Eversion of Sac (Jaboulay's / Winkelman's Procedure)

Position & Anaesthesia

• Supine position
• Spinal or general anaesthesia

Operative Steps

1. Incision

• A transverse or longitudinal scrotal incision (~5–6 cm) is made over the most prominent part of the hydrocele, away from the median raphe, cord, and epididymis.

2. Exposure of the Hydrocele Sac

• The incision is deepened through skin → dartos → external spermatic fascia → cremasteric layer.
• The hydrocele sac (lined by the parietal layer of the tunica vaginalis) is delivered into the wound.
• The sac is separated from the dartos muscle layer by blunt finger dissection.

3. Incision of the Sac (Stab Incision)

• A stab incision is made into the tunica vaginalis in an avascular area anteriorly, away from the cord, testis, and epididymis.
• Straw-coloured fluid is drained into a kidney tray.

4. Extension of the Incision & Delivery of Testis

• The stab incision is extended to open the sac widely.
• The testis is delivered through the aperture in the sac and inspected.

5. Excision of Excess Sac

• A generous portion of the parietal layer of the tunica vaginalis is excised, leaving a ~1–2 cm cuff around the testis and cord structures.
• Bleeding edges are cauterised or ligated.

6. Eversion of the Sac (Key Step)

• The cut margins of the tunica vaginalis are everted around behind the testis ("inside-out" / behind the epididymis).
• The opposing everted edges are sutured together behind the testis using interrupted 1-0 or 2-0 chromic catgut (or Vicryl), without compressing the spermatic cord.
• This is the Jaboulay manoeuvre: the raw surface of the tunica faces outward → prevents fluid reaccumulation.

7. Haemostasis & Replacement

• Haemostasis is secured meticulously.
• The testis with the everted, sutured sac is placed back into the scrotal sac.

8. Closure

• Dartos muscle is closed with 1-0 absorbable sutures.
• Skin is closed with interrupted or subcuticular absorbable sutures.
• A scrotal support / firm dressing is applied.

Variations of Hydrocelectomy

Key Points

• Jaboulay's technique has the lowest recurrence rate among excisional techniques.
• The raw/secretory surface of the tunica is turned outward so fluid cannot reaccumulate in a closed cavity.
• The spermatic cord must not be compressed when suturing the everted edges.
• Haemostasis is critical — post-op haematoma is the most common complication.

Steps of Circumcision

Indications

• Medical: Phimosis, paraphimosis, recurrent balanoposthitis, recurrent UTIs, balanitis xerotica obliterans (BXO)
• Prophylactic: Reduced risk of UTIs, STIs (including HIV), penile cancer
• Religious/Social: Most common worldwide indication

Contraindications (Absolute)

• Hypospadias — foreskin is needed for repair
• Chordee, dorsal hood deformity, buried penis, webbed penis
• Bleeding disorders (until corrected)
• Neonatal illness/instability

Anaesthesia

Note: Monopolar electrocautery must never be used in neonates — risk of devastating tissue loss.

Pre-operative Steps

1. Examination: Confirm normal anatomy — intact foreskin, straight shaft, equal dorsal/ventral skin, normal meatus, defined penoscrotal junction. Rule out hypospadias/anomalies.
2. Prep: Genitalia prepped with iodine-based solution.
3. Analgesia: Administer penile block.

Operative Steps — Sleeve (Double-Incision) Technique (standard for adults and older children)

Step 1: Retract the Foreskin

• Retract the prepuce fully.
• If fibrotic/phimotic → make a dorsal slit first.
• Lyse any preputial adhesions using a blunt-tipped curved haemostat with iodine-soaked gauze.
• Clean out accumulated smegma.

Step 2: Inspect the Glans & Meatus

• Carefully examine the glans, position of the urethral meatus, and corona.
• Detect any anomalies (megameatus, hypospadias) before any incision is made — critical from a medico-legal standpoint.

Step 3: Divide the Frenulum

• Pass a fine curved clamp underneath the frenulum to create a potential space.
• Clamp for ~10 seconds to crush tissue and achieve haemostasis.
• Divide the crushed frenulum sharply or with electrocautery on cut setting.
• Be careful not to come too close to the ventral glans.

Step 4: Mark the Outer Incision

• Replace the foreskin to its natural position.
• Using a fine-tipped marking pen, trace the outer (proximal) incision at the level of the coronal sulcus on the skin surface.

