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Abdominal wall hydrocele: A rare late postoperative complication of drain site wound incisional hernia
J Ped Surg Case Reports 3 (2015) 16e18
Contents lists available at ScienceDirect
Journal of Pediatric Surgery CASE REPORTS journal homepage: www.jpscasereports.com
Abdominal wall hydrocele: A rare late postoperative complication of drain site wound incisional herniaq Edgar D. Sy a, *, Yan-Shen Shan b a b
Section of Pediatrics Surgery, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan Department of Surgery, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 October 2014 Received in revised form 20 November 2014 Accepted 22 November 2014
Late postoperative abdominal wall hydrocele is a rare complication following surgery. It may be form from a small untreated incisional hernia that passed through the musculo-aponeurotic layer of the abdominal wall. Diagnosis is easily made by clinical history of prolonged non-tender, non-reducible cystic mass below an incisional scar. Hydrocele should always be suspected when CT scan showed a fluid containing mass in the subcutaneous layer of abdominal wall with the presence of musculo-aponeurotic defect and absence incarcerate viscera in patient with chronic hypoalbuminemia. Surgical treatment should include total excision of hydrocele, facial repair and closure of hernia sac, preferably invertedly close into the abdominal cavity in order that the fluid secreting portion of the sac drained directly into in the abdominal cavity. Ó 2015 The Authors. Published by Elsevier Inc. All rights reserved.
Key words: Abdominal wall hydrocele Incisional hernia Incisional hydrocele
Incisional hernia can occur in small incision such as in laparoscopic surgery with an incidence of about 0.08e0.14% [1,2] as a result of fascial defect. The formation of incisional hydrocele had never been reported and may occur when the hernial sac pass through the muscular layer of the abdominal wall. The pinching effect of muscle contraction causes obliteration of the intramuscular portion, dividing the sac into supra and infra muscular portion. The increased production or decreased desorption of serous fluid in the supra muscular portion may result in the formation of a hydrocele such as in patient with chronic hypoalbuminemia. 1. Case report This is a 28 y.o. female with history of biliary atresia who underwent Kasai’s procedure during the neonatal period and developed progressive biliary cirrhosis with sign and symptoms of hypoalbuminemia, ascites, pitting edema, splenomegaly and recurrent GI bleeding from esophago-gastric varices, which she was treated with endoscopic ligation and sclerotherapy. At age of 7
q This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/3.0/). * Corresponding author. Department of Surgery, Section of Pediatric Surgery, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng Li Road, Tainan 704, Taiwan. Tel.: þ886 6 2353535; fax: þ886 6 2766676. E-mail addresses: [email protected], [email protected] (E.D. Sy).
y.o., she underwent splenectomy with drain placed intraoperatively and exists in the left lower quadrant of the abdomen. At the age of 22 y.o., she started to notice a small mass over the left lower quadrant of the abdomen, which disappeared on pressure and supine position. However, at the age of 28 y.o, the mass gradually enlarged, without changes in size despite of pressure compression and supine position. Evaluation at the Pediatric OPD Department was done. A CT scan showed a 7e8 cm cystic mass, subcutaneously located with a musculo-aponeurotic defect of the abdominal wall below the cystic lesion (Fig. 1 AeD). A peritoneal scintigraphy, with direct injection of 3 mCi Tc-99 m DTPA into the cystic mass, showed accumulation of radiotracer within the mass, without extravasations into the abdominal cavity. She was referred to surgical department for further evaluation. Physical examination revealed a cystic lesion, about 7 cm in diameter, a 2e3 cm incision scar and striae above the mass (Fig. 2A). During the past 12 month, her serum albumin level ranged from 1.8 to 2.5 g/L and was treated with albumin infusion. She underwent surgical treatment and intraoperative finding showed a well-defined cystic lesion attached to distal end hernia sac (Fig. 2B). The hernial sac open into the peritoneal cavity with an opening orifice of about 1.5 cm (Fig. 2C), which pass through a musculo-aponeurotic defect just lateral to the linea semilunaris (Fig. 2D). The cystic lesion was excised, the hernial sac was inverted closed into the peritoneal cavity and the musculo-aponeurotic defect was repaired. Histopathologic examination showed that both the cystic lesion and
2213-5766/$ e see front matter Ó 2015 The Authors. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.epsc.2014.11.012
E.D. Sy, Y.-S. Shan / J Ped Surg Case Reports 3 (2015) 16e18
17
Fig. 1. Preoperative abdominal CT scan. A1. CT scan at preoperative 6 years, showed disrupted musculoaponeurotic layer (white arrow). A2 showed subcutaneously located lesion above the musculoaponeurotic layer of abdominal wall (arrow head). At preoperative two month, CT scan showed, B1 (transverse view) and B2 (sagittal view), persistent of disrupted musculoaponeurotic layer (white arrow) with about 7e8 cm cystic mass (C).
