Hydrocelectomy

CPT 55040
Approach Open
Add-on / Variant CPTs
  • 55041 — Hydrocelectomy, bilateral
Preoperative Diagnosis:

Right [left] [bilateral] hydrocele — [simple / multiloculated / reactive] — symptomatic, requiring surgical repair

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] [bilateral] hydrocelectomy — [Lord plication / bottle procedure (eversion) / excision]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Nurse/tech name]

Anesthesia:

General endotracheal [/ spinal / local with sedation]

Indications:

The patient is a [age]-year-old male with right [left] hydrocele causing [scrotal discomfort / significant enlargement / quality-of-life impairment]. Scrotal ultrasound confirmed [simple hydrocele / ruled out testicular malignancy] with a normal-appearing testis. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

The hydrocele sac contained [X] mL of [clear / slightly turbid] fluid. The tunica vaginalis was [thin / thickened / multiloculated]. The testis and epididymis were [normal / with [epididymal cyst / no mass]] on direct inspection after drainage.

Description of Procedure:

The patient was positioned supine. The scrotum was prepped and draped. A [4]-cm transverse scrotal incision was made over the hydrocele. The dartos and cremasteric layers were divided and the hydrocele sac was delivered into the wound.

The sac was opened and [X] mL of [clear / straw-colored] fluid was drained. The testis and epididymis were inspected — [normal appearance, no mass identified].

[LORD PLICATION:]
The tunica vaginalis was plicated with [5–6] interrupted [2-0 Vicryl / 2-0 chromic] sutures placed radially around the epididymis, bunching the sac behind the testis. This technique is preferred for [thin, pliable hydrocele sacs].

[BOTTLE PROCEDURE / EVERSION:]
The tunica vaginalis was incised circumferentially. The sac edges were everted behind the testis and epididymis and sutured together with a running [2-0 chromic / Vicryl] suture (Jaboulay procedure). Excess sac was excised if voluminous.

The testis was returned to the scrotum. Hemostasis was achieved. A small [Jackson-Pratt / Penrose] drain was placed [if indicated for large sac]. The dartos was closed with [3-0 Vicryl]. Skin was closed with [3-0 Chromic].

Complications:

None

Specimens:

[Excised tunica vaginalis — sent to pathology if thickened or suspicious]

Estimated Blood Loss:

Minimal

Drains:

None / [Penrose