Step 5: Mark the Inner Incision

• Retract the prepuce again.
• Mark the inner (distal) incision approximately 0.5–1 cm from the edge of the glans, following the curve of the glans.
• Avoid drifting too close to the glans.

Step 6: Make Both Incisions

• Incise along both marked lines using a #15 blade, stretching the skin taut with dry gauze.
• A collar of skin (sleeve of prepuce) is now isolated between the two incisions.
• Check haemostasis. Avoid deep incision ventrally to prevent urethral injury.

Step 7: Remove the Prepucial Collar

• Divide the skin collar longitudinally with a knife/scissors to convert it into a single strip, then remove it.
• Electrocautery on cut setting can minimise blood loss during this step.

Step 8: Free the Skin Edges from Dartos

• Pick up edges of skin and free from the underlying dartos fascia using sharp dissection (scissors or electrocautery).
• Achieve thorough haemostasis with bipolar cautery or 5-0/6-0 absorbable suture ligatures.

Step 9: Approximate the Skin Edges

• Sew the penile shaft skin to the inner preputial collar using fine absorbable sutures:
  • Infants/children: 6-0 absorbable
  • Adults: 5-0 absorbable
• First suture: 12 o'clock (dorsal) — prevents torsion.
• Second suture: 6 o'clock (ventral).
• Additional stay sutures at 3 and 9 o'clock if needed.
• Incorporate subcutaneous tissue in suture bites to align edges and prevent suture tracks.
• Alternative: subcuticular interrupted 5-0/6-0/7-0 absorbable sutures for better cosmesis.
• Sutureless technique with 2-octyl cyanoacrylate skin adhesive is also described.

Step 10: Dressing

• Apply bacitracin ointment to the glans tip, ± Telfa/Tegaderm/gauze dressing.
• Scrotal support.

Neonatal Techniques (Clamp Methods)

Complete separation of prepuce from glans and inspection of the meatus must occur before applying any clamp.

Complications

Steps of Total Thyroidectomy

Indications

• Thyroid cancer (papillary, follicular, medullary, anaplastic)
• Graves' disease / toxic multinodular goiter (when medical therapy fails)
• Large symptomatic goitre with compression
• Bilateral multinodular goitre
• Suspicious bilateral thyroid nodules

Contraindications / Preoperative Checklist

• Render euthyroid before surgery (antithyroids ± β-blockers; Lugol's solution / SSKI 10 days preop for Graves')
• Preop voice assessment — baseline vocal cord function; laryngoscopy if history of voice change, prior neck surgery, or posterior ETE/bulky nodal disease
• Neck ultrasound; FNA biopsy results
• Serum calcium (especially MEN2A); TFTs
• Informed consent discussing RLN injury, hypoparathyroidism, scar, haematoma

Anaesthesia & Positioning

1. General endotracheal anaesthesia — neuromonitoring ETT with contact electrodes at vocal cords if intraoperative neuromonitoring (IONM) planned.
2. Position: Supine, both arms tucked; back raised 20°, neck gently extended with a soft roll behind the scapulae; head on foam/gel ring.
   • Avoid hyperextension — crowds field and causes postop neck pain.
   • Mild extension brings a substernal goitre to a more anterior, accessible position.
3. Preincision neck ultrasound — confirm anatomy, plan incision placement.

Step 1: Incision

• Kocher's collar incision: centrally placed transverse incision along Langer's lines, 2–3 cm above the clavicular heads, between sternal notch and cricoid cartilage.
• Length typically 4–5 cm, sized to gland volume and patient habitus.
• Incision carried through skin → subcutaneous fat → platysma.

Step 2: Raising Subplatysmal Flaps

• Subplatysmal flaps raised:
  • Superiorly to the thyroid cartilage
  • Inferiorly to the sternal notch (clavicular heads)
• Identify and protect the anterior jugular veins draped between platysma and strap muscles.

Step 3: Separation of Strap Muscles & Exposure of Thyroid

• Strap muscles separated in the midline through the superficial layer of deep cervical fascia — from sternal notch to thyroid cartilage (avascular midline raphe).
• Sternohyoid (superficial) separated from sternothyroid (deep) by blunt dissection.
• Sternothyroid dissected off the thyroid capsule.
• Thyroid lobe retracted and rotated anteromedially → carotid sheath identified laterally.
• Middle thyroid vein identified, ligated, and divided (between thyroid and internal jugular vein).
• For very large/firm glands: sternothyroid muscle may be divided near its superior attachment to the thyroid cartilage (innervation from ansa cervicalis enters inferiorly — divide high to preserve).

