{"paper_id":"dabc98f8-2f94-437b-9f0f-312fe932f945","body_text":"Wang et al. surg case rep            (2021) 7:52  \nhttps://doi.org/10.1186/s40792-021-01137-3\nCASE REPORT\nLaparoscopic assisted hydrocelectomy \nof the canal of Nuck: a case report\nLiming Wang* , Taku Maejima, Susumu Fukahori, Katayose Shun, Daitaro Yoshikawa and Toru Kono\nAbstract \nBackground: Accurate diagnosis and complete resection of hydrocele of canal of Nuck (HCN) is still a challenge for \nsurgeons.\nCase presentation: A 28-year-old woman presented with a suspected inguinal hernia due to swelling in her right \ngroin and was introduced for surgical treatment. Computed tomography scan revealed local cyst formation in the \nright groin and eliminated intestinal incarceration. In order to further confirm the diagnosis, we used laparoscopic \nexploration; after excluding a combined hernia, HCN was surgically removed using a conventional anterior peritoneal \napproach and a mesh patch repair was not needed. Postoperative pathology results showed no endometriosis or \nmalignancy.\nConclusions: Laparoscopic assisted anterior approach provides both an accurate intraoperative diagnosis and a \nquick complete resection of HCN; it is the preferred treatment for women of childbearing age with pure HCN.\nKeywords: Hydrocele of canal of Nuck, Anterior approach, Laparoscopic assist\n© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which \npermits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the \noriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or \nother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line \nto the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory \nregulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this \nlicence, visit http://creat iveco mmons .org/licen ses/by/4.0/.\nBackground\nHydrocele of canal of Nuck (HCN) is a rare disease in \nadult women that is difficult to diagnose by preopera -\ntive imaging alone, and some patients may have a com -\nplicated inguinal hernia [1–3]. The traditional treatment \nmethod is to completely remove the hydrocele through \nan open anterior approach surgery [4, 5]. Although there \nare recent reports of cases of laparoscopic surgery, the \nanatomical location of the inguinal canal is deep, and \nit is also a challenge to strip the distal end of hydrocele \nthrough an inguinal canal [6–8]. Therefore, accurate \ndiagnoses and removal of HNC quickly and completely \nremain a common problem faced by surgeons [9]. We \nreport a case involving the diagnosis and rapid treatment \nof HCN using a combination of traditional and laparo -\nscopic surgery.\nCase presentation\nA 28-year-old woman presented with a swelling in her \nright groin. She was suspected of having an inguinal \nhernia and was referred to surgery. There was no obvi -\nous enlargement of the mass when the abdomen was \ncompressed in the standing position. Ultrasonography \nrevealed a hypoechoic fluid region in the right inguinal \nregion, with no blood flow (Fig.  1a). Computed tomog -\nraphy (CT) examination revealed cystic edema in the \nright groin and no incarceration of the intestinal canal \n(Fig. 1b). The patient was diagnosed as having HCN.\nConsidering that some patients may have a HCN com -\nbined with a hernia, we explored the abdominal cavity \nwith a laparoscope. There was a 1-cm fluid area in the \ninner ring area of the right groin, which oppresses the \nfront of the groin and swells the peritoneum (Fig.  2a). \nAlthough the inner ring is slightly weak, because there \nwas no obvious hernia, we chose the anterior approach \nfor tumor resection. We opened the external oblique \nmuscle fascia to confirm that the HCN was free to the \npreperitoneal fat, ligated the root of the canal of Nuck \nat a high position (Fig.  2b, d), and performed a complete \nOpen Access\n*Correspondence:  wuminami@hotmail.com\nDepartment of Surgery, Sapporo Higashi Tokushukai Hospital, 3-1, N-33, \nE-14, Higahi-ku, Sapporo, Hokkaido 0650033, Japan\n\nPage 2 of 4Wang et al. surg case rep            (2021) 7:52 \nexcision of the HCN. Finally, using laparoscopy, we \nreconfirmed there was no defect in the peritoneum. The \noperative time was 56  min. The patient recovered well \nand was discharged the next day.\nPostoperative pathology showed that the size of the \ncyst was 4 × 4  cm. When the specimen was cut open, \nthe capsule was filled with clear liquid and the wall \nwas relatively smooth and flat (Fig.  2c). Hematoxylin \nand eosin-stained section showed HCN accompanied \nby obvious congestion and mild inflammatory tissue. \nThere was no specific glandular tissue or endometrial \ntissue in the specimen, and no malignant cells were \nfound (Fig. 3 a, b).