATMENT OF

PRIMARY VAGINAL HYDROCELE

Dissertation submitted to

THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY

CHENNAI – 600032

M.S. GENERAL SURGERY (BRANCH - I)

DEPARTMENT OF GENERAL SURGERY MADURAI MEDICAL COLLEGE AND GOVERNMENT RAJAJI

HOSPITAL, MADURAI – 625020

MAY – 2019

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CONTENTS

1. Certificate

2. Declaration by the candidate

3. Acknowledgement

4. Bonafide certificates

5. Introduction

6. Review of Literature

7. Aim & objectives

8. Design of study

9. Compartments of the study

10. Statistical analysis

11. Study population

12. Eligibility criteria

13. Types of operations to be studied

14. End point

15. Results

16. Conclusion

17. Bibliography

18. Annexures

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CHARTS (COMPARTMENT I)

SHARMA JHAWER(SJ) Vs LORD’S PLICATION(LP)

1. Age distribution in I compartment (SJ Vs LP)

2. Distribution of occupation in I compartment

3. Distribution of socio-economic status in I compartment

4. Distribution of occupation in both procedures

5. Distribution of socioeconomic status among both procedures

6. Side distribution in I compartment

7. Side distribution among SJ v LP procedures

8. Distribution of symptoms in I compartment

9. Symptoms within each procedure

10. Distribution of duration of illness in I compartment

11. Duration of illness among both the procedures

12. Percentage of hematoma in both procedures

13. Percentage of scrotal edema in both procedures

14. Percentage of pain in both the procedures

15. Percentage of fever in both the procedures

16. Complications in both procedures

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CHARTS (COMPARTMENT II)

SHARMA JHAWER(SJ) Vs JABOULEY’S OPERATION(JAB)

17. Age distribution in II compartment (SJ Vs JAB)

18. Distribution of occupation in II compartment

19. Distribution of socio-economic status in II compartment

20. Distribution of occupation in both procedures

21. Distribution of socioeconomic status among both procedures

22. Side distribution in II compartment

23. Side distribution among SJ v LP procedures

24. Distribution of symptoms in II compartment

25. Symptoms within each procedure

26. Distribution of duration of illness in II compartment

27. Duration of illness among both the procedures

28. Percentage of hematoma in both procedures

29. Percentage of scrotal edema in both procedures

30. Percentage of pain in both the procedures

31. Percentage of fever in both the procedures

32. Complications in both procedures

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TABLES

1. Distribution of socio-demographic variables SJ v LP procedures

2. Clinical profile among patients in both the procedures (SJ vs LP)

3. Complications in I compartment

4. Outcome measures in I compartment

5. Distribution of socio-demographic variables SJ v JAB procedures

6. Clinical profile among patients in both the procedures (SJ vs JAB)

7. Complications in II compartment

8. Outcome measures in II compartment

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CERTIFICATE

This is to certify that this Dissertation titled “RANDOMISED

PROSPECTIVE COMPARATIVE STUDY ON THE EFFICACY OF

SHARMA JHAWER’S OPERATION WITH LORD’S PLICATION

AND JABOULEY’S OPERATION IN THE TREATMENT OF

PRIMARY VAGINAL HYDROCELE” submitted by Dr. M. JOYNER

ABRAHAM to the faculty of general surgery, The Tamilnadu Dr.M.G.R

Medical University, Chennai in partial fulfilment of the requirement for the

award of MS Degree (Branch I) General Surgery, is a bonafide research work

carried out by him under our direct supervision and guidance from June 2016

to May 2018.

.

Prof.Dr. K. G. Subangi., M.S., D.G.O Prof. Dr.S.R.Dhamodharan., M.S Professor of General Surgery Professor & Head of the Department

Department of General Surgery Department of General Surgery

Madurai Medical College, Madurai. Madurai Medical College, Madurai

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DECLARATION BY THE CANDIDATE

I Dr. M. JOYNER ABRAHAM, hereby solemnly declare that this

Dissertation entitled “RANDOMISED PROSPECTIVE COMPARATIVE

STUDY ON THE EFFICACY OF SHARMA JHAWER’S OPERATION

WITH LORD’S PLICATION AND JABOULEY’S OPERATION IN

THE TREATMENT OF PRIMARY VAGINAL HYDROCELE” is a

bonafide and genuine research work carried out by me.

This is submitted to The Tamil Nadu Dr. M.G.R. Medical

University, Chennai, in partial fulfilment of the regulations for the award

of M.S Degree (Branch I) in General Surgery.

Place: Madurai

Date : 10-2018 (Dr. M. JOYNER ABRAHAM)

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ACKNOWLEDGEMENT

It is my honour and privilege to thank Prof. Dr. K.G. SUBANGI

M.S.,DGO Professor of General Surgery, who helped me in choosing the

subject for this study and guided me at every stage. Her valuable suggestions

and timely advice were of immense help to me throughout all phases of this

study.

I express my gratitude towards Prof. Dr. S.R. DHAMODHARAN.,

M.S., Head of the Department of General Surgery, Madurai Medical College,

Madurai, for his valuable suggestions, support and guidance.

I thank Dr..G.Saravanakumar,M.S.,D.A., Dr.K.S.Gokulnath

Premchand, M.S., D.ortho., Dr.R.Rani M.S.,DDVL., for their

encouragement and guidance.

I am very thankful to my colleagues who helped me in preparing

this dissertation. My ‘sincere thanks’ to all the patients without whose

co-operation this study would have not been possible and last but not the

least, I wish to express my gratitude to my family & friends also, without

them, this study would have not been possible.

Date: 10-2018 (Dr. M. JOYNER ABRAHAM)

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BONAFIDE CERTIFICATE FROM THE GUIDE

This is to certify that this dissertation entitled “RANDOMISED




PRIMARY VAGINAL HYDROCELE” is the bonafide work of

Dr. M. JOYNER ABRAHAM in partial fulfilment of the university

regulations of the Tamil Nadu Dr.M.G.R.Medical University, Chennai, for

M.S.General Surgery Branch I examination to be held in May 2019.

Prof.Dr.K. G. SUBANGI., M.S.,DGO., Professor of Surgery,

Department of General Surgery

Madurai Medical College, Madurai.

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BONAFIDE CERTIFICATE FROM THE HOD









Prof. Dr.S.R.Dhamodharan., M.S Professor & Head of the Department

Department of General Surgery

Madurai Medical College, Madurai

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BONAFIDE CERTIFICATE FROM THE DEAN









Dr. D. MARUTHUPANDIAN, M.S, FICS, FIAS.,

DEAN

Madurai Medical College, Madurai.

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INTRODUCTION

Hydrocele is known to occur in man since time immemorial. Indian

surgeons have reported it as early as 5th century BC.

Hydrocele has been described in ancient Indian surgery by Sushrutha

(6th century BC), who stated that any swelling in the body is due to

thridhosha (three faults), viz. vatha, pitta and kaffa. Sushrutha, the

father of Indian surgery had written the details regarding hydrocele in

his book “Sushrutha Samhitha” about 2,500 years ago.

According to Charaka the causes of diseases are:

✓ The excessive, deficient or wrongful administration of drugs.

✓ The climatic characteristics of heat and cold.

✓ The misuse of intelligence.

Celsus in 53 B.C. – 17 A.D. distinguished hydrocele from hernia by

translucency. Arvelius Cornelius Celsus, a roman encyclopaedist of the first

century A.D. who dealt very extensively with hernia, was the most important

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single figure in the long history of this subject for more than a millennium.

He described hydrocele, varicocele and tumor.

Sauncuoglu, an ancient surgeon (1385-1470) defined hydrocele as “a fluid

collection between the white fascia beneath the skin (tunica vaginalis

parietalis) and fascia surrounding the testis (tunica vaginalis visceralis),

resembling a natural capsule” .He cautioned that if the sac was not excised

appropriately, hydrocele might recur. He also listed the complications

Edward Gibbon, 1737 - 93, the English historian, who is best known for

history of the decline and fall of the Roman empire, was greatly embarrassed

by a large hydrocele. The second time this was tapped, the hydrocele became

infected and Gibbon died a few days after the operation. The hydrocele was

associated with a large scrotal hernia, probably was punctured.

Dupeutyran, 1834 and later Lister, 1858 did some work on hydrocele

especially on abdomino scrotal hydrocele.