Step 4: Dissection of the Isthmus & Pyramidal Lobe

• Isthmus is dissected off the trachea; draining veins of isthmus and pyramidal lobe are isolated and ligated.
• For lobectomy only: early isthmus division facilitates delivery through small incisions.
• Pyramidal lobe (when present) is identified and included in the specimen.

Step 5: Mobilisation of the Superior Pole

• Inferior countertraction on thyroid + superolateral and posterior dissection using a peanut sponge.
• Develop the avascular cricothyroid space (space of Reeve/Reeves) — between medial superior pole and cricothyroid muscle.
• Identify the External Branch of the Superior Laryngeal Nerve (EBSLN) (visually or with IONM) before any ligation — courses medial to superior pole vessels along cricothyroid muscle.
• Superior thyroid artery isolated and divided individually and close to the gland capsule (to protect EBSLN — Cernea type 2B nerves cross below the superior border of the superior pole).
• Superior thyroid vein similarly ligated.
• Filmy posterior tissue swept away bluntly → superior parathyroid gland often identified at this step, posterior to mid-superior pole at the level of the cricoid cartilage.

Step 6: Mobilisation of the Inferior Pole

• Inferior thyroid lobe grasped and retracted anteromedially with Allis/Kelly clamp.
• Inferior pole vessels ligated and divided close to the thyroid (avoid straying deep/lateral — risks RLN injury and devascularisation of inferior parathyroid).
• Inferior parathyroid gland identified: lies anterolateral to the RLN and inferior to the inferior thyroid artery — usually adherent to posterolateral surface of inferior thyroid lobe.
• All parathyroid glands carefully dissected and swept away on as broad a vascular pedicle as possible.

Step 7: Medial Rotation & Identification of the RLN

• Thyroid gland delivered anteromedially out of the wound by rotation — exposes the tracheoesophageal groove and carotid sheath.
• Inferior thyroid artery and RLN visualised in the posterior field.
  • Right RLN: more oblique/lateral course; loops around subclavian artery.
  • Left RLN: more vertical in tracheoesophageal groove; loops around aortic arch.
  • ⚠️ Non-recurrent laryngeal nerve (~0.5%) on right, associated with aberrant right subclavian artery — near-transverse trajectory.
• IONM: Stimulate vagus nerve to confirm circuit → stimulate RLN during dissection to confirm identity and preserve signal.
• RLN is at greatest risk at: (1) ligament of Berry, (2) near the inferior thyroid artery branches, (3) thoracic inlet.

Step 8: Division of Tertiary Branches of the Inferior Thyroid Artery (Capsular Dissection)

• Tertiary branches of the inferior thyroid artery divided individually along the thyroid capsule — this is the key manoeuvre to preserve parathyroid blood supply.
• Avoid truncal ligation of the inferior thyroid artery proximal to parathyroid branches.

Step 9: Division of the Ligament of Berry & Removal of the Lobe

• The ligament of Berry (posterior suspensory ligament, connecting thyroid to trachea) is divided under direct vision of the RLN — highest risk point for RLN injury.
• The Zuckerkandl tubercle (posterior condensation of thyroid tissue) is mobilised anteromedially to expose the nerve fissure.
• Thyroid lobe separated from trachea — isthmus included in the specimen.
• Contralateral lobe resected using identical steps.

Step 10: Haemostasis & Parathyroid Autotransplantation

• Meticulous haemostasis — bipolar cautery for vessels; suture ligation for larger vessels.
• Valsalva manoeuvre to inspect field for bleeding.
• If a parathyroid gland is clearly devascularised or inadvertently removed:
  • Confirm it is parathyroid (frozen section or ex vivo PTH staining).
  • Mince into 1×1 mm fragments; autotransplant into sternocleidomastoid muscle or brachioradialis (in reoperative/cancer cases).
  • Mark with a clip.

Step 11: Closure

• No routine drainage after uncomplicated thyroidectomy.
• Strap muscles reapproximated in midline with absorbable suture — leave ≥1 cm gap inferiorly to allow blood/fluid to decompress and prevent tracheal compression.
• Platysma closed with absorbable suture.
• Skin: subcuticular absorbable suture ± topical scar agent ± dilute steroid injection for cosmesis.

Postoperative Care

Major Complications