Laparoscopic Versus Open Surgical Management of Hydrocele of the Canal of Nuck: A Retrospective Analysis of 20 Cases

Abstract

Introduction: Hydrocele of the canal of Nuck is a condition that arises due to incomplete obliteration of the processus vaginalis or an abnormal outpouching from the round ligament during fetal development. It usually presents as a painless, rarely painful, groin swelling. The definitive diagnosis for this condition is magnetic resonance imaging. Various management options have been proposed for this condition, including open surgery, transabdominal preperitoneal approach, totally extraperitoneal approach, and a combination of laparoscopic and open surgery. The present study highlights the benefits of the transabdominal preperitoneal approach when compared with the open anterior approach and addresses the intraoperative challenges faced during laparoscopic surgery.

Materials and methods: The study is a retrospective study inclusive of 20 patients who underwent surgery for the hydrocele of the canal of Nuck from June 2019 to December 2023. Case records of patients were studied for information such as demographic features, type of pathology, the surgery performed, intraoperative challenges encountered, operative time, duration of hospital stay, scores from the visual analog scale pain assessment chart at various intervals, and time taken to return to work. The variables were documented and statistically analyzed.

Results: The average age group of the study population was 27.8 ± 8.34 years. Of the 20 patients, 10 had undergone a transabdominal preperitoneal approach (Group A), and 10 had undergone an open anterior approach (Group B). Eleven out of 20 patients had an associated inguinal hernia, of which three were identified preoperatively and eight were identified incidentally during surgery. The mean operative time of Group A cases was 97.95 ± 7.54 minutes, while it was 66.3 ± 6.20 minutes for Group B cases. The Mann-Whitney U test showed a statistically significantly lesser operative time for Group B than for Group A (p-value < 0.001). The duration of hospital stays was comparable for the two groups with no significant difference (two days versus 3.8 ± 3.08 days, respectively). When the difference in the means of time taken to return to normal work was compared using the Mann-Whitney U test between Group A and B (6.1 ± 0.87 days and 11.2 ± 1.81 days, respectively), a statistically significant early return to normal work in the former group (p-value = 0.001) was revealed. Similarly, the Mann-Whitney U test when used to compare the median postoperative pain score of both groups at 12-24 hours, 48-72 hours, seven days, and three months showed a significantly lesser pain score among patients of Group A at all intervals (p-value < 0.001, p-value = 0.005, p-value = 0.005, p-value < 0.001, respectively). The incidence of intraoperative challenges, sero-hematoma, and surgical site infection were insignificant in comparison.

Conclusion: The transabdominal preperitoneal approach for the hydrocele of the canal of Nuck is ideal as it offers excellent intraoperative delineation of pathology and postoperative outcomes. Prophylactic placement of a mesh in all cases can help prevent a future occurrence of inguinal hernia in these cases.

Keywords: hydrocoele of canal of nuck; magnetic resonance imaging; open anterior approach; processus vaginalis; trans-abdominal pre-peritoneal approach.

Figure 1. Port placement for TAPP approach. A 10-mm camera port was placed 1.5 cm above the umbilicus, and two 5-mm working ports were placed as shown in the clinical image, 5 cm lateral to the umbilicus

TAPP: Transabdominal preperitoneal.

Figure 2. Steps of TAPP approach to HCN. (A) Cyst seen entering the deep ring. (B) Lateral traction was applied, and the cyst was separated from the artery and attached to the fascia transversalis. The black arrow indicates the IEA. (C) The distal most part of the cyst was dissected. (D) An indirect hernial sac is seen entering the internal ring. The black arrow shows the hernial sac, and the white arrow shows the widened internal ring. (E) Polypropylene mesh was fixed medially to Cooper’s ligament. (F) Polypropylene mesh covered the defect in the deep ring.

TAPP: Transabdominal preperitoneal; IEA: Inferior epigastric artery; HCN: Hydrocele of the canal of Nuck.

Figure 3. Mean operative time among patients of Group A and Group B

The mean operative time was lesser for Group B patients as compared to patients of Group A when compared using the Mann-Whitney U test (Z = -3.781, p-value < 0.001).

Figure 4. Duration of hospital stay and time taken to return to work

The Mann-Whitney U test revealed that the time taken to return to work was significantly less for patients in Group A when compared to Group B (Z = -3.841, p-value < 0.001). TAPP: Transabdominal preperitoneal; OAA: Open anterior approach.