THE ABDOMINOSCROTAL HYDROCELE

While hydrocele is among the commonest inguinal anomalies in children, less than 20 cases have been reported of its extreme form, the abdomi noscrotal hydrocele (ASH). This anomaly consists of a large inguinoscr otal hydrocele which communicates in an hour-glass fashion with a larg e ''intra-abdominal'' component. The latter lies deep to the narrow in ternal inguinal ring, but superficial to the peritoneal cavity proper, which is displaced superiorly and medially. The abdominal component o f the ASH thus lies latero- and retroperitoneally, sometimes reaching the lower pole of the kidney. We report five ASH in four children unde r one year old. All four underwent complete resection of the ASH. If t he abdominal portion of the hydrocele can not be delivered through a s tandard approach, we advocate a properitoneal approach as described fo r recurrent adult hernias. The external oblique, internal oblique and transversalis muscles are divided horizontally above the level of the internal inguinal ring. The peritoneal cavity is retracted superiorly, separating it from the ASH. By decompressing the scrotal component of the ASH, its abdominal part can be emptied through the narrow communi cation at the internal ring. In this fashion, the processus vaginalis can be identified and ligated deep to internal ring, and the floor of the inguinal canal is left intact. The pathophysiology of ASH is not c lear. A one-way valve effect of the patent processus vaginalis may be one cause of the massive accumulation of peritoneal fluid in the ASH. Complete resection is curative, and the properitoneal approach should be considered.