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It was MATHEW JABOULAY (1860-1913) who contributed the

operation of partial excision with eversion of the sac in the treatment of

hydrocele.

In 1907, Andrews described the bottle operation for treatment of

Hydrocele.

Dupuytren described hydrocele en bissac in 1834 and the name

abdomino scrotal hydrocele was proposed by Bickle in 1919.

In 1955, salomon described the extrusion operation for hydrocele.

Ozdilek 1957 and Rinker and Allen, 1951 gave some theoretical evidence

that an imbalance in the secretion and absorption in responsible for the

collection of the fluid.

In 1960 Wallace found that, the hydrocele is due to the result of lymphatic

obstruction, either due to the low grade inflammation of epididymis or due to

trauma to the scrotum.

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Peter Lord (1964) described the plication operation for hydrocele. In

1970, he described a blood less operation for spermatocele and

epididymal cyst.

In 1975, Moloney reported good results with sclerotherapy. It is

performed as an outpatient procedure and thus, it is cost effective.

In 1979 SHARMA – JHAWER described a technique which involved

lesser complications as compared to other procedures.

In 1995, study done by Gunaydin G et al, indicated that fluids within

spermatoceles and epididymal cysts do not become infected under

normal circumstances.

However, still the surgery for hydrocele has a significant morbidity

rate. The common complications include

➢ Bleeding

➢ Haematoma

➢ Scrotal Edema

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➢ Testicular pain

➢ Infection

➢ Injury to the cord structures and epididymis

➢ Torsion of the testis

in the order of decreasing frequency.

Commonest among these is post-operative haematoma which is due to

oozing from small vessels. Unless meticulous haemostasis is secured oozing

from small vessels may continue into the layers of the loose scrotal tissue

giving rise to a haematoma. It is apt to say that a patient comes for surgery of

a tennis ball and goes back with a cricket ball, considering the size and

weight.

To study which among all these procedures has the least morbidity, in

our study we have compared the popularly used Lord’s plication for small

and Jaboulay’s operation for medium sized uncomplicated primary vaginal

hydroceles with Sharma and Jhawer’s minimal dissection technique in two

separate compartments.

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REVIEW OF LITERATURE

ANATOMICAL CONSIDERATIONS

SCROTUM

The scrotum is a cutaneous bag containing the right and left testes, the

epididymis and the lower parts of the spermatic cords. Externally, the

scrotum is divided into right and left parts by a ridge or raphe which is

continued forwards on to the under surface of the penis and backwards along

the middle of the perineum to the anus. The left half of the scrotum hangs a

little lower than the right, in correspondence with the greater length of the

left spermatic cord. Under the influence of cold, and in young and robust

persons, the scrotum is short, corrugated and closely applied to the testis.

This is due to contraction of the subcutaneous muscle of scrotum, called the

dartos. However, under the influence of warmth, and in old and debilitated

persons, the scrotum is elongated and flaccid due to relaxation of dartos.

From this it appears that the dartos muscle helps in regulation of temperature

within the scrotum.

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Layers of the Scrotum

The scrotum is made up of the following layers from outside to inside

1. Skin.

2. Dartos muscle which replaces the superficial fascia.

3. The external spermatic fascia.

4. The cremasteric muscle and fascia.

5. The internal spermatic fascia.

The dartos muscle is prolonged into a median vertical septum between

the two halves of the scrotum.

Blood Supply

The scrotum is supplied by the following arteries:

• Superficial external pudendal

• Deep external pudendal

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• Scrotal branches of internal pudendal

• Cremasteric branch of inferior epigastric.

Nerve Supply

The anterior one-third of the scrotum is supplied by

• Segment LI of the spinal cord through the ilioinguinal nerve.

• Genital branch of the genitofemoral nerve.

The posterior two-thirds of the scrotum are supplied by

• Segment S3 of the spinal cord through the posterior scrotal branches of

the pudendal nerve.

• Perineal branch of the posterior cutaneous nerve of the thigh.

The areas supplied by segments LI and S3 are separated by the ventral

axial line.

The dartos muscle is supplied by the

• genital branch of the genitofemoral nerve.

TESTIS

The testis is the male gonad. It is homologous with the ovary of the

female. It is suspended in the scrotum by the spermatic cord. It lies obliquely,

so that its upper pole is tilted forwards and medially. The left testis is slightly

lower than the right. The testis is oval in shape, and is compressed from side

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to side. It is 3.75 cm long, 2.5 cm broad from before backwards, and 1.8 cm

thick from side to side. An adult testis weighs about 10 to 15 g.

External Features

The testis has:

1. Two poles or ends, upper and lower.

2. Two borders, anterior and posterior.

3. Two surfaces, medial and lateral.

The upper and lower poles are convex and smooth. The upper pole

provides attachment to the spermatic cord. The anterior border is convex and

smooth, and is fully covered by the tunica vaginalis. The posterior

border is straight, and is only partially covered by the tunica vaginalis. The

epididymis lies along the lateral part of the posterior border. The lateral part

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of the epididymis is separated from the testis by an extension of the cavity of

the tunica vaginalis. This extension is called the sinus of epididymis. The

medial and lateral surfaces are convex and smooth. Attached to the upper

pole of the testis, there is a small oval body called the appendix of the testis.

It is a remnant of the paramesonephric duct.

Coverings of the Testis

The testis is covered by three coats. From outside inwards, these are

the tunica vaginalis, the tunica albuginea and the tunica vasculosa. The

tunica vaginalis represents the lower persistent portion of the processus

vaginalis. It is invaginated by the testis from behind and, therefore, has a

parietal and a visceral layer with a cavity in between. It covers the whole

testis, except for its posterior border. The tunica albuginea is a dense, white

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fibrous coat covering the testis all around. It is covered by the visceral layer

of the tunica vaginalis, except posteriorly where the testicular vessels and

nerves enter the gland. Albuginea is thickened to form an incomplete vertical

septum, called the mediastinum testis, which is wider above than below.

Numerous septa extend from the mediastinum to the inner surface of the

tunica albuginea. They incompletely divide the testis into 200 to 300 lobules.

The tunica vasculosa is the innermost, vascular coat of the testis lining its

lobules.

Structure of the Testis

The glandular part of the testis consists of 200 to 300 lobules. Each

lobule contains two to three seminiferous tubules. Each tubule is highly

coiled on itself. When stretched out, each tubule measures about 60 cm in

length, and is about 0.2 mm in diameter. The tubules are lined by cells which

represent stages in the formation of spermatozoa. The seminiferous tubules

join together at the apices of the lobules to form 20 to 30 straight tubules

which enter the mediastinum. Here they anastomose with each other to form

a network of tubules, called the rete testis. In its turn, the rete testis gives rise

to 12 to 30 efferent ductules which emerge near the upper pole of the testis

and enter the epididymis. Here each tubule becomes highly coiled and forms

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a lobe of the head of the epididymis. The tubules end in a single duct which

is coiled on itself to form the body and tail of the epididymis. It is continuous

with the ductus deferens.

Arterial Supply

The testicular artery is a branch of the abdominal aorta given off at the

level of vertebra L2. It descends on the posterior abdominal wall to reach the

deep inguinal ring where it enters the spermatic cord. At the posterior border

of the testis, it divides into branches. Some small branches enter the posterior

border, while larger branches; medial and lateral, pierce the tunica albuginea

and run on the surface of the testis to ramify in the tunica vasculosa.

Venous Drainage

The veins emerging from the testis form the pampiniform plexus

(pampiniform = like a vine). The anterior part of the plexus is arranged

around the testicular artery, the middle part around the ductus deferens and

its artery, and the posterior part is isolated. The plexus condenses into four

veins at the superficial inguinal ring, and into two veins at the deep inguinal

ring. These veins accompany the testicular artery. Ultimately one vein is

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formed which drains into the inferior vena cava on the right side, and into

the left renal vein on the left side.

Lymphatic Drainage

The lymphatics from the testis ascend along the testicular vessels and

drain into the preaortic and paraaortic groups of lymph nodes at the level of

second lumbar vertebra.

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Nerve Supply

The testis is supplied by sympathetic nerves arising from segment T10

of the spinal cord. They pass through the renal and aortic plexuses. The

nerves are both afferent for testicular sensation and efferent to the blood

vessels (vasomotor).

