Epidermal Cyst - Operative Notes

Preoperative

• Cosmetic concern or symptomatic enlargement
• Recurrent inflammation or prior rupture
• Rapidly enlarging lesion (to exclude rare malignant transformation - SCC, BCC, melanoma have been reported)
• Curative excision after resolution of acute infection (I&D performed as a separate prior procedure if acutely infected)

Anaesthesia

• Local infiltration anaesthesia - standard for solitary lesions
• General anaesthesia - if multiple cysts are to be removed at once
• Agent: 1% lidocaine +/- adrenaline (1:100,000) infiltrated circumferentially around the cyst

Patient Position

Procedure

1. Preparation

• Skin cleaned with antiseptic (chlorhexidine or betadine)
• Sterile draping applied

2. Skin Incision

• An elliptical incision is made centered on and including the punctum (the comedo-like central pore that identifies the cyst)
• The ellipse is made longer than the cyst and approximately one-third of the cyst diameter in width
• The ellipse of skin with the punctum is excised, serving as a handle and preventing cyst rupture
• Incision carried down to the level of the cyst capsule

3. Dissection and Cyst Enucleation

• The line of cleavage is identified between the cyst wall and surrounding subcutaneous tissue
• If the cyst has never been infected, it shells out readily with blunt and sharp dissection
• A suture may be looped through the cyst and overlying skin to provide traction during dissection
• The cyst is freed circumferentially, avoiding rupture

4. If Cyst Ruptures

• Express all contents and meticulously excise all cyst wall fragments - retained epithelium causes recurrence
• A curette may be used to scrape out residual fragments of the cyst wall
• Alternatively, the lining can be eradicated by cauterisation with 20% trichloroacetic acid

5. Cyst Wall (Capsule)

• The pearly white capsule is the key structure - it must be completely removed to prevent recurrence
• If the cyst was previously infected (inflamed, adherent), it will be more firmly adherent and require careful sharp dissection
• For infected cysts: a two-stage approach is acceptable - I&D acutely, then formal capsule excision at a subsequent visit once inflammation has resolved. Alternatively, complete excision can be performed at the initial operation.

6. Inspection of Wound

• Confirm complete removal of capsule and any "daughter" cysts
• Achieve haemostasis with diathermy or pressure
• Irrigate wound with saline

7. Closure

• Dead space is obliterated with interrupted absorbable deep sutures (e.g. 3-0 Vicryl) if required
• Skin closed with interrupted non-absorbable sutures (e.g. 3-0 Prolene or 4-0 Nylon) or subcuticular absorbable suture depending on site and surgeon preference
• Dressing applied

Postoperative

• Wound check at 48-72 hours
• Suture removal at 7-10 days (face) or 10-14 days (trunk/extremities)
• Specimen sent for histology - mandatory if any atypical features (rapid enlargement, hard consistency, ulceration)
• Advise patient: recurrence is possible if any capsule remains; report any new swelling or signs of infection

Alternative / Minimally Invasive Technique

• A 4 mm punch biopsy tool can be used to make a small circular incision over the punctum, and the cyst contents and wall are expressed or retrieved through this small opening - suitable for smaller, non-infected cysts with a clear punctum
• This results in a smaller scar but carries a higher risk of incomplete removal

Notes on Infected / Inflamed Cysts

1. Primary resection at initial presentation - faster healing, fewer pain days, less scarring (supported by an RCT by Kitamura et al., 71 patients)
2. Staged approach - I&D first, formal excision once inflammation has fully settled

Jaboulay's Procedure (Hydrocelectomy by Eversion) - Operative Notes

Background

• Lord's plication - sutures plicate the sac without excision; lowest haematoma risk; for thin-walled, small hydroceles
• Jaboulay's eversion - partial excision + eversion; for moderate to large, thin/floppy sacs
• Simple excision - full sac excision with oversewn edges; for thick-walled, chronic, or multiloculated hydroceles

Indications

• Large, symptomatic primary (vaginal) hydrocele
• Secondary hydrocele once underlying cause (infection, tumour) is excluded
• Thin to moderately thick-walled sac (Jaboulay preferred over Lord's when sac is too large to plicate)
• Patient preference for definitive surgical treatment over aspiration/sclerotherapy

• Suspected testicular malignancy - hydrocele must not be punctured (risk of malignant needle-track implantation); inguinal approach required
• Acute infection (pyocele) - treat infection first
• Communicating (congenital) hydrocele in children - requires inguinal herniotomy, not scrotal approach

Preoperative

• Investigations: Scrotal ultrasound to confirm hydrocele, exclude underlying testicular pathology (epididymo-orchitis, torsion, tumour), assess sac thickness
• Tumour markers (AFP, bHCG, LDH) if any doubt about testicular malignancy
• Consent: risks - haematoma (most common significant complication), wound infection, recurrence, injury to vas deferens or testicular vessels, chronic scrotal pain

Anaesthesia

• General anaesthesia (most common in adults)
• Spinal anaesthesia is an acceptable alternative
• Local infiltration alone is generally insufficient for larger hydroceles

Patient Position

Procedure

1. Incision

• A transverse or longitudinal anterior scrotal incision is made over the most prominent aspect of the hydrocele
• Incision carried through skin and dartos muscle
• The investing layers (external spermatic fascia, cremasteric fascia) are divided to expose the bluish, tense parietal layer of the tunica vaginalis

2. Delivery of the Sac

• The hydrocele sac is delivered through the wound into the operative field
• The sac is inspected - note its size and wall thickness

3. Aspiration / Opening the Sac

• A stab incision is made into the anterior surface of the tunica vaginalis to drain the hydrocele fluid
• The incision is extended with scissors to open the sac widely along its anterior surface
• Fluid is expressed and swabbed out
• The testis, epididymis, and spermatic cord are inspected for any underlying pathology

4. Partial Excision of the Tunica (Key Step)

• The excess / redundant parietal tunica vaginalis is resected, leaving approximately a 1-2 cm margin of sac tissue around the testis, epididymis, and cord structures
• Care is taken not to injure the vas deferens or testicular vessels during this step
• Meticulous haemostasis of the cut edges is achieved with diathermy - this is the most important step to prevent haematoma
• Cut edges may be oversewn with continuous 3-0 chromic catgut (chromic suture) to further secure haemostasis

5. Eversion (The Jaboulay Step)

• The remaining sac is everted behind the testis so that the raw/secretory inner surface faces posteriorly
• The opposing cut edges of the everted parietal tunica are approximated to each other with interrupted absorbable sutures (e.g. 2-0 or 3-0 chromic/Vicryl) without compressing the spermatic cord
• The testis is placed in a pouch created by blunt dissection in the fascial planes of the scrotum

6. Wound Closure

• The testis is returned to the scrotum
• Haemostasis is re-checked
• A small suction drain may be placed if oozing persists (especially in large hydroceles)
• The dartos layer is closed with interrupted absorbable sutures (e.g. 2-0 Vicryl)
• Skin is closed with interrupted or subcuticular absorbable sutures (e.g. 3-0 Monocryl)
• Supportive scrotal dressing (fluffed gauze or scrotal support) applied

Postoperative

• Scrotal support worn for 2-4 weeks to reduce swelling
• Ice packs for first 24-48 hours
• Analgesia (simple analgesics; NSAIDs unless contraindicated)
• Drain removed at 24-48 hours if placed
• Wound review at 7-10 days
• Warn patient: some scrotal swelling and bruising is normal; haematoma is the most common significant complication - re-attend if rapidly enlarging, painful swelling develops

Complications