hernial sac were lined with mesothelial layer with chronic inflammation and congestion. 2. Discussion The term hydrocele literally means a sac of water. In the pediatric age group, it is due to non-obliteration of patent processus vaginalis. In postoperative small abdominal incision wound complicated with hernia, the obliteration of the midportion of the sac can lead to formation of hydrocele.
Integrity of the endoabdominal fascia is absolutely essential and a hernia may in fact be defined as a hole in the endoabdominal fascia or transversalis fascia [3]. The prevalence of incisional hernia is about 15e20% in abdominal surgery and as low as 0.08e0.14% in laparoscopic surgery [1,2] in which the incision wound are within 1.5 cm. In all laparoscopic surgical patients, herniation usually affects the supraumbilical port site, the only location where open trocar insertion is employed. There was a trend for patients with trocar hernias to have a higher body mass index than those without hernias (mean BMI, 29.4 kg/m2 vs. 27.2 kg/m2, p 4 0.13) [4].
Fig. 2. A. Abdominal wall mass (broken line) located subcutaneously below the incision scar (black arrow) and skin striae (white arrow). B. Junction of the cystic mass and hernia (arrow head) with the open hernia sac (white arrow). C. hernia sac opening into the peritoneal cavity without any incarcerated viscera. D. Musculoaponeurotic defect (white arrow) just lateral to the rectus abdominis and linea semilunaris (black arrow).
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E.D. Sy, Y.-S. Shan / J Ped Surg Case Reports 3 (2015) 16e18
In drain site or trocar site with wound less than 1 cm, the fascial defect are usually not closed and sutured. This is based on the fact that the musculature of the abdominal wall that underlies the anterior fascia, together with the normal fascial elasticity, will usually prevent any herniation of the bowel through the small fascial defect and also prevent any future enlargement of the opening [5]. However, according to Reissman et al. and as shown by our case, it has been suggested that in both elderly and thin patients, the abdominal wall muscles tend to be weak with reduced strength and increased elasticity of the fascia [5]. The combination of such factors can thus lead to the development of late hernia. The process of formation of hydrocele in postoperative abdominal wall wound is somewhat similar in pediatric. During the embryogenesis [6], as the testis descends through the inguinal canal, the processus vaginalis is drawn into the scrotum. Hydrocele results, either when the processus vaginalis remains patent, allowing fluid from the peritoneum to accumulate in the scrotum or when the distal tunica vaginalis overlying the testis and the epididymis, which composed of two portions, visceral and parietal lamina, is not obliterated and constitutes the cavity of the tunica vaginalis. In postoperative drain site wound, reparative growth of the peritoneum and adhesion around the drain may occur especially when drain was place for a period of time. During removal of drain, the peritoneum may be drawn beyond the musculoaponeurotic layer of the abdominal wall leading to formation of peritoneal diverticulum. The persistent of fascial defect can lead to later incisional hernia. The pinching process of abdominal muscular contraction on the trapped muscular portion of peritoneal diverticulum may later obliterate, dividing the sac into supra and infra muscular portion. The inner surface of sac, which is covered by a layer of simple cuboidal mesothelial cells, secrete fluid and any process that acts to stimulate increased production of serous fluid (e.g., tumor, inflammation, trauma, hypoalbuminemia as in our case) or decreases the desorption of this fluid (e.g., obstruction of scrotal lymphatic or venous system) result in fluid accumulation and formation of a hydrocele. Diagnosis is easily made when a cystic mass is located below a surgical scar. Image studies, such sonogram [7], CT scan [8], MRI [7], can be used to differentiate the content of mass such as fat, blood, fluid and bowel loop and the continuity of mass with the abdominal cavity. Sonographic studies have the advantage of absence of radiation and low cost, however, the detection of small fascial defect may technically difficult especially when the sac pass thru the muscular layer. Thin sliced CT scan had the advantage of ability to define the anatomic relation of the mass and the abdominal cavity and detect the presence of musculo-aponeurotic defect as in our case while Tc-99 m DTPA peritoneal scintigraphy can be used to prove the non-communication of cystic mass with the peritoneal cavity [9] and further improve the surgical planning, however, it’s
