• Processus vaginalis - forms during 3rd month of gestation as peritoneum bulges into inguinal canal, just before testicular descent
• Supposed to obliterate after descent; 20% are closed at term, 60% after 1-2 years of age; 80% in adulthood
• Majority of hydroceles before puberty are a/w patent processus vaginalis = communicating hydrocele
• Widely patent processus = indirect inguinal hernia
• Closure proximally/distally = hydrocele of spermatic cord/encysted hydrocele
• Closure distally (not in scrotum, but in inguinal canal) = funicular hydrocele
• Majority of hydroceles that spontaneously resolve during infancy or appear after puberty = noncommunicating - delayed fluid absorption, or in response to trauma/inflammation
• If no evidence of communication (fluctuating/enlarging in size), wait til after 6-12 mo of age to see if hernia will resolve spontaneously

Adult

• Transverse incision on hemiscrotum through dartos
• Take down layers to tunica vaginalis, bring out/evert testicle
• Open tunica, drain hydrocele
• Open tunica along length of cord, and evert
• Trim excess, cauterize edges
• Evert edges and either oversew (3-0 Vicryl running), or sew edges together behind testicle (Jaboulay)
• Check hemostasis, do cord block (0.25% Marcaine)
• Put testicle back into scrotum
• Close dartos with 2-0 Vicryl suture
• Close skin with 3-0 Chromic
• (Eisenberg does dartos with 3-0 chromic, skin with 4-0 vicryl)

Peds

• If communicating and < 2 y old, frequently do diagnostic lap to check other side due to increased incidence of contralateral patent processus. If > 2 y old and have not manifested yet, then just do one side
• Want to repair communicating due to risk of incarcerated hernia

Hydrocelectomy/hernia repair

• Inguinal incision
• Divide Scarpas, incise external
• Isolate hernia sac/patent processus (anteromedial)
• Suture ligate with 4-0 Vicryl
• Rate of recurrence of inguinal hernia after open repair - 0.5-1%.