Hydrocele‐en‐bisac in a young adult: a rare encounter

Abstract

Hydrocele-en-bisac in a young adult: a rare encounter 'Hydrocele-en-bisac', otherwise known as abdominoscrotal hydrocele (ASH), is among one of the rarest cases encountered by a general surgeon in his whole surgical career. The rarity of such cases is that it accounts for only 0.17% of all types of hydrocele. More so, over last 16 years, only 85 cases were documented in adults and less than 20 in children until 2011. The ASH has a shape like a dumb-bell where one cystic swelling remaining inside the abdomen communicates to another cystic swelling in the scrotum through the inguinal canal, the constriction being at the internal ring. 1 A man aged 20 years presented with a large right-sided scrotal swelling with another large abdominal swelling in the hypogastric region for 2 years with intermittent severe abdominal pain (Fig. 1). The patient was first catheterized and on examination, both the swellings showed cross-fluctuation 2 in between the swellings and the scrotal swelling showed positive transillumination test. Routine investigations including renal function tests showed no abnormality. Ultrasonography revealed bilocular cystic swellings communicating through the right inguinal canal. Based on the above findings, a tentative provisional diagnosis of 'Hydrocele-en-bisac' was made. In fact, the diagnosis was almost confirmed on clinical grounds.The operation was conducted under general anaesthesia with a right inguino-scrotal incision and on exposure of inguinal canal; the diagnosis of an intra-abdominal cystic swelling was confirmed by cutting the internal ring (Fig. 2). The abdominal cystic swelling was downsized by needle aspiration, delivered and excised out in toto along with the scrotal part barring only the cord structures (Fig. 3). The cut internal ring was repaired and the posterior inguinal canal was strengthened by an onlay prolene mesh with anchorage stitches in anticipation of any future occurrence of hernia. The post-operative period was uneventful without any complications.Dupuytren first described ASH in 1854 and coined the entity as 'Hydrocele-en-bisac'. 3 Though, the exact mechanism of ASH is not clear, but one of the postulations is that the processus vaginalis should be patent (at least partially) for ASH to develop. The most accepted proposition is that the increased pressure in the scrotal area or oven-distension of scrotal hydrocele sac pushes the proximal end of the hydrocele sac inside the inguinal canal with an intraabdominal herniation and one-way valve effect of the patent processus vaginalis to allow further redirection of scrotal fluid into the abdomen. 1 At times, the ASH may present with a spectrum of complications due to compression of adjacent structures, like hydroureter, hydronephrosis, leg oedema and testicular flattening. Occasionally, it may have neoplastic change like mesothelioma. 3,4 Other reported complications in association with ASH are torsion Fig. 1. Lateral view of the patient showing hypogastric mass along with right scrotal mass.Fig. 2. Right inguino-scrotal in...

Abdominoscrotal Haematocele in an Adult and Its Successful Treatment

“…India has the highest incidence of ASH in the world. 3 Literature review suggests that ASH is more common on the right side than the left. ASH is usually a congenital anomaly; it starts from birth as an inguinoscrotal swelling that extends to the abdomen.…”

“…It is diagnosed clinically, and imaging is used to support the diagnosis. 3 Treatment can be conservative or surgical. In adults, there is no role of conservative management, and treatment is by surgical options, either open or laparoscopic approach.…”