Received: 12 September 2019 Revised: 22 October 2019 Accepted: 4 November 2019

DOI: 10.1111/ases.12769

CASE REPORT

Laparoscopic total extraperitoneal treatment for a

hydrocele of the canal of Nuck located entirely within the
inguinal canal: A case report

Shigehiro Kojima | Tsuguo Sakamoto

Department of Surgery, Sainokuni

Higashiomiya Medical Center, Saitama,
Japan
Correspondence
Shigehiro Kojima, Department of Surgery,
Sainokuni Higashiomiya Medical Center,
1522 Toro, Kita, Saitama 331-0804, Japan.
Email: shigehiro.kojima@shmc.jp
Abstract
A 43-year-old woman was diagnosed with a hydrocele of the canal of Nuck, for
which laparoscopic total extraperitoneal excision was successfully undertaken.
The hydrocele was located entirely within the inguinal canal and was barely
visible at the internal inguinal ring, even with strong retraction. The inferior
epigastric vessels were at risk of injury secondary to excessive tension when
retracting the round ligament. To overcome these problems, the hydrocele was
approached from the medial side of the inferior epigastric vessels across
the transversalis fascia. This approach allowed us to reach the distal end of the
hydrocele and avoid excessive traction on the vessels. Thus, a hydrocele of the
canal of Nuck can be addressed successfully with minimally invasive laparo-
scopic total extraperitoneal excision. Approaching the hydrocele from the
medial side of the inferior epigastric vessels across the transversalis fascia may
be useful.

KEYWORDS
cyst, laparoscopy, minimally invasive surgery

1 | INTRODUCTION 2 | CASE PRESENTATION

Hydroceles of the canal of Nuck are rare, with the inci-
dence in adult women still unclear.1 However, general
surgeons sometimes encounter this condition, and some
cases involve difficult decisions regarding the diagnostic
approach and/or the therapeutic course because of the
condition's rarity. The recommended treatment involves
excising the hydrocele and closing the enlarged inguinal
ring,2 which is usually performed using the anterior
approach. We report a patient with a hydrocele of the
canal of Nuck located entirely within the inguinal canal.
The patient underwent successful laparoscopic total
extraperitoneal (TEP) excision across the transversalis
fascia.
A 43-year-old woman was referred to our hospital with
an inguinal mass that had been gradually increasing in
size for 3 months. The patient had inguinal pain which
she thought might be associated with her menstrual
cycle. Physical examination showed a thumb-sized
unreducible mass in the left inguinal area. Ultrasonogra-
phy revealed a simple cyst—an anechoic fluid collection
with a thin wall. Color Doppler revealed a lack of inter-
nal vascular flow. We diagnosed the inguinal mass as a
hydrocele of the canal of Nuck. When considering the
therapeutic plan, we consulted the patient, who stated
that she had no desire for pregnancy in the future and
agreed to the use of mesh if her internal inguinal ring

© 2019 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd

Asian J Endosc Surg.. 2019;1–4. wileyonlinelibrary.com/journal/ases 1

2 KOJIMA AND SAKAMOTO

was indeed enlarged. As she was mainly concerned about

early resumption of work, we selected a laparoscopic
technique.
Under general anesthesia, a 15-mm longitudinal inci-
sion was made on the lower aspect of the umbilicus and a
12-mm blunt-tip trocar placed in the extraperitoneal space.
A 3-mm working port was then established under the lap-
aroscope directly below the first trocar. After performing
extraperitoneal dissection with 3-mm monopolar scissors
on the midline toward Cooper's ligament, we placed an
additional 5-mm working port three finger widths above
the pubic symphysis. Further extraperitoneal dis-
F I G U R E 2 The ligated stump of the round ligament was
section was carefully performed. The hydrocele was not
retracted through the medial side of the inferior epigastric vessels
observed in the extraperitoneal space, but by pulling on after dissecting the transversalis fascia (white arrow, hydrocele of
the round ligament (Figure S1), we could see its proximal the canal of Nuck; black arrowheads, inferior epigastric vessels;
portion, which appeared at the internal ring dashed circle, left internal inguinal ring; white arrowheads,
The hydrocele was located entirely within the ingui- opening in the transversalis fascia)
nal canal and, even with strong retraction of the round
ligament, the hydrocele was barely visible at the internal
inguinal ring. Moreover, the inferior epigastric vessels
were at risk of injury secondary to excessive tension
when the round ligament was medially retracted
(Figure 1). To avoid injuring the inferior epigastric ves-
sels, we first transected the round ligament proximally
using laparoscopic coagulating shears. We then, after dis-
secting the transversalis fascia, retracted the ligated
stump through the medial side of the epigastric vessels
(Figure 2). This maneuver permitted further dissection of
the hydrocele, and we eventually succeeded in reaching
its distal end (Figure 3). We then transected the distal
side of the round ligament and placed the resected speci- F I G U R E 3 Approaching the hydrocele from the medial side
men in an endo-bag, which was extracted through the of the inferior epigastric vessels across the transversalis fascia
12-mm trocar. There was no intraoperative injury to the allowed us to reach the distal end of the hydrocele (white arrow,
cyst wall (Figure S2). A lightweight polypropylene mesh hydrocele of the canal of Nuck; black arrowheads, inferior
was introduced to cover the entire myopectineal orifice; epigastric vessels; white arrowheads, opening in the transversalis
we did not use staples or glue to fix the mesh (Figure S3). fascia)