\na b\nFig. 1 Preoperative imaging examination. a Ultrasound images revealed a hypoechoic fluid region in the right inguinal region. b Abdominal CT \nshows the right groin cyst, and no incarceration of the intestinal canal\na b\nd\npubic\n← Cephalic side ← Cephalic side\nc\nFig. 2 Intraoperative photos. a Laparoscope showed that there was a 1-cm liquid area in the ring in the right inguinal area, and the peritoneum is \nswollen by pressing the inguinal area in front (white arrows). b Complete excision of HCN by anterior approach (white arrowheads). c The groin cyst \nwas filled with clear liquid and the wall was relatively smooth and flat. d Schematic illustration of right HCN\n\nPage 3 of 4\nWang et al. surg case rep            (2021) 7:52 \n \nDiscussion\nIn 1691, Dutch anatomist Anton Nuck first described \nHCN, which manifested as groin pain and compress -\nible or incompressible local swelling of the labia [10, \n11]. Unclosed HCN can cause asymptomatic effusion \nor hernia resulting in protrusion of abdominal organs, \nmost commonly the intestine and ovaries [10]. This \ncan lead to emergent situations such as strangulation \nobstruction of the intestine or torsion of the ovary. \nAdditionally, part of the HCN may contain endometrial \ntissue, causing periodic swelling during menstruation \n[3, 12]. Due to these potential complications, timely \ndiagnosis and prompt treatment of HCN is critical [8 ].\nImaging, especially ultrasound (US), is helpful for \ntimely diagnosis; Doppler ultrasound can confirm \nintestinal obstruction and ischemic necrosis [5 ]. It has \nbeen reported that CT scan or magnetic resonance \nimaging can more effectively observe the anatomy \naround the cyst and determine whether the cyst com -\nmunicated with the abdominal cavity [1 ]. Even so, in \nsome cases, the final diagnosis depends on the intra -\noperative findings [4 , 5]. Compared with the traditional \nanterior approach, the pneumoperitoneum in lapa -\nroscopic surgery will increase intra-abdominal pres -\nsure. Laparoscopy may be the best tool for diagnosing \npotential weak areas of the inner ring of the groin and \ncan rule out the incarceration of internal organs in the \nabdominal cavity [13– 15].\nWith the development of laparoscopy in recent years, \nthere are related reports of laparoscopic removal of \nHCN, but HCN patients with indirect inguinal hernia \ncan actively consider laparoscopic surgery [7 , 16]. The \ninguinal hernia can be repaired at the same time. How -\never, if it is only a simple HCN, laparoscopic removal \nof HCN will definitely lead to enlargement of the inner \nring and a patch must be placed for repair [17].\nFor adult women of childbearing age, whether the \npatient has HCN combined with inguinal hernia, or the \npatient intends to be pregnant in the future [11, 14]. In \naddition, during laparoscopic HCN resection, it is dif -\nficult to successfully free the distal end of HCN because \nof the obstructed view of the deep inguinal canal and \nthe inferior epigastric vessels [6 , 7]. At this time, once \nlaparoscopy finds that the patient has a pure HCN, \nthe simplest anterior resection without hesitation may \nshorten the operation time [18].\nTherefore, for the diagnosis and treatment of HNC, \nsurgeons need to choose the best method according to \nthe woman’s age, whether the patient has HCN com -\nbined with inguinal hernia, or the patient intends to be \npregnant in the future. Laparoscopic combined with \nanterior approach undoubtedly provides the most accu -\nrate diagnostic method and the most rapid treatment \nfor treatment of pure HCN. It may be considered as the \npreferred treatment method for young women of child -\nbearing age without complicated hernia.\nConclusion\nLaparoscopic assisted anterior approach can not only \nprovide accurate intraoperative diagnosis, but also a \nquick complete resection of HCN, which is the pre -\nferred treatment for women of childbearing age with \npure HCN.\nAbbreviations\nUS: Ultrasonography.; CT: Computed tomography.; HCN: Hydrocele of canal \nof Nuck.\nAcknowledgements\nThe authors thank experts of BioMed Proofreading LLC for English \ncopyediting.\nFig. 3 Pathological results. a Histopathology showing HCN accompanied by obvious congestion and mild inflammatory tissue (hematoxylin and \neosin [HE], × 40). b There was no specific glandular tissue, endometrial tissue, or malignant cells ([HE], × 100)\n\nPage 4 of 4Wang et al. surg case rep            (2021) 7:52 \nAuthors’ contributions\nLMW drafted the manuscript and provided the original pictures. TM, SF, KS, \nDY, and TK reviewed the manuscript. All authors read and approved the final \nmanuscript.\nFunding\nThis study was not supported by any outside research funding.\nAvailability of data and materials\nThe datasets supporting the conclusions of this article are included within the \narticle and its additional files.\nEthics approval and consent to participate\nNot applicable.\nConsent for publication\nWritten informed consent was obtained from the patient for publication of \nthis case report and any accompanying images.\nCompeting interests\nThe authors declare that they have no competing interests.\nReceived: 5 January 2021   Accepted: 9 February 2021\nReferences\n 1. Prodromidou A, Paspala A, Schizas D, Spartalis E, Nastos C, Machairas N. \nCyst of the Canal of Nuck in adult females: a case report and systematic \nreview. Biomed Rep. 2020;12(6):333–8.\n 2. Counseller VS, Black BM. Hydrocele of the Canal of Nuck: report of seven-\nteen cases. 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J Surg Case Rep. 2020;2020(8):rjaa222.\nPublisher’s Note\nSpringer Nature remains neutral with regard to jurisdictional claims in pub-\nlished maps and institutional affiliations.","source_license":"CC0","license_restricted":false}