Fig. 102.—Elephantiasis of the scrotum. After operation. Note change in mental state. (Fauntleroy.)
The flaps which are to cover the penis and testicles should be mapped out with shallow incisions and care must be exercised that only sound skin is included in these flaps. A horseshoe shaped incision is made commencing at the left side of the base of the tumor about 1 inch from the thigh and about at the level of the penis in health. The incision is carried downward and passes just below the opening of the penis on the tumor surface. A similar incision on the right side completes the horseshoe curve. Next a downward incision in the sound skin is made over the posterior surface of the tumor, thus encircling the base of the scrotum. The anterior horseshoe incision is now deepened to free the penis, care being taken not to injure the spermatic cord. Next the incisions are deepened laterally until the testicles are reached. The testicles are usually in the center of the tumor imbedded in a blubbery tissue from which they can be easily stripped. The remains of the gubernacula are then hooked up and cut close to the testicles. The tunicae vaginales are often thickened and contain fluid which has to be drawn off.
In 60% of Fauntleroy’s cases it was necessary to remove one testicle on account of extensive disease. One must also bear in mind the possibility of hernial complications and undescended testicle.
A sound is now introduced into the urethra and the septum of the scrotum divided close to the sheath of the penis, then dissecting away the blubbery tissue. At this stage there may be considerable bleeding.
The testicles and spermatic cords are then dissected away from the tunicae vaginales. The penis is now freed by a circular incision around and above the opening in the anterior part of the mass. The remainder of the horseshoe flap is now dissected up and the penis freed. The proximal covering for the penis is made from this horseshoe flap which is stitched to the distal one shaped from the prepuce, carefully trimmed of elephantoid tissue.
The lateral flaps are brought together with linen or silk-worm gut sutures leaving space for a drainage tube and we thus form a new scrotum for the testicles.
The mortality is usually given as 5% but Fauntleroy did not lose a case among 149 such operations, the tumors varying from 10 to 85 pounds in weight.
Chylous Hydrocele
Filarial affections of the tunica vaginalis or the testicle itself are not rare. In the milky fluid obtained by tapping such a hydrocele we may find filarial embryos.