Elephantiasis may involve: (1) the outer skin of a patient's penis (but not its inner layer or its shaft), (2) his scrotum, or (3) his testes which have hydroceles, but are otherwise normal; or, often, all three.
If he has a scrotum like A, in Fig. 31-7, and you cannot refer him, you can excise it. His penis will either be buried in it, or separate, but covered with much thickened skin. This is a very satisfactory operation, and he will be immensely grateful.
Fig 31-7 ELEPHANTIASIS OF THE SCROTUM. A, as the patient presented. B, arrangements to suspend his scrotum (optional). C, catheterization and the first incision. D, his penis delivered. E, preserving a cuff of preputial skin to cover his penis. F, his penis covered with gauze while the operation continues. G, the lateral incisions carried posteriorly. H, his testes found and delivered. I, the completed operation. Partly after Charles Bowesman, with kind permission.
ELEPHANTIASIS [s8]OF THE SCROTUM AND PENIS THE DIFFERENTIAL DIAGNOSIS includes giant hydroceles (23.23), which may be present with elephantiasis, and hernias (14.4). In elephantiasis the texture of the skin of the patient's scrotum is altered, it pits on pressure, it cannot be moved over the deeper tissues, veins are not visible, and the mass cannot be reduced.
TREATMENT depends on the extent of his elephantiasis.
If he has elephantiasis of his prepuce (31-8, unusual), don't do a standard circumcision, or you will remove its inner normal layer. Instead, dissect off the thickened outer layer, and fold the inner one back over the shaft of his penis.
If his elephantiasis is mild and early, a limited operation may be all that is necessary. For example, you may only need to remove a dorsal strip of thickening on his penis, and close the resulting defect.
ANAESTHESIA. Subarachnoid anaesthesia (A 7.1)is suitable.
PREPARATION. Clean his skin thoroughly. You may need to put him in a hip bath of chlorhexidine. If his scrotum is enormous (A, in Fig. 31-7), either operate with him sitting and his legs over the edge of the table, or arrange a hook, and a block and tackle, in the theatre ceiling before the operation starts (B), so that you can raise it.
Control his urine temporarily with a Foley or Gibbon's catheter (C). If this is difficult to insert, you may have to wait until you have exposed his penis. You will find that a catheter, or sound, in his urethra will be useful in locating it, when you come to operate on his perineum.
Bleeding can be a problem. Don't apply a tourniquet to the base of his scrotum to control bleeding. Instead, use a long needle, such as a lumbar puncture needle, to inject his tissues with adrenalin in saline, or anaesthetic solution (A 5.4).
CAUTION ! Never use adrenalin on the subcutaneous tissues of the penis (A 5.3); you can if necessary use it in the corpora (priapism, 23.29).
INCISION. If he has large hydroceles, tap them. Make a midline incision downwards, from his pubic symphysis, to just above his prepuce (C). Carefully deepen the incision, until you reach the shaft of his penis (D). Make a circular incision around his external preputial orifice, and preserve the internal layer of his prepuce, or the cuff of skin with which his penis communicates with the exterior (E). Use it later to cover his penis. Clamp the cuff just beyond his glans, and divide his skin distal to it. Cover his raw isolated penis with saline swabs (F), while you deal with his scrotum.
Make two lateral incisions round the root of his scrotum, to meet one another posteriorly in his perineum (G). Carefully deepen these lateral incisions, until you reach his spermatic cords on each side. If necessary, trace them from his external inguinal rings. Follow his cords to his testes, and deliver them (H).
If his testes are of normal size and he has no hydroceles, don't open their tunicae vaginales.
If he has large hydroceles, you may have to drain them first (if you have not already done so). Open them, and evert their sacs and suture them behind his testis, as in Fig. 23-30. If the sacs are thick, excise part of them.
Turn his scrotum up on to his abdominal wall. Make two incisions starting 3 cm in front of his anus, and running 3 cm medial to his cruro-genital folds. His tissues are under tension, so that the incisions will open immediately. Identify, tie, and divide the many large veins that run from his scrotum. There is one large central one running up from his scrotum under his urethra. Extend these incisions to join the inguinal ones.
Remove the bulk of his scrotum with a short amputation knife. Excise all thickened oedematous tissue. Either, make him a new scrotum from the apron of normal skin that was dragged down by the mass. Or, or bury his testes in pockets, under the skin on the adductor aspects of his thighs. Push a long pair of scissors 15 cm into the subcutaneous tissues of his thighs, and open them in various directions to create a pocket with a 5 cm mouth. These pockets will be easier to make, if you stand on the opposite side of the table when you make them. You may meet, and need to tie, his superficial external pudendal vessels, and their two companion veins. Control bleeding before you insert his testes. Close the perineal part of his wound loosely, with a drain at its lowest point.
Remove the clamp from the cuff of skin that was his prepuce, trim away the part that was crushed, and roll the rest back to cover the shaft of his penis. Deliver this through a slit in the apron of skin dragged down from his abdominal wall (I). Suture this to the skin of the shaft of his penis, starting with a single central stitch, and proceeding laterally on both sides. Graft any remaining raw areas with grafts from his thigh, and dress them with vaseline gauze.
Leave his catheter in place for a few days, to prevent his urine contaminating the wound. Any redundant tissue that you may have left will probably get smaller as time passes.
Fig. 31-8 ELEPHANTIASIS OF THE PENIS. A, before the operation. The patient's scrotum was not involved. B, after a ''basal circumcision'. The skin of the inside of his prepuce has been used to cover the shaft. After Charles Bowesman, ''Surgery and Pathology in the Tropics', E and S Livingstone, with kind permission.