This script is in the process of conversion from a pdf file to a wiki file.
In the meantime you can still use the pdf version below.
EPIDIDYMAL CYST EXCISION
GRADE 3 (VERY DIFFICULT)
A PANTOGEN OPERATION SCRIPT
MICHAEL EDWARDS
THIS SCRIPT COVERS:
SINGLE EPIDIDYMAL CYST
MULTIPLE EPIDIDYMAL CYSTS
RECURRENT EPIDIDYMAL CYST(S)
Be prepared for a difficult dissection in
tough fibrous tissue with many delicate
vessels.
BILATERAL EPIDIDYMAL CYSTS
CHRONIC EPIDIDYMITIS usually tuberculous, unresponsive to
chemotherapy. A very rare circumstance.
OTHER EPIDIDYMAL SWELLINGS eg. sperm granuloma.
GENERAL/EPIDURAL/SPINAL ANAESTHESIA
Local anaesthesia is unlikely to give
satisfactory pain control during the
operation.
STAGES
STEPS
1 PRELIMINARIES
9 ANAESTHESIA
10 POSITION
11 STANCE
12 PREPARE THE SKIN
18 INCISE THE SKIN
21 FIND THE CYST(S)
25 TREAT THE CYST(S)
34 CLOSURE
41 FINAL TOUCHES
47 EQUIPMENT LIST
48 MATERIALS LIST
QUICK STEPS First steps
SURGEON
STEP
NUMBER
1 PRELIMINARIES - READ ON
2 CHECK YOU HAVE THE CORRECT PATIENT
3 CHECK THE PATIENT KNOWS THE OPERATION CAN LEAD TO
STERILITY
4 CHECK THE CORRECT SIDE
5 CHECK ANY NEW CYSTS ON EITHER SIDE
6 CHECK THERE IS NO OTHER PROCEDURE TO DO
7 CHECK THERE IS A DIATHERMY PAD
8 CHECK THE SCROTUM IS COMPLETELY SHAVED
9 ANAESTHESIA - GENERAL ANAESTHESIA
10 POSITION Supine with the feet apart to allow access to
the scrotum.
11 STANCE Stand on the side of the largest cyst, with
your one assistant on the opposite side.
12 PREPARE THE SKIN from the inguinal ligament to mid-thigh
and from one anterior superior iliac crest to
the other, including the scrotum and penis.
Use 2 swabs on sticks with 0.5% Chlorhexidine
in 70% Propanol, followed by one to dry off.
13 TOWEL UP with a lower towel over the lower limbs up to the
groin skin creases, with the scrotum lying on
top. (Lift the scrotum up to do this).
Draw an upper towel upwards to the base of
the penis to expose the front of the scrotum
with the penis tucked upwards out of the way.
Place lateral towels over the thighs.
14 FIX THE TOWELS with towel clips.
15 CHECK THE DIATHERMY is working.
16 START WITH THE BIGGEST CYST
17 GRASP THE TESTIS AND CYST with your left hand, so that
they are fixed firmly against the stretched
scrotal skin.
18 INCISE THE SKIN over the testis and cyst.
Make the incision big enough to let the cyst
and testis out through the wound.
Place the incision on the lateral side of the
testis, so that you will open into the tunica
when the wound is deepened, and not into the
side of the epididymis.
Incise between the vessels you see running
under the skin to avoid bleeding.
19 DEEPEN THE INCISION into the sub dartos tissues with a
scalpel until you open the tunica.
Keep holding the testis and cyst in your left
hand during this procedure.
Avoid or coagulate vessels in the subdartos
tissues to prevent bleeding.
When the tunica is opened, you will see the
testis bulging through the opening, or straw-
coloured hydrocele fluid leaking out.
20 STRETCH THE OPENING IN THE TUNICA with your fingers widely
enough to let the testis and cyst(s) through.
21 FIND THE CYST(S) - READ ON
22 DELIVER THE TESTIS AND CYST(S) into the wound.
23 EXAMINE THE TESTIS
If you have cut the covering of the testis
so that seminiferous tubules are leaking out,
repair the defect with a continuous 2/0
catgut stitch (Ethicon W441).
If there is more than 5ml. of hydocele fliud,
plicate the tunica later.(not until STEP 30).
Treat other diseases of the testis on their
own merits.
24 EXAMINE THE EPIDIDYMIS
FOR a typical bluish, thin-walled epididymal
cyst, or cysts, on the upper epididymis,
DO a PARTIAL EPIDIDYMECTOMY - GO TO STEP 25
A partial epididymectomy will remove all the
cysts plus epididymal tissue which is
potentially cystic.
It avoids the problem of cyst rupture before
removal.
FOR all other well defined epididymal
swellings, and chronic tuberculous
epididymitis,
DO a PARTIAL EPIDIDYMECTOMY - GO TO STEP 25
If there is just indefinite epididymal
thickening, consider just taking a biopsy for
histology and bacteriology.
GO TO STEP 30 (PLICATE THE TUNICA).
25 TREAT THE CYST(S)/SWELLING - READ ON
DO A PARTIAL EPIDIDYMECTOMY.
The steps for CYSTS apply equally for
SWELLINGS.
26 DISSECT OUT CYST-BEARING EPIDIDYMIS using artery forceps
dissection.
Aim to remove only 5mm. of normal epididymis
around the cyst.
Find a plane between the epididymis and the
testis.
Coagulate vessels as you meet them.
Avoid vessels supplying the testis.
Free the cyst-bearing epididymis from the
testis so that it is held only by the lower
part of the vas and the upper part of the
more distal epididymis.
27 CLIP THE CYST-BEARING EPIDIDYMIS top and bottom with
artery forceps.
28 CUT THE CYST-BEARING EPIDIDYMIS FREE and send it for
histological examination.
29 TRANSFIX AND TIE THE CLAMPED TISSUE with 0 silk (Ethicon
W334)
Make sure there is no bleeding from the cut
ends.
Cut the ends 10mm. long.
30 PLICATE THE TUNICA if there were more the 5ml.of hydrocele
fluid originally.
Plicate the loose tunica which lies on the
epididymis and spermatic cord
Use interrupted stitches of 2/0 silk (Ethicon
333) in a radial fashion 1cm.apart.
Pass each stitch 4 times through the tunica
to gather the tunica up into pleats
(plication).
This plication should prevent the reformation
of hydrocele fluid.
31 CHECK HAEMOSTASIS, particularly on the testis.
32 RETURN THE TESTIS to the inside of the scrotum.
This can be quite difficult, particularly after a tunica plicaation.
Take your time.
33 CHECK THE SWAB, NEEDLE, AND INSTRUMENT COUNTS
34 CLOSURE - READ ON
35 CLOSE THE WOUND in a single layer using deep interrupted
skin stitches of 2/0 catgut (Ethicon W440).
This will control bleeding from skin and
subdartos tissues.
36 FOR EPIDIDYMAL CYST(S) ON THE OTHER SIDE
Change your gloves
GO BACK TO STEP 17 (GRASP THE TESTIS AND
CYST)
37 SPRAY THE WOUND with Nobecutaine.
38 CHECK THERE IS NO OTHER PROCEDURE TO DO
39 DRESS THE WOUND with 10 dry gauzes.
40 FIT ELASTIC NET PANTS to hold the dressings in place.
41 FINAL TOUCHES
42 PULL EACH TESTIS into a correct positionin the scrotum.
43 WRITE LEGIBLE OPERATION DETAILS
44 FILL IN THE SURGICAL AUDIT FORM
45 FILL IN THE HISTOLOGY FORM
46 DICTATE AN OPERATION LETTER TO THE GENERAL PRACTITIONER
47 EQUIPMENT LIST
48 MATERIALS LIST
(You will need Abobe Acrobat Reader which can be downloaded from here)
WE WELCOME YOUR COMMENTS
- Click on the Discussion tab at the top of the Wikisurgery screen.
- Type in your comment.
- Remember to sign your name and institution on the comment.
- You can sign your name by clicking on the second icon on the right at the top of this
- editing screen or just type in 4 tildes. (A tilde looks like this ~)
Michael Edwards
