Pre-op Diagnosis: Hydrocele, left [N43.3]
Post-op Diagnosis: Large left hydrocele s/p left hydrocelectomy
Procedure(s): Left - HYDROCELECTOMY - Wound Class: Clean
Proc. Description(s) & CPT Code(s): HYDROCELECTOMY: 55040 (CPT®)
Anesthesia: General
Surgeon(s) and Role:
Wayne J Hellstrom (primary)
Garrett Brinkley (assistant 1)
Estimated Blood Loss: 5mL
Quantitative Blood Loss: 5mL
Drain: None
Total IV Fluids: see anesthesia report
Indication:
*** y/o african american male presented to OR today for surgical management of large left hydrocele that causes discomfort and dull pain. Preoperative scrotal ultrasound confirmed large left sided fluid filled sac.
Specimens:
None
Implants: none
Complications: none
Findings:
1. Large left hydrocele, filled with 400cc of straw colored fluid
2. Normal left testis and epididymis
Technique:
The indications, alternatives, benefits, and risks were discussed with the patient and informed consent was obtained.
The patient was brought onto the operating room table, positioned supine, and secured with a safety strap. All pressure points were carefully padded and pneumatic compression devices were placed on the lower extremities.
After the administration of intravenous antibiotics and general, the patient’s scrotum was examined and the left hydrocele palpated. The lower abdomen and external genitalia were prepped and draped in the standard sterile manner.
A time‐out was completed, verifying the correct patient, surgical procedure, site, and positioning, prior to beginning the procedure.
A 4 cm skin incision from medial to lateral over the lateral scrotum immediately over the hydrocele. The dartos fascia was incised, exposing the hydrocele. The hydrocele was excised and the fluid was aspirated. Approximately 400mL of straw colore fluid was removed. Using manual pressure, the testicle was delivered. Usint the Lord technique, the edges of the sac were plicated with 7 4-0 monocryl sutures in a clock format. All bleeding points were cauterized, maintaining meticulous hemostasis.
The testis, epididymis and spermatic cord were inspected and found to be intact without any evidence of injury. They were carefully placed back into the scrotum, in their normal anatomic position, making sure that the spermatic cord was not twisted.
The dartos fascia was closed with interupted horizontal mattress 4-0 monocryl sutures and the skin was closed with interrupted horizontal mattress 4-0 monocryl sutures. Dermabond was applied over closed scrotal incision. The incision was covered with kerlex and coban, and an athletic supporter was applied to help minimize swelling.
At the end of the procedure, all counts were correct.
Dr. Hellstrom was scrubbed and active throughout the entire procedure.
Disposition: awakened from anesthesia, extubated and taken to the recovery room in a stable condition, having suffered no apparent untoward event.
Condition: doing well without problems
Post Procedure Instructions:
1. Will come to clinic in 3 weeks for postop wound check.
Garrett Brinkley
Tulane Urology PGY1