All skin incisions were infiltrated with local anesthetic

and then closed (Figure 4).
Histological examination of the surgical specimen
revealed that the cystic wall was lined by a single layer of
mesothelial cells and that the cyst consisted of fibrous
components without endometrial glands or stroma. The
patient had an uneventful postoperative course and was
discharged the next day.

F I G U R E 1 The inferior epigastric vessels were at risk of
injury secondary to excessive tension when the round ligament was
retracted medially (white arrow, round ligament; black arrowheads,
inferior epigastric vessels; dashed circle, left internal inguinal ring)
3 | DISCUSSION
Our patient's course suggested two important clinical
issues. First, minimally invasive TEP can be used success-
fully to treat a hydrocele of the canal of Nuck. To the best
KOJIMA AND SAKAMOTO
FIGURE 4 Appearance of the wounds two weeks after
surgery
of our knowledge, few reports have reported successful
treatment of a hydrocele of the canal of Nuck using the
laparoscopic TEP technique.2 Surgery to remove a hydro-
cele of the canal of Nuck is usually performed using the
anterior approach. Because these hydroceles occur more
commonly in young women; however, when determining
the therapeutic course due consideration should be given
to the patient's early recovery and preserving her cos-
metic appearance. For inguinal hernioplasty, TEP results
in a significantly earlier return to work and better
cosmesis than an open operation.3 These advantages of
TEP should be considered when choosing the best opera-
tion to remove a hydrocele of the canal of Nuck.
Second, approaching the hydrocele from the medial
side of the inferior epigastric vessels across the tra-
nsversalis fascia may be useful for overcoming the oper-
ative difficulty associated with treating hydroceles of
the canal of Nuck. A previous report concluded that
TEP could be useful when hydroceles are in the
extraperitoneal space.2 However, technical difficulty
increases when the hydrocele is in the inguinal canal, as
in our patient, because the entire hydrocele cannot be
easily retracted through the internal inguinal ring. Fur-
thermore, excessive traction force can damage the infe-
rior epigastric vessels and cystic wall. Our approach
allowed us to easily reach the distal end of the hydrocele
and avoided excessive retraction force on the vessels.
Hydroceles of the canal of Nuck are divided into three
types according to the hydrocele's communication with
the peritoneal cavity.4 However, it is often difficult to
3
intraoperatively determine the presence or absence of
communication. Therefore, ligating the proximal side of
the hydrocele is required to prevent cellular dissemina-
tion because endometriosis and angiomyofibroblastoma
in the canal of Nuck have been reported.5-8 Grasping the
hydrocele directly should be avoided as much as possible.
Even with a laparoscopic approach, conversion to an
anterior approach should be performed without hesita-
tion in the event of technical difficulty.
In conclusion, minimally invasive laparoscopic TEP
excision of hydroceles of the canal of Nuck can be suc-
cessfully performed with optimal cosmetic outcomes.
Approaching the hydrocele from the medial side of the
inferior epigastric vessels across the transversalis fascia
may be useful.
ACKNOWLEDGMENTS
The authors thank Yukiko Arai for image editing. We
thank Jane Charbonneau, DVM, from Edanz Group
(www.edanzediting.com), for editing a draft of this
manuscript.
CONFLICT OF INTEREST
The authors have no conflicts of interest to declare.
AUTHOR CONTRIBUTIONS
S.K. participated fully in the patient's clinical treatment
and follow-up and drafted the manuscript. T.S. provided
final approval of the version to be published. All authors
read and approved the final manuscript.
DA TA A C C ES SI B I LI TY
Data sharing is not applicable to this article as no
datasets were generated or analyzed.
ET HI CS S TA TE MEN T
The present study was approved by the institutional
ethics review board of Sainokuni Higashiomiya Medical
Center. Written informed consent was obtained from the
patient for publication of this article.
ORCID
Shigehiro Kojima https://orcid.org/0000-0003-0321-
7419
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SU PP O R TI N G I N F O RMA TI O N
Additional supporting information may be found online
in the Supporting Information section at the end of this
article.
How to cite this article: Kojima S, Sakamoto T.
Laparoscopic total extraperitoneal treatment for a
hydrocele of the canal of Nuck located entirely
within the inguinal canal: A case report. Asian
J Endosc Surg. 2019;1–4. https://doi.org/10.1111/
ases.12769