DEVELOPMENT OF TESTIS

Testis: It is comprised of spermatogenic cells, cells of Sertoli and

Leydig’s cells. Spermatogenic series of cells are derived from endoderm of

dorsocaudal part of yolk sac, i.e. endoderm. Cells of Sertoli are derived from

epithelial cells, i.e. coelomic epithelium. Leydig’s cells: Mesoderm.

Descent of the Testis

The testes develop in relation to the developing mesonephros, at the

level of segments T10 to T12. Subsequently, they descend to reach the

scrotum. Each testis begins to descend during the second month of

intrauterine life. It reaches the iliac fossa by the 3rd month, rests at the deep

inguinal ring from the 4th to the 6th month, traverses the inguinal canal

during the 7th month, reaches the superficial inguinal ring by the 8th month

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and the bottom of the scrotum by the 9th month. An extension of peritoneal

cavity called the processus vaginalis precedes the descent of testis into the

scrotum, into which the testis invaginates. The processus vaginalis closes

above the testis. Descent does not occur after one year of age. The causes of

descent are not well known. The following factors may help in the process.

1. Hormones including the male sex hormone produced by the testis, and

maternal gonadotropins.

2. Differential growth of the body wall.

3. Formation of the gubernaculum: This is a band of loose tissue extending

from the lower pole of the testis to the scrotum. It was earlier thought that

contraction of this tissue was responsible for descent of the testis, but it is

now known that this tissue is not contractile.

4. Intra-abdominal temperature and intraabdominal pressure may have

something to do with descent of the testis.

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HYDROCELE

It is the collection of fluid between the two layers of tunica vaginalis of

testis.

Types

• Congenital

• Acquired

• Primary

• Secondary

Aetiology

✓ Defective absorption of fluid by the tunica vaginalis, probably due to

damage to the endothelial wall by low-grade infection.

✓ Excessive production of fluid as in secondary hydrocele.

✓ Interference with drainage of fluid by lymphatic vessels of the cord.

✓ Communication with the peritoneal cavity.

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Hydrocele fluid is amber-coloured with specific gravity of 1.022 to 1.024.

It contains water, salts, albumin, fibrinogen. Per se, hydrocele fluid does not

clot, but if it comes in contact with the blood, fibrinogen gets activated and

clots firmly. Often fluid contains cholesterol and tyrosine crystals.

(a) communicating hydrocele, (b) non-communicating or scrotal hydrocele, (c)

funicular hydrocele, (d) encysted hydrocele or spermatic cord cyst, (e)

inguinoscrotal hydrocele and (f) abdominoscrotal hydrocele.

PRIMARY VAGINAL HYDROCELE

Occurs in middle-aged, common in tropical countries. Testis is not

palpable as it usually attains a large size (unlike secondary hydroceles which

are small, except in filarial hydrocele). Fluctuant (elicited by, fixing the

hydrocele with hand and feeling for the fluid movement using fingers placed

in two perpendicular directions). Can get above the swelling (you can feel

only cord structures and nothing else at the root of the scrotum, unlike in

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hernia). Testicular sensation can be elicited in vaginal hydrocele by

transmitting the pressure sensation through the fluid.

Infantile Hydrocele

Here tunica and processus vaginalis (hydrocele) are distended up to

internal ring, but sac has no connection with the general peritoneal cavity.

Congenital Hydrocele

Processus vaginalis communicates with the peritoneal cavity. As this

communicating orifice is too small, bowel does not descend and so hernia

usually will not develop. While lying down, fluid disappears gradually and

while standing fluid recollects. Hydrocele cannot be emptied by digital

pressure as it causes “inverted ink bottle” effect. Ascites, tuberculous

peritonitis are the aetiologies for the same.

Encysted Hydrocele of the Cord

It is the fluid collection in a portion of patent funicular process part of

the tunica vaginalis; but closed above and below; located in

inguinal/inguinoscrotal/scrotal part which is fluctuant and transilluminant.

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On gentle traction to the testis, the swelling becomes less mobile (traction

test).

Hydrocele-en-bisac (Bilocular Hydrocele)

Hydrocele has got two intercommunicating sacs, one above and one

below the neck of the scrotum. Upper one lies superficial or in the inguinal

canal or may insinuate itself between the muscle layers—cross-fluctuant.

Hydrocele of the Canal of the Nuck

It occurs in females, in relation to the round ligament, always in the

inguinal canal.

Hydrocele of the Hernial Sac

It is due to adhesions of the content of hernial sac. Fluid secreted

collects in the hernial sac and forms hydrocele of the hernial sac.

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SECONDARY HYDROCELE

Causes

• Infection: Filariasis

• Tuberculosis of epididymis

• Syphilis

• Injury: Trauma, postherniorrhaphy hydrocele

• Malignancy

Secondary hydrocele rarely attains large size. It is usually small, lax and

testis is usually palpable (unlike primary hydrocele). Exception is, secondary

hydrocele due to filariasis. It can be very large.

Post herniorrhaphy Hydrocele

It is a secondary hydrocele occurring after the surgery for inguinal hernia. It

is due to the damage to lymphatic vessels of the tunica vaginalis and is 0.2%

common. It is treated like any hydrocele but usually after about 6 months

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Filarial Hydrocele and Chylocele

Occurs commonly in coastal region, and in and around the equator. Usually

occurs after repeated attacks of filarial epididymitis. Hydrocele is usually of

large size and the sac is thickened. Fluid contains fat, rich in cholesterol, and

is derived from ruptured lymph varix into the tunica. It is often difficult to

differentiate from primary hydrocele.

Complications of hydrocele

✓ Infection

✓ Pyocele

✓ Haematocele

✓ Atrophy of testis, hernia of hydrocele (rare)

✓ Infertility

✓ Hernia of hydrocele sac (rare)

Differential diagnosis

➢ Inguinal hernia

➢ Epididymal cyst

➢ Spermatocele

➢ Testicular tumour

➢ Scrotal oedema

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Role of Scrotal Ultrasound

Ultrasound of the scrotum can detect intra scrotal masses with a sensitivity

of nearly 100%. It plays a major role in the evaluation of scrotal masses

because of its accuracy of 98% to 100% in differentiating intra testicular and

extra testicular pathology. This distinction is important in patient

management because most extra testicular masses are malignant. All intra

testicular masses should be considered potentially malignant until

proven otherwise.

A direct contact scan is most commonly performed, but a water

bath approach may also be employed. The patient is examined in supine

position and 7.5 MHZ or 10 MHZ transuducer is commonly used

because it provides increased resolution of the scrotal contents.

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Sonographically the normal testis has homogenous granular echotexture

composed of uniformly distributed medium level echoes. The tunica

albuginea is not usually visualized as separate structure. The septum of

testis may be seen as linear echogenic or hypoechoic structure. The

epididymis is normally iso echogenic or slightly more echogenic than

the testis.

Intra testicular cysts have sonographic characteristics of benign

simple cysts occurring in other organs. They are well defined, anechoic

lesions with thin, smooth walls and posterior acoustic enhancement.

Epidermoid cysts are generally well defined, solid hypoechoic masses.

The mass typically has an echogenic capsule. Testicular abscess

demonstrates, an enlarged testicle containing a predominantly fluid

filled mass with hypoechoic or mixed echogenic areas. Sonography

plays an important role in the evaluation of hydroceles. They are

characteristically anechoic collections with good sound to transmission

surrounding the anterolateral aspects of the testis. The fluid provides an

excellent acoustic window for imaging the testis, however to medium

level echoes from fibrin bodies or cholesterol crystals may occasionally

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be visualized moving freely within a hydrocele. Both haematoceles and

pyoceles contain internal septations and loculations.

Treatment for Hydrocele

Surgery

✓ Tapping

✓ Lord’s plication

✓ Sub-total excision

✓ Partial excision and eversion (Jaboulay’s operation)

✓ Evacuation and eversion

✓ Sharma and Jhawer’s technique

✓ Total excision of sac

Procedure

Under G/A or spinal or L/A, after cleaning and draping, vertical

incision of about 6-8 cm in length is made over the scrotum, anteriorly 1 cm

lateral to the median raphe. Skin, dartos, external spermatic fascia, internal

spermatic fascia are incised. Bluish hydrocele sac is identified, i.e. parietal

layer of the tunica vaginalis of testis. Fluid is evacuated using trocar and

cannula. Sac is opened.

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If the sac is small, thin and contains clear fluid, either Lord’s plication,

i.e. tunica is bunched into a “ruff” by placing series of multiple interrupted

chromic catgut sutures so as to make the sac to form fibrous tissue (It is

relatively avascular and so haematoma will not occur).

Or evacuation and eversion of the sac behind the testis (after eversion,

everted sac is sutured with chromic catgut by continuous sutures) is done.

If the sac is thick, in large hydrocele and chylocele, subtotal excision of

the sac is done (as tunica vaginalis is reflected on to the cord structures and

epididymis posteriorly, total excision leads to orchidectomy with division of

cord).

Often the sac is excised partially and then eversion is done, which is

called as Jabouley’s operation.

After evacuation, the sac with the testis is placed in a newly created

pocket between the fascial layers of the scrotum (Sharma and Jhawer’s

technique).

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Aspiration must be avoided as much as possible as it is only a

temporary measure (recurrence occurs very early) and chances of

haematocele, infection are higher.

A drain is placed near the root of the scrotum on the lateral aspect

because it becomes the most dependent portion, when scrotal support is

given. Scrotal support is given to reduce the scrotal oedema. Wound is closed

in layers. Drain is removed in 48 hours.

Complications of surgery

➢ Reactionary haemorrhage

➢ Oedema

➢ Pain

➢ Infection

➢ Pyocele

➢ Sinus formation

➢ Recurrent hydrocele

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AIM & OBJECTIVES

➢ To study the various clinical presentations of primary vaginal

hydrocele.

➢ To compare the efficacy of Sharma & Jhawer’s surgery Vs Lord’s

plication for small sized uncomplicated primary vaginal hydrocele

(<7cms)

➢ To compare the efficacy of Sharma & Jhawer’s surgery Vs Jaboulay’s

for medium sized uncomplicated primary vaginal hydrocele (>7cms

and <14cms)

➢ To assess postoperative complications, morbidity associated with the

above surgical procedures.

➢ To analyze the simplicity, expenditure & effectiveness of the three

procedures.

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DESIGN OF STUDY

➢ Randomized prospective comparative Study

➢ Simple Randomization

➢ Sample Size

➢ Epi info software

➢ Time taken to revert back to normal taken as mean

➢ SD 1.7 and 1.36 for respective procedure

➢ Confidence interval 95% and Power 80%

➢ 23 rounder off to in each group

➢ Duration

➢ 2 Years (June 2016 to May 2018)

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COMPARTMENTS OF THE STUDY

• The study was done in two compartments to assess the efficacy of

Sharma and Jhawer’s for both small and medium sized primary vaginal

hydrocele.

• Hydrocele size < 7cm diameter are considered as small sized hydrocele

and are included in compartment I.

• In compartment I, Sharma & Jhawer’s technique was compared with

the Lord’s Plication procedure for small sized hydrocele.

• Hydrocele size >7 cm and <14 cm diameter are considered as medium

sized hydrocele and are included in compartment II.

• In compartment II Sharma & Jhawer’s technique was compared with

Jaboulay’s procedure for medium sized hydrocele.

• Size measured using Vernier’s Caliper.

41

STATISTICAL ANALYSIS

• Data entered into Microsoft Excel (Windows 7; Version 2007)

• Analysis done using the Statistical Package for Social Sciences (SPSS)

for Windows software (trial version 22.0; SPSS Inc, Chicago)

• Descriptive statistics

– Mean and Standard Deviation (SD) for continuous variables

– Frequencies and percentages will be calculated for categorical

variable

• Comparison between groups analyzed using

– Chi square test of independence and Fischer’s test for

categorical variables

– Unpaired T test for quantitative variables

• Bar charts and Pie charts for visual representation of analysed data

• Level of significance set at 0.05

42

STUDY POPULATION

• All patients with primary vaginal hydrocele satisfying eligibility

criteria admitted for surgery in the surgical ward of Government Rajaji

hospital / Madurai Medical College during the study period of June

2016 to May 2018.

43

ELIGIBILITY CRITERIA

INCLUSION CRITERIA

✓ Solitary swelling in the scrotum incorporating the testis.

✓ The swelling should be positive for trans-illumination.

✓ It should be possible to get above the swelling at the root of scrotum.

✓ Hydrocele size < 7cm diameter are considered as small sized hydrocele

and are included in compartment I.

✓ Hydrocele size between 7 to 14 cm diameter are considered as medium

sized hydrocele and are included in compartment II.

✓ In a patient with bilateral hydrocele each hydrocele will be considered

as a separate case in this study.

44

ELIGIBILITY CRITERIA

EXCLUSION CRITERIA

✓ Swelling arising from the skin of scrotum.

✓ Solitary swelling in the scrotum which is separate from the testis.

✓ Diffuse swelling in the scrotum incorporating the testis but negative on

trans-illumination. (All secondary long standing complicated hydrocele

are ruled out of the study).

✓ Swelling in which there is associated impulse on coughing and

reducibility.

45

TYPES OF OPERATIONS TO BE STUDIED

• Lord’s Plication

• Jaboulay’s procedure

• Sharma and Jhawer’s technique

46

LORD’S PLICATION

Peter Herent Lord, FRCS, surgeon, High Wycombe, England and

Karger Verlaz, Basel, Switzerland evolved an operation in which there is

no direct mobilization of the tunica vaginalis. The hydrocele is entered

directly and plication is performed

An incision of one and half inches is made on the anterior aspect of

the scrotum avoiding the superficial vessels. The incision is extended

through the skin and dartos but not through the tunica vaginalis.

Hemostasis is secured through diathermy or by ligation. To further

control the oozing, the wound edges including all the tissues to the

tunica are grasped by Allis forceps. The hydrocele is then emptied by

incising the sac.

The testis is evaginated through the scrotal incision which results

in turning the sac inside out. Since the sac is not dissected from the

scrotal covering, the maneuver is bloodless. Using ‘00’ chromic catgut

with an atraumatic needle interrupted gathering or plication sutures

small bites being taken at 1cm intervals are inserted from the cut edges

of the sac to the junction of the epididymis and testis. Depending upon

the size of the hydrocele 8-10 such sutures are inserted in series. This

47

step pleats the sac obliterating the subcutaneous tissue between the

scrotal incision and opening in the tunica vaginalis.

Fig: Plication of tunica vaginalis.

JABOULAY’S OPERATION

In Jaboulay’s operation, we grasp scrotum firmly in one hand to stretch

scrotal skin. 6-10 cm incision made on anterior surface of scrotum over most

prominent part of hydrocoele, well away from testicle which lies postero

inferior.

Skin, dartos and thin cremasteric fascia are incised and reflected

together as a single layer from the underlying parietal layer of the tunica

vaginalis which is the outer wall of the hydrocoele.

When hydrocoele is well separated laterally and medially from overlying

layers, it is grasped with 2 Allis forceps and a trocar is inserted to aspirate the

48

fluid. With one finger inside the sac, we dissect it free from the overlying

scrotum so that spermatic cord and testicle with attached hydrocoele lie free

in operative field.

Hydrocele sac is then opened completely. Testicle is then carefully

inspected and palpated. Redundant wall sac is trimmed leaving a margin of

2cm. Great care must be taken with haemostasis. Sac is then everted behind

testis with interrupted suture.

Fig: Excision & Eversion of tunica vaginalis

49

SHARMA JHAWER’S TECHNIQUE

It has been quoted that tissue handling and dissection during

hydrocele operation proportionately increase oozing of blood from the

scrotal coverings with resultant tissue edema and hematoma formation.

Hence the minimal dissection was devised

STEPS:

The scrotum is scrubbed well and painted with spirit & betadine.

Incision:

The scrotum is held with its skin stretched by the assistant, 4cm

incision made avoiding subcutaneous vessels.

Evacuation of the sac:

The sac with all the fascial layers together is picked up with two

tissue forceps and emptied with a trocar and cannula. The same holes are

then extended on either side avoiding visible blood vessels. Through the

opening polar delivery of testis is done.

50

Creation of space in the scrotum:

To lodge the testis, with its sac back into the scrotum, a testis size

space is created between the scrotal subcutaneous layers outside and the

testicular fascial layers on the inside. This is easily done by introducing

the two index fingers to do blunt separation of tissues and make room

just enough to allow a tight fit of testis when reloaded in the scrotum.

Reloading of testis:

The testis with its everted sac is put back into the new space in the

scrotum very carefully.

Wound closed in layers:

After achieving complete haemostasis, wound is closed in layers with

3’0 chromic catgut.

Complications like hematoma and sepsis are remarkably low, sutures

are not used inside the scrotum thus saving on operation time and reducing

an infection factor hence reducing hospital stay.

51

Incision

Evacuation of Sac

52

Delivering the testis out

Creation of Sub dartos pouch

53

Reloading of testis in newly created pouch

Wound closed in layers

54

3rd Postoperative Day

5th Postoperative Day

55

POST OPERATIVE COMPLICATIONS

Mostly operations are successful and the patients recover soon and go

home. In certain number of instances, however complications develop.

The complication will prolong the stay in hospital. The complications

associated with these procedures are:

Pain: As the effect of the anaesthetic passes off the patient begins to

feel the post-operative pain of the operation. Faulty reposition of the testis

(torsion of testis) will cause agonizing pain. If the pain is persisting re-

exploration is indicated and the testis should be repositioned. If the testis

is totally infarcted it should be removed. Pain will also be present in

massive haematoma and in infected wound usually after 3 days. In a scale

of 0 to 10 in Visual Analog Scale, >5 is considered pain in our study.

Fever: The temperature is often 1 or 2 degrees, even after clean

surgery up to 3 days, this is aseptic traumatic fever. >99O F is considered

as fever in our study.

56

Haematoma: This is a common postoperative complication because of

following factors.

• Inadequate / imperfect haemostasis

• Oozing from small vessels

• In heavy spinal anaesthesia blood pressure falls. Hence bleeding

points are few. Though haemostasis is secured with care, after

the effect of anaesthesia is worn off, the blood vessels of the

testis which arise from the aorta directly, bleed profusely and

cause haematoma along with its complications.

• Testis is covered by loose scrotal layers

It is usually manifested with a sensation of pressure or pain in the

scrotum (Shortly after the anaesthetic affect wears off). Scrotum will be big

in size and firm in consistency. The haematoma can be prevented by

meticulous haemostasis and scrotal support. Drain can be used if tissue

dissection has been extensive. It will eventually be absorbed. Persisting

haematoma is treated with evacuation of the clot.

57

Skin Oedema:

It is due to abnormal increase in interstitial fluid following tissue

dissection and disruption of scrotal lymphatics, can be prevented by

careful dissection and gentle handling of tissues. Treatment consists of

scrotal support and anti-inflammatory drugs.

Infection:

Infection is a major cause of postoperative morbidity. The hallmark of

developing infection is fever usually associated with leucocytosis. An

increase in the pulse-rate occurs. The local signs of wound infection

consist of pain, swelling erythema and soaking of the dressing.

Stitch abscess: This is usually seen after 6th or 7th postoperative days.

It is localized suppuration in relation to one of the stitches, localised

blister will be formed. If the stitch is thick blood stained pus will come

out.

58

Superficial infection: The wound becomes red, swollen and the stiches

are buried in the oedematous skin. Treatment includes regular dressing of

wound and antibiotics.

Deep infection or disruption of wound: This is severe type of

infection involving all the layers of scrotum. The wound is gaped and the

testis is seen.

Treatment includes regular dressing of wound, debridement, antibiotics

and secondary suturing.

Infection can be prevented by shaving the scrotum and cleansing it

with savlon preoperatively and use of antibiotics.

59

END POINT

• The primary end point was once the testis returned back to normal size

• The secondary end points were hematoma, infection and wound

disruption.

• So the follow up period was different for every patient which varied

from 8 to 28 days

60

RESULTS OF I COMPARTMENT

• A total of 40 patients were included in the study COMPARTMENT I

with 20 in each surgical procedure.

• The follow up period ranged from 7 to 28 days

• There was no difference in baseline characteristics among the two

groups.

• The age of the study population ranged between 18-59 with a mean of

38.75 and standard deviation of 13.14.

• None of the cases had wound disruption .

61

15-25 26-35 36-45 46-55 >55

30%

5%

25%32.5%

7.5%

CHART 1: AGE DISTRIBUTION IN I COMPARTMENT (SJVLP)

AgricultureLaborers

Coolie Others

57.5%27.5%

15%

CHART 2: DISTRIBUTION OF OCCUPATION IN I COMPARTMENT

62

TABLE 1: DISTRIBUTION OF SOCIO-DEMOGRAPHIC

VARIABLES SJ V LP PROCEDURES

SOCIO-

DEMOGRAPHIC

VARIABLES

SHARMA

AND

JHAWAR

LORD’S

PLICATION

P VALUE

AGE (MEAN) 43.4 39.5 0.314

OCCUPATION

Agriculture

laborers

Coolie

Others

12(52.2%)

5(45.5%)

3(50%)

11(47.8%)

6(54.5%)

3(50%)

0.935

SOCIO-

ECONOMIC

STATUS

II

III

IV

V

3(43%)

3(43%)

8(57%)

6(50%)

4(57%)

4(57%)

7(43%)

6(50%)

0.903

II III IV V

17.5% 17.5%

35% 30%

CHART 3: DISTRIBUTION OF SOCIO-ECONOMIC STATUS IN I COMPARTMENT

63

Sharma andJhawar

Lord's Plication

60% 55%

25% 30%15% 15%

CHART 4: DISTRIBUTION OF OCCUPATION WITHIN PROCEDURES IN COMPARTMENT I

Agriculture Laborers Coolie Others

Sharma andJhawar

Lord's Plication

15% 20%15% 20%40% 30%

30% 30%

CHART 5: DISTRIBUTION OF SOCIOECONOMIC STATUS WITHIN PROCEDURES IN COMPARTMENT I

II III IV V

64

47%53%

CHART 6: SIDE DISTRIBUTION IN COMPARTMENT I

Right Left

Right Left

47.4% 52.6%

52.4% 47.6%

CHART 7: SIDE DISTRIBUTION WITHIN PROCEDURES IN COMPARTMENT I

Sharma and Jhawar Lord's Plication

65

Only swelling Only Pain Pain andSwelling

70%

17.5% 12.5%

CHART 8: DISTRIBUTION OF SYMPTOMS IN I COMPARTMENT


75% 65%

15% 10%10% 15%

CHART 9: SYMPTOMS WITHIN EACH PROCEDURE IN COMPARTMENT I

Only swelling Only Pain Pain and Swelling

66

0-6months

6m - 1year

1-3years

3-5years

5-10years

>10years

10%22.5%

35%

12.5%2.5%

17.5%

CHART 10: DISTRIBUTION OF DURATION OF ILLNESS IN I COMPARTMENT

Sharma andJhawar

Lord's Plication

75% 60%

5% 25%20% 15%

CHART 11: DURATION OF ILLNESS WITHIN PROCEDURES IN COMPARTMENT I

0-3 years 3-10 years >10 years

67

TABLE 2: CLINICAL PROFILE AMONG PATIENTS IN BOTH THE

PROCEDURES (SJ VS LP)

CLINICAL

PROFILE

SHARMA

AND

JHAWAR

LORD’S

PLICATION

P VALUE

SIDE

RIGHT

LEFT

9(47.4%)

11(52.4%)

10(50%)

10(50%)

0.752

SYMPTOMS

ONLY

SWELLING

ONLY PAIN

SWELLING AND

PAIN

15(53.6%)

3(43%)

2(40%)

13(46.4%)

4(57%)

3(60%)

0.784

DURATION OF

ILLNESS

6MONTHS –

3YEARS

4YR – 6YR

>6YR

15(55.6%)

1(16.7%)

4(57%)

12(44.4%)

5(83.3%)

3(43%)

0.208

68

Sharma andJhawar

Lord's Plication

0%

15%

CHART 12: PERCENTAGE OF HAEMATOMA IN BOTH PROCEDURES IN COMPARTMENT I

Sharma andJhawar

Lord's Plication

0%

20%

CHART 13: PERCENTAGE OF SCROTAL EDEMA IN BOTH PROCEDURES IN COMPARTMENT I

69

Sharma andJhawar

Lord's Plication

10%20%

CHART 14: PERCENTAGE OF PAIN IN BOTH THE PROCEDURES IN COMPARTMENT I

Sharma andJhawar

Lord's Plication

5%10%

CHART 15: PERCENTAGE OF FEVER IN BOTH THE PROCEDURES IN COMPARTMENT I

70

TABLE 3: COMPLICATIONS IN I COMPARTMENT

COMPLICATIONS SHARMA

AND

JHAWAR

LORD’S

PLICATION

P VALUE

HAEMATOMA

PRESENT

ABSENT

0(0%)

20(55.6%)

4(100%)

16(44.4%)

0.035

SCROTAL

EDEMA

PRESENT

ABSENT

0(0%)

20(55.6%)

4(100%)

16(44.4%)

0.035

PAIN

PRESENT

ABSENT

2(33.3%)

18(53%)

4(66.7%)

16(47%)

0.376

FEVER

PRESENT

ABSENT

1(33.3%)

19(51.4%)

2(66.7%)

18(48.6%)

0.548

Haematoma Scrotaledema

Pain Fever

0% 0%

10%5%

15%20% 20%

10%

CHART 16: COMPLICATIONS IN BOTH PROCEDURES IN COMPARTMENT I


71

TABLE 4: OUTCOME MEASURES IN I

COMPARTMENT

OUTCOME

MEASURES

SHARMA AND

JHAWAR

MEAN(SD)

LORD’S

PLICATION

MEAN(SD)

P VALUE

TIME TAKEN

FOR

SCROTUM TO

REVERT TO

NORMAL (IN

DAYS)

3.8(0.89)

6.25(1.68)

<0.001

DURATION OF

SURGERY

19.25(1.55) 25.2(1.15) <0.001

72

RESULTS II COMPARTMENT

• Sharma Jhawer’s Vs Jaboulay’s (II compartment).

• A total of 40 patients were included in the study compartment-II with

20 in each surgical procedure.

• The follow up period ranged from 7 to 28 days.

• There was no difference in baseline characteristics among the two

groups (SJ vs Jab).

• The age of the study population ranged between 18-58 with a mean of

39.38 and standard deviation of 9.6.

• None of the cases had wound disruption.

73

15-25 26-35 36-45 46-55 >55

10%20%

42.5%

22.5%5%

CHART 17: AGE DISTRIBUTION IN II COMPARTMENT (SJ VS JAB)

Agriculturelaborers

Coolie Others

55%27.5% 17.5%

CHART 18: OCCUPATION DISTRIBUTION IN II COMPARTMENT (SJ VS JAB)

74

II III IV V

10%22.50%

40%27.50%

CHART 19:SOCIOECONOMIC STATUS DISTRIBUTION IN II COMPARTMENT (SJ VS JAB)

Sharma and Jhawar Jaboulays

60% 50%

25% 30%

15% 20%

CHART 20: OCCUPATION DISTRIBUTION WITHIN PROCEDURES IN II COMPARTMENT

Agriculture laborers Coolie Others

75


15% 5%

15% 30%

40% 40%

30% 25%

CHART 21: SOCIOECONOMIC STATUS WITHIN PROCEDURES IN II COMPARTMENT

II III IV V

45%

55%

CHART 22: SIDE DISTRIBUTION IN II COMPARTMENT (SJ VS JAB)

Right Left

76

Only swelling Only pain Pain andSwelling

72.50%

17.50% 10%

CHART 23: SYMPTOMS AMONG THE PATIENTS IN II COMPARTMENT (SJ VS JAB)

0-6months

6m-1year

1-3years

3-6years

6-10years

>10years

5% 2.50%12.5%

32.5%40%

7.5%

CHART 24: DURATION OF ILLNESS IN II COMPARTMENT

77

TABLE 5 : CLINICAL PROFILE AMONG PATIENTS IN

BOTH THE PROCEDURES (SJ VS JAB)

CLINICAL

PROFILE

SHARMA AND

JHAWAR

JABOULAYS P VALUE

SIDE

Right

Left

11(55%)

9(45%)

11(55%)

9(45%)

1.000

SYMPTOMS

Only Swelling

Only Pain

Swelling And

Pain

15(75%)

3(15%)

2(10%)

14(70%)

4(20%)

2(10%)

0.915

DURATION OF

ILLNESS

6months – 3years

4yr – 6yr

>6yr

5(62.5%)

12(41.4%)

3(100%)

3(37.5%)

17(58.6%)

0(0.0%)

0.113

78

Sharma andJhawar

Jaboulays

55% 55%

45% 45%

CHART 25: SIDE DISTRIBUTION WITHIN PROCEDURES IN II COMPARTMENT

Right Left


75% 70%

15% 20%10% 10%

CHART 26: SYMPTOMS WITHIN PROCEDURES IN II COMPARTMENT

Only swelling Only pain Pain and Swelling

79

Sharma andJhawar

Jaboulays

25% 15%

60% 85%15% 0%

CHART 27: DURATION OF ILLNESS WITHIN PROCEDURES IN II COMPARTMENT

0-3 years 3-10 years >10 years

Sharma andJhawar

Jaboulays

0%

20%

CHART 28: PERCENTAGE OF HAEMATOMA IN BOTH PROCEDURES (SJ VS JAB)

80


0%

25%

CHART 29: PERCENTAGE OF SCROTAL EDEMA IN BOTH PROCEDURES (SJ VS JAB)

Sharma andJhawar

Jaboulays

15%30%

CHART 30: PERCENTAGE OF PAIN IN BOTH PROCEDURES (SJ VS JAB)

81

Sharma andJhawar

Jaboulays

10%20%

CHART 31: PERCENTAGE OF FEVER IN BOTH PROCEDURES (SJ VS JAB)

Haematoma Scrotaledema

Pain Fever

0% 0%

10%15%

20%25%

20%

30%

CHART 32: COMPLICATIONS WITHIN PROCEDURES IN II COMPARTMENT


82

TABLE 6: COMPLICATIONS IN II COMPARTMENT

COMPLICATIONS SHARMA AND

JHAWAR

JABOULAYS P VALUE

HAEMATOMA

PRESENT

ABSENT

0

20(55.6%)

4(100%)

16(44.4%)

0.035

SCROTAL

EDEMA

PRESENT

ABSENT

0(0%)

20(57%)

5(100%)

15(43%)

0.017

PAIN

PRESENT

ABSENT

3(33.3%)

17(55%)

6(66.7%)

14(45%)

0.256

FEVER

PRESENT

ABSENT

2(33.3%)

18(53%)

4(66.7%)

16(47%)

0.376

83

TABLE 7: OUTCOME MEASURES IN II

COMPARTMENT

OUTCOME

MEASURES

SHARMA AND

JHAWAR

JABOULAYS P VALUE

TIME TAKEN

FOR

SCROTUM TO

REVERT TO

NORMAL (IN

DAYS)

3.8(0.89)

11.1(2.1)

<0.001

DURATION

OF SURGERY

19.2(1.55) 31.1(1.34) <0.001

84

DISCUSSION

To study which among the surgical procedures available for primary

vaginal hydrocele has the least morbidity and most beneficial for the patient,

in our study we have compared the popularly used Lord’s plication with

Sharma Jhawer’s operation for small sized uncomplicated primary vaginal

hydrocele and Jaboulay’s operation with Sharma Jhawer’s operation for

medium sized uncomplicated primary vaginal hydroceles in two separate

compartments.

The study was done in two compartments in the patients satisfying the

eligibility criteria to assess the efficacy of Sharma and Jhawer’s for both

small and medium sized hydrocele. Hydrocele size < 7cms diameter are

considered as small sized hydrocele and are included in compartment I. In

compartment I Sharma & Jhawer’s technique was compared with the Lord’s

Plication procedure for small sized hydrocele. Hydrocele size between 7 to

14 cms diameter are considered as medium sized hydrocele and are included

in compartment II. In compartment II Sharma & Jhawer’s technique was

compared with Jaboulay’s procedure for medium sized hydrocele. Size

measured using Vernier’s Caliper.

85

In both compartments patients were allocated in either of the two arms

in each compartment by simple randomization technique and were surgically

intervened after prior consent, pre-op evaluation and anaesthesia assessment.

Patients were followed up for post-operative complications and return

of testis to normal size. The primary end point was once the testis returned

back to normal size. The secondary end points were hematoma, infection and

wound disruption. So, the follow up period was different for every patient. It

varied from 8 to 28 days in both compartments.

In compartment I, 40 patients who satisfied the eligibility criteria with

swelling less than 7cm in size were included. Of which 20 were included in

the Sharma and Jhawer’s(SJ) arm and another 20 were included in the Lord’s

plication(LP) arm.

On analysing the socio demographic variables in compartment I,

(Table: 1, Chart:1,2,3,4,5) mean age of patients in SJ arm is 43.4 and LP arm

is 39.5. 57.5% of patients in compartment I were agricultural laborers, 27.5%

coolies and 15% other occupation. 65% of patients in compartment I

86

belonged to lower and lower middle class. In compartment I there was no

significant difference in the base line characteristics in the two arms.

On analysing the clinical profile in compartment I, (Table: 2, Chart:

6,7,8,9,10,11), 53% had swelling pain the right side, 47% in the left side.

70% of the patients had complaints of only swelling, 17.5% had only pain,

12.5% had both pain and swelling. 80% patients had complaints less than 5

years’ duration.

On analysing the mean time taken for duration of surgery in

compartment I (Table: 4), it took 19.25 minutes in SJ arm and 25.2 minutes

in LP arm. Time taken for Sharma and Jhawer’s procedure is less than the

time taken for Lord’s plication which was statistically significant.

On analysing the post-operative complications in compartment I

(Table: 3, Chart: 12,13,14,15,16) the SJ arm had less post-operative

haematoma and oedema than the LP arm which was again statistically

significant (p value < 0.05). SJ arm also had less pain and fever though it was

not statistically significant (p value >0.05).

87

On analysing the time taken for scrotum to revert to normal size in

compartment I (Table: 4), mean time for SJ arm was 3.8 days and mean time

for LP arm was 6.25 days. Hence SJ arm had less time for scrotum to revert

to normal size when compared with LP arm which again was statistically

significant (p value < 0.05).

In compartment II, 40 patients who satisfied the eligibility criteria with

swelling more than 7cm and less than 14 cm in size were included. Of which

20 were included in the Sharma and Jhawer’s(SJ) arm and another 20 were

included in the Jaboulay’s procedure(Jab) arm.

On analysing the socio demographic variables in compartment II,

(Chart:17,18,19,20,21,22) mean age of patients in SJ arm is 43.6 and Jab arm

is 40.8. 55% of patients in compartment II were agricultural laborers, 27.5%

coolies and 17.5% other occupation. 67.5% of patients in compartment II

belonged to lower and lower middle class. In compartment II there was no

significant difference in the base line characteristics in the two arms.

On analysing the clinical profile in compartment II, (Table: 5, Chart:

22,23,24,25,26,27), 55% had swelling pain the right side, 45% in the left

88

side. 72.5% of the patients had complaints of only swelling, 17.5% had only

pain, 10% had both pain and swelling. 52.5% patients had complaints less

than 5 years duration.

On analysing the mean time taken for duration of surgery in

compartment II (Table: 4), it took 19.2 minutes in SJ arm and 31.1 minutes in

Jab arm. Time taken for Sharma and Jhawer’s procedure is less than the time

taken for Jaboulay’s procedure which was statistically significant. (p value <

0.05)

On analysing the post-operative complications in compartment II

(Table: 6, Chart: 28,29,30,31,32) the SJ arm had less post-operative

haematoma and oedema than the Jab arm which was again statistically

significant (p value < 0.05). SJ arm also had less pain and fever though it was

not statistically significant (p value >0.05).

On analysing the time taken for scrotum to revert to normal size in

compartment II (Table: 7), mean time for SJ arm was 3.8 days and mean time

for Jab arm was 11 days. Hence SJ arm had less time for scrotum to revert to

89

normal size when compared with Jab arm which again was statistically

significant (p value < 0.05).

Analysing the results of compartment I, we conclude that in treating

small uncomplicated primary vaginal hydrocele (hydrocele size < 7cms)

Sharma and Jhawer’s minimal dissection technique has statistically

significant less operative time and statistically significant less post-operative

complications (haematoma and oedema) and also has less time for scrotum to

revert to normal size which is again statistically significant when compared

with Lord’s plication.

Analysing the results of compartment II, we conclude that in treating

medium sized uncomplicated primary vaginal hydrocele (hydrocele size

>7cms and <14 cms) Sharma and Jhawer’s minimal dissection technique has

statistically significant less operative time and statistically significant less

post-operative complications (haematoma and oedema) and also has less time

for scrotum to revert to normal size which is again statistically significant

when compared with Jaboulay’s procedure.

90

CONCLUSION

➢ Between the three procedures analyzed, in our setting Sharma and

Jhawer’s minimal dissection technique had statistically significant

✓ lesser complications

✓ lesser time to revert back to normal and

✓ cost effective

than Lord’s plication for small sized primary vaginal hydrocele

and Jaboulay’s operation for medium sized primary vaginal

hydrocele.

➢ Hence Sharma Jhawer’s is the most beneficial for the patient and

with least complications for treating small and medium sized

primary vaginal hydrocele.

➢ Further multi centric randomized trials and meta-analysis are

needed to emphasize the significance of the results in our study.

91

BIBLIOGRAPHY

[1] Ku JH, et al. The excisional placation and internal drainage

techniques: A comparison of results for idiopathic hydrocele. BJU Ent

2001; 87(1): 82-84.

[2] Albercht W, Hohl. The best operation for hydrocele? Br. J Urol

1991;68(2):187-9.

[3] Shah PA, et al. Ambulatory hydrocele surgery – a review of 50 cases.

Jr Coll Surg Edinb 1992; 37(6): 385-6.

[4] Dunaeuskii Iaz, Gorokhov. A comparative evaluation of surgical

methods for treating hydrocele. Urol (Mosk) 1990; 1: 59-62.

[5] Singh DR, Gupta SK, Gupta S, Lord‟s procedure a curative outpatient

operation for primary hydrocele. J Indian Med. Assoc 1996; 94(4):141-2

[6] Sharma LS, Jhawar PK. Surgery of hydrocele (A simplified minimal

dissection technique). Ind J Surg 1979; 41: 700-704.

92

[7] Chalasani V, Woo HH. Why not use a small incision to treat large

hydroceles. ANZ Surg 2002; 72(8): 594-5.

[8] Christopher G Fowler. Hydrocele, Bailey and Love, short practice of

surgery 25th ed, India: Edward Arnold ltd; 2008. p.1381-1382.

[9] Parviz K. Kavoussi, Raymond A. Costabile. Hydrocelectomy,

Campbell walsh urology 10th ed,. United States of America: Elsevier

Saunders; 2012.p.1009-1010. 105

[10] Margaret Farquharson, Brenden Moran. Farquharson‟s textbook of

operative general surgery. 9th ed, India: Edward Arnold; 2005.p. 474.

[11] Tanga et al., 1973, "Abdomino scrotal hydrocele-Shoffhotes of Rare

of obscure Cases, British Journal Surgery. 60: 834-836.

[12] Andrews E.W., 1907, "The bottle operation method for the radical

cure of hydrocele", Annals of Surgery. 46: 915

[13] Solomon A.A., 1955, "The extrusion operation for Hydrocele", N.Y,

State Journal of Medicine. 55: 1885.

93

[14] Lord P.H., 1970, "A bloodless operation for spermatocele or cyst of

the epididymis", British Journal of Surgery. 57(9): 641-544.

[15] Singh DR, Gupta SK, Gupta Saroj, Lord's procedure - A curative

outpatients operation for primary hydrocele, J.Indian Med. Association

1996, April, Vol. 94, NO. 4, 141-2.

[16] Lord H Peter. "A bloodless operation for the radical cure of

Idiopathichydrocele", British Journal of Surgery, 1964 Dec, Vol. 51,NO.

12: 914-16

[17] Johstone J.M.S, Hargreave T.B, "Male Urethra and Genital

organs", Edited by R.F. Rintoul. Farquharson's Text Book of

Operative Surgery, Churchill Living stone 8th Edn. 1995; 672-683.

[18]Guyton, Arthur C, "The lymphatic system, interstitial fluid

dynamics edema and pulmonary fluid" Chapter 31 in Textbook of

Medical Physiology, Philadelphia, 1986, 366-7.

94

[19]Role of filariasis in the etiology of Idiopathic Hydrocele, I.J.S 44,

161- 66, March 1982.

[20]Hamilton Bailey & McNeil Love, Arnold Publishers’ Short

Practice of Surgery, 24th

edition, 1407-9.

[21]H. Kimleyeryl, David C. Sabiston, W.B. Sounders publication

Sabiston Text Book of Surgery, 16th edition, 1499-1500.

[22]Wendy Cowler Hurser, Seymour L. Schwartz, Flanc Spencer, G.

Tom Shires, McGraw-Hill Publishers’ Schwartz Principles of

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[23]Park John Evert, "Lympahtic filariasis", Ch. 5 in Parks Textbook

of preventive and social medicine, Calcutta, 2000: 199-203.

[24]Belokar W.K. et.al. : A simple eversion operation for radical cure of

large scrotal hydrocele; I.J.S., July 1979; Vol. 41, 414-17.

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95

PROFORMA(ANNEXURE I)

A) PARTICULARS OF THE PATIENT:

Name : IP No.:

Age : D.O.A:

Sex : D.O.S:

Occupation: D.O.D:

Religion :

Address :

B) PRESENTING SYMPTOMS:

a) Swelling Duration Uni/Bilateral

b) Mode of Onset Right/Left

c) Trauma

d) Fever

e) Pain

f) Progress

g) Difficulty in micturition

96

h) Other Symptoms

C) PAST HISTORY

a. Any operative procedures

b. Co morbidities

c. Urinary tract infection

d. Suggestive of T.B:

e. STD

D) FAMILY HISTORY

a. Married/Single

b. Children

c. Any other members with similar complaints

E) PERSONAL HISTORY

a. Food Habits

b. Micturition

c. Bowel Habits

d. Sleep

e. Smoking

f. Alcohol

g. Tobacco

97

F) SOCIO ECONOMIC STATUS

G) GENERAL AND PHYSICAL EXAMINATION

a. Pulse

b. BP

c. Anaemia

d. Oedema

e. Lymphadenopathy

f. Cyanosis

g. Others

H) LOCAL EXAMINATION

a. Scrotal Swelling

b. Side

c. Size

d. Skin

e. Impulse on coughing

f. Consistency

g. Fluctuation

h. Get above the swelling

i. Trans illumination

98

j. Testis and cord structures

k. Lymph nodes PR:

I) SYSTEMIC EXAMINATION

a. CVS

b. RS

c. CNS

d. P/A

J) INVESTIGATIONS

a. Routine Blood Investigations

b. B G & T

c. BT & CT

d. Urine Investigations

e. USG Scrotum

K) DIAGNOSIS\

L) ANAESTHESIA ASSESMENT

M) OPERATION DONE

a) Sharma & Jhawer’s

b) Lord’s Plication

99

c) Jaboulay’s Operation

N) INTRA OPERATIVE TIME

O) COMPLICATIONS

a) Fever

b) Pain

c) Oedema

d) Haematoma

e) Wound Infection

P) FOLLOW UP

Q) TIME FOR SCROTUM TO REVERT BACK TO NORMAL SIZE

100

CONSENT(ANNEXURE II)

I_______ Hosp No _______ in my full senses hereby give my

complete for _______________ or any other procedure deemed fit

which is a diagnostic/therapeutic/procedure/biopsy/transfusion/operation

to be performed on me/my/son/daughter/ward _________ age

_________ under any anaesthesia deemed fit. The nature and risks involved

in the procedure have been explained to me in my own language to my

satisfaction. For academic and scientific purpose, the operation/procedure be

television or photographed, or used for statistical measurements.

Date:

Signature/Thumb Impression/ of Patient/Guardian

Name:

Designation:

Guardian

Relationship

Full Address

101

ANNEXURE III

102

ANNEXURE IV

103

CERTIFICATE – II

This is to certify that this dissertation work titled

RANDOMISED PROSPECTIVE COMPARATIVE STUDY ON THE

EFFICACY OF SHARMA JHAWER’S OPERATION WITH LORD’S

PLICATION AND JABOULEY’S OPERATION IN THE TREATMENT OF

PRIMARY VAGINAL HYDROCELE of the candidate Dr. JOYNER

ABRAHAM M with registration number 221611112 for the award of

MASTER DEGREE in the branch of GENERAL SURGERY. I have personally

verified the urkund.com website for plagiarism check. I found that the uploaded

thesis file contains all from introduction to conclusion pages and result shows

ZERO percentage of plagiarism in the dissertation

Guide and Supervisor Sign with Seal

MASTER CHART SJ VS JAB

S No AGE SIDE SYMPTOMS OCCUPATION SESDURATION

OF ILLNESS

DURATION

OF ILLNESS

1 40 left only swelling agriculture laborers 4 5 0-6m

2 42 right only swelling coolie 4 7 6m-1y

3 45 left only pain agriculture laborers 3 8 5y-10y

4 36 left only swelling agriculture laborers 4 4 3y-5y


6 46 left only pain coolie 5 6 5y-10y

7 47 right only swelling coolie 5 12 >10y

8 50 right only swelling agriculture laborers 2 8 5y-10y

9 52 left only swelling coolie 5 14 >10y

10 28 left only swelling others 5 4 3y-5y



13 45 right both swelling and pain others 4 4 3y-5y

14 42 right both swelling and pain agriculture laborers 5 5 3y-5y

15 48 right only swelling agriculture laborers 3 11 >10y





20 18 right only swelling coolie 2 5 3y-5y



23 31 left only swelling coolie 4 9 5y-10y

24 32 right only pain coolie 3 6 5y-10y


26 34 right only pain others 4 3 3y-5y





31 39 left both swelling and pain others 3 3 3y-5y

32 40 right both swelling and pain agriculture laborers 3 2 1y-3y









MASTER CHART SJ VS JAB

S NoDURATION OF

SURGERYHAEMATOMA FEVER

SCROTAL

EDEMAPAIN

TIME TO

REVERT

PROCEDURE

DONE

1 21 absent absent absent absent 4 sj















16 17 absent present absent present 3 sj


18 20 absent absent absent present 3 sj



21 30 present present present present 7 jab


23 31 absent present present present 11 jab


25 32 present absent present present 10 jab

26 34 absent absent absent present 12 jab

27 30 absent absent absent absent 10 jab














MASTER CHART SJ VS LP

S No AGE SIDE SYMPTOMS OCCUPATION SESDURATION OF

ILLNESSDURATION OF ILLNESS

1 51 right only swelling agriculture laborers 3 11 >10y



4 25 left only swelling agriculture laborers 2 8 6m-1y


6 40 left only swelling agriculture laborers 4 11 >10y

7 42 right only swelling coolie 4 12 >10y

8 45 left only pain agriculture laborers 3 5 0-6m

9 36 left only swelling agriculture laborers 4 3 6m-1y

10 38 left only pain agriculture laborers 5 2 6m-1y

11 46 left only pain coolie 5 5 6m-1y



14 52 left only swelling coolie 5 2 0-6m

15 53 left only swelling others 5 3 0-6m



18 45 right both pain and swelling others 4 2 1y-3y

19 42 right both pain and swelling agriculture laborers 5 2 1y-3y

20 48 right only swelling agriculture laborers 3 8 6m-1y



23 35 left only swelling coolie 4 12 >10y


25 45 left only pain coolie 5 5 3y-6y

26 52 right only pain others 5 8 6m-1y

27 55 right only pain others 5 2 1y-3y


29 19 right both pain and swelling agriculture laborers 4 10 1y-3y




33 45 left both pain and swelling coolie 4 1 1y-3y



36 24 left both pain and swelling agriculture laborers 5 2 1y-3y





MASTER CHART SJ VS LP

S NoDURATION OF

SURGERYHAEMATOMA FEVER

SCROTAL

EDEMAPAIN

TIME TO

REVERT

PROCEDURE

DONE

1 17 absent absent absent present 3 sj




















21 25 absent present present present 3 lp

22 26 present absent present present 8 lp

23 26 present absent absent present 6 lp

24 24 present absent present present 5 lp

25 24 present absent present absent 6 lp

26 25 absent present absent absent 5 lp

27 23 absent absent absent absent 6 lp














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