cost effectiveness and usefulness in the management may be controversial. Management of drain site wound complication hernia/hydrocele includes preventive measures and surgical treatment. The former includes correct drain site insertion, which should be inserted via mid transmuscular route, early removal of drain when desired function stopped [10] and prior to fistula formation, debridement of significant epithelial or mesothelial growth within the drain wound, complete removable or reinsertion of any intraabdominal tissue into abdominal cavity that extrudes during removal of drain, fascial closure of drain site wound that significantly enlarged if possible [10] and nutritional support for proper wound healing. The latter should include total excision of hydrocele, fascial repair and hernial sac closure, preferably invertedly closed into the abdominal cavity (plication technique) [11], in order that the fluid-secreting surface of the sac is within the abdominal cavity and any fluid secreted is directly drain into the abdominal cavity. 3. Conclusion Postoperative abdominal wall hydrocele can occurs in transmuscular abdominal wall incisional hernia. The fascial defect should be repair and hernia sac is invertedly plicated into the abdominal cavity in order to avoid recurrence formation of hydrocele. References [1] Voiculescu S, Jitea N, Burcos T, Cristian D, Angelescu N. Incidents, accidents and complications in laparoscopic surgery. Chirurgia (Bucur) 2000;95:397e9. [2] Hussain A, Mahmood H, Singhal T, Balakrishnan S, Nicholls J, El-Hasani S. Long-term study of port-site incisional hernia after laparoscopic procedures. JSLS 2009;13:346e9. [3] Kevin M, Sittig MSR, McDonald John C. Abdominal wall, umbilicus, peritoneum, mesenteries, omentum, and retroperitoneum. In: David C, Sabiston J, editors. Textbook of surgery, the biological basis of modern surgical practice. 14th ed. Philadelphia, PA 19106: W.B. Saunders company; 1991. p. 722e35. [4] Bowrey DJ, Blom D, Crookes PF, Bremner CG, Johansson JL, Lord RV, et al. Risk factors and the prevalence of trocar site herniation after laparoscopic fundoplication. Surg Endosc 2001;15:663e6. [5] Reissman P, Shiloni E, Gofrit O, Rivkind A, Durst A. Incarcerated hernia in a lateral trocar siteean unusual early postoperative complication of laparoscopic surgery. Case report. Eur J Surg 1994;160:191e2. [6] Lao OB, Fitzgibbons Jr RJ, Cusick RA. Pediatric inguinal hernias, hydroceles, and undescended testicles. Surg Clin North Am 2012;92:487e504, vii. [7] Safak AA, Erdogmus B, Yazici B, Gokgoz AT. Hydrocele of the canal of Nuck: sonographic and MRI appearances. J Clin Ultrasound 2007;35:531e2. [8] Bernardy MO, Umer MA, Flanigan RC. Computed tomography of hydrocele of the tunica vaginalis. J Comput Assist Tomogr 1985;9:203e4. [9] Juergensen PH, Rizvi H, Caride VJ, Kliger AS, Finkelstein FO. Value of scintigraphy in chronic peritoneal dialysis patients. Kidney Int 1999;55:1111e9. [10] Makama JG, Ameh EA. Surgical drains: what the resident needs to know. Niger J Med 2008;17:244e50. [11] Ku JH, Kim ME, Lee NK, Park YH. The excisional, plication and internal drainage techniques: a comparison of the results for idiopathic hydrocele. BJU Int 2001;87:82e4.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery CASE REPORTS journal homepage: www.jpscasereports.com
Abdominal wall hydrocele: A rare late postoperative complication of drain site wound incisional herniaq Edgar D. Sy a, *, Yan-Shen Shan b a b
Section of Pediatrics Surgery, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan Department of Surgery, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 October 2014 Received in revised form 20 November 2014 Accepted 22 November 2014
Late postoperative abdominal wall hydrocele is a rare complication following surgery. It may be form from a small untreated incisional hernia that passed through the musculo-aponeurotic layer of the abdominal wall. Diagnosis is easily made by clinical history of prolonged non-tender, non-reducible cystic mass below an incisional scar. Hydrocele should always be suspected when CT scan showed a fluid containing mass in the subcutaneous layer of abdominal wall with the presence of musculo-aponeurotic defect and absence incarcerate viscera in patient with chronic hypoalbuminemia. Surgical treatment should include total excision of hydrocele, facial repair and closure of hernia sac, preferably invertedly close into the abdominal cavity in order that the fluid secreting portion of the sac drained directly into in the abdominal cavity. Ó 2015 The Authors. Published by Elsevier Inc. All rights reserved.
Key words: Abdominal wall hydrocele Incisional hernia Incisional hydrocele
Incisional hernia can occur in small incision such as in laparoscopic surgery with an incidence of about 0.08e0.14% [1,2] as a result of fascial defect. The formation of incisional hydrocele had never been reported and may occur when the hernial sac pass through the muscular layer of the abdominal wall. The pinching effect of muscle contraction causes obliteration of the intramuscular portion, dividing the sac into supra and infra muscular portion. The increased production or decreased desorption of serous fluid in the supra muscular portion may result in the formation of a hydrocele such as in patient with chronic hypoalbuminemia. 1. Case report This is a 28 y.o. female with history of biliary atresia who underwent Kasai’s procedure during the neonatal period and developed progressive biliary cirrhosis with sign and symptoms of hypoalbuminemia, ascites, pitting edema, splenomegaly and recurrent GI bleeding from esophago-gastric varices, which she was treated with endoscopic ligation and sclerotherapy. At age of 7
q This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/3.0/). * Corresponding author. Department of Surgery, Section of Pediatric Surgery, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng Li Road, Tainan 704, Taiwan. Tel.: þ886 6 2353535; fax: þ886 6 2766676. E-mail addresses: [email protected], [email protected] (E.D. Sy).
y.o., she underwent splenectomy with drain placed intraoperatively and exists in the left lower quadrant of the abdomen. At the age of 22 y.o., she started to notice a small mass over the left lower quadrant of the abdomen, which disappeared on pressure and supine position. However, at the age of 28 y.o, the mass gradually enlarged, without changes in size despite of pressure compression and supine position. Evaluation at the Pediatric OPD Department was done. A CT scan showed a 7e8 cm cystic mass, subcutaneously located with a musculo-aponeurotic defect of the abdominal wall below the cystic lesion (Fig. 1 AeD). A peritoneal scintigraphy, with direct injection of 3 mCi Tc-99 m DTPA into the cystic mass, showed accumulation of radiotracer within the mass, without extravasations into the abdominal cavity. She was referred to surgical department for further evaluation. Physical examination revealed a cystic lesion, about 7 cm in diameter, a 2e3 cm incision scar and striae above the mass (Fig. 2A). During the past 12 month, her serum albumin level ranged from 1.8 to 2.5 g/L and was treated with albumin infusion. She underwent surgical treatment and intraoperative finding showed a well-defined cystic lesion attached to distal end hernia sac (Fig. 2B). The hernial sac open into the peritoneal cavity with an opening orifice of about 1.5 cm (Fig. 2C), which pass through a musculo-aponeurotic defect just lateral to the linea semilunaris (Fig. 2D). The cystic lesion was excised, the hernial sac was inverted closed into the peritoneal cavity and the musculo-aponeurotic defect was repaired. Histopathologic examination showed that both the cystic lesion and
2213-5766/$ e see front matter Ó 2015 The Authors. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.epsc.2014.11.012
E.D. Sy, Y.-S. Shan / J Ped Surg Case Reports 3 (2015) 16e18
17
Fig. 1. Preoperative abdominal CT scan. A1. CT scan at preoperative 6 years, showed disrupted musculoaponeurotic layer (white arrow). A2 showed subcutaneously located lesion above the musculoaponeurotic layer of abdominal wall (arrow head). At preoperative two month, CT scan showed, B1 (transverse view) and B2 (sagittal view), persistent of disrupted musculoaponeurotic layer (white arrow) with about 7e8 cm cystic mass (C).
hernial sac were lined with mesothelial layer with chronic inflammation and congestion. 2. Discussion The term hydrocele literally means a sac of water. In the pediatric age group, it is due to non-obliteration of patent processus vaginalis. In postoperative small abdominal incision wound complicated with hernia, the obliteration of the midportion of the sac can lead to formation of hydrocele.
Integrity of the endoabdominal fascia is absolutely essential and a hernia may in fact be defined as a hole in the endoabdominal fascia or transversalis fascia [3]. The prevalence of incisional hernia is about 15e20% in abdominal surgery and as low as 0.08e0.14% in laparoscopic surgery [1,2] in which the incision wound are within 1.5 cm. In all laparoscopic surgical patients, herniation usually affects the supraumbilical port site, the only location where open trocar insertion is employed. There was a trend for patients with trocar hernias to have a higher body mass index than those without hernias (mean BMI, 29.4 kg/m2 vs. 27.2 kg/m2, p 4 0.13) [4].
Fig. 2. A. Abdominal wall mass (broken line) located subcutaneously below the incision scar (black arrow) and skin striae (white arrow). B. Junction of the cystic mass and hernia (arrow head) with the open hernia sac (white arrow). C. hernia sac opening into the peritoneal cavity without any incarcerated viscera. D. Musculoaponeurotic defect (white arrow) just lateral to the rectus abdominis and linea semilunaris (black arrow).
18
E.D. Sy, Y.-S. Shan / J Ped Surg Case Reports 3 (2015) 16e18
In drain site or trocar site with wound less than 1 cm, the fascial defect are usually not closed and sutured. This is based on the fact that the musculature of the abdominal wall that underlies the anterior fascia, together with the normal fascial elasticity, will usually prevent any herniation of the bowel through the small fascial defect and also prevent any future enlargement of the opening [5]. However, according to Reissman et al. and as shown by our case, it has been suggested that in both elderly and thin patients, the abdominal wall muscles tend to be weak with reduced strength and increased elasticity of the fascia [5]. The combination of such factors can thus lead to the development of late hernia. The process of formation of hydrocele in postoperative abdominal wall wound is somewhat similar in pediatric. During the embryogenesis [6], as the testis descends through the inguinal canal, the processus vaginalis is drawn into the scrotum. Hydrocele results, either when the processus vaginalis remains patent, allowing fluid from the peritoneum to accumulate in the scrotum or when the distal tunica vaginalis overlying the testis and the epididymis, which composed of two portions, visceral and parietal lamina, is not obliterated and constitutes the cavity of the tunica vaginalis. In postoperative drain site wound, reparative growth of the peritoneum and adhesion around the drain may occur especially when drain was place for a period of time. During removal of drain, the peritoneum may be drawn beyond the musculoaponeurotic layer of the abdominal wall leading to formation of peritoneal diverticulum. The persistent of fascial defect can lead to later incisional hernia. The pinching process of abdominal muscular contraction on the trapped muscular portion of peritoneal diverticulum may later obliterate, dividing the sac into supra and infra muscular portion. The inner surface of sac, which is covered by a layer of simple cuboidal mesothelial cells, secrete fluid and any process that acts to stimulate increased production of serous fluid (e.g., tumor, inflammation, trauma, hypoalbuminemia as in our case) or decreases the desorption of this fluid (e.g., obstruction of scrotal lymphatic or venous system) result in fluid accumulation and formation of a hydrocele. Diagnosis is easily made when a cystic mass is located below a surgical scar. Image studies, such sonogram [7], CT scan [8], MRI [7], can be used to differentiate the content of mass such as fat, blood, fluid and bowel loop and the continuity of mass with the abdominal cavity. Sonographic studies have the advantage of absence of radiation and low cost, however, the detection of small fascial defect may technically difficult especially when the sac pass thru the muscular layer. Thin sliced CT scan had the advantage of ability to define the anatomic relation of the mass and the abdominal cavity and detect the presence of musculo-aponeurotic defect as in our case while Tc-99 m DTPA peritoneal scintigraphy can be used to prove the non-communication of cystic mass with the peritoneal cavity [9] and further improve the surgical planning, however, it’s
cost effectiveness and usefulness in the management may be controversial. Management of drain site wound complication hernia/hydrocele includes preventive measures and surgical treatment. The former includes correct drain site insertion, which should be inserted via mid transmuscular route, early removal of drain when desired function stopped [10] and prior to fistula formation, debridement of significant epithelial or mesothelial growth within the drain wound, complete removable or reinsertion of any intraabdominal tissue into abdominal cavity that extrudes during removal of drain, fascial closure of drain site wound that significantly enlarged if possible [10] and nutritional support for proper wound healing. The latter should include total excision of hydrocele, fascial repair and hernial sac closure, preferably invertedly closed into the abdominal cavity (plication technique) [11], in order that the fluid-secreting surface of the sac is within the abdominal cavity and any fluid secreted is directly drain into the abdominal cavity. 3. Conclusion Postoperative abdominal wall hydrocele can occurs in transmuscular abdominal wall incisional hernia. The fascial defect should be repair and hernia sac is invertedly plicated into the abdominal cavity in order to avoid recurrence formation of hydrocele. References [1] Voiculescu S, Jitea N, Burcos T, Cristian D, Angelescu N. Incidents, accidents and complications in laparoscopic surgery. Chirurgia (Bucur) 2000;95:397e9. [2] Hussain A, Mahmood H, Singhal T, Balakrishnan S, Nicholls J, El-Hasani S. Long-term study of port-site incisional hernia after laparoscopic procedures. JSLS 2009;13:346e9. [3] Kevin M, Sittig MSR, McDonald John C. Abdominal wall, umbilicus, peritoneum, mesenteries, omentum, and retroperitoneum. In: David C, Sabiston J, editors. Textbook of surgery, the biological basis of modern surgical practice. 14th ed. Philadelphia, PA 19106: W.B. Saunders company; 1991. p. 722e35. [4] Bowrey DJ, Blom D, Crookes PF, Bremner CG, Johansson JL, Lord RV, et al. Risk factors and the prevalence of trocar site herniation after laparoscopic fundoplication. Surg Endosc 2001;15:663e6. [5] Reissman P, Shiloni E, Gofrit O, Rivkind A, Durst A. Incarcerated hernia in a lateral trocar siteean unusual early postoperative complication of laparoscopic surgery. Case report. Eur J Surg 1994;160:191e2. [6] Lao OB, Fitzgibbons Jr RJ, Cusick RA. Pediatric inguinal hernias, hydroceles, and undescended testicles. Surg Clin North Am 2012;92:487e504, vii. [7] Safak AA, Erdogmus B, Yazici B, Gokgoz AT. Hydrocele of the canal of Nuck: sonographic and MRI appearances. J Clin Ultrasound 2007;35:531e2. [8] Bernardy MO, Umer MA, Flanigan RC. Computed tomography of hydrocele of the tunica vaginalis. J Comput Assist Tomogr 1985;9:203e4. [9] Juergensen PH, Rizvi H, Caride VJ, Kliger AS, Finkelstein FO. Value of scintigraphy in chronic peritoneal dialysis patients. Kidney Int 1999;55:1111e9. [10] Makama JG, Ameh EA. Surgical drains: what the resident needs to know. Niger J Med 2008;17:244e50. [11] Ku JH, Kim ME, Lee NK, Park YH. The excisional, plication and internal drainage techniques: a comparison of the results for idiopathic hydrocele. BJU Int 2001;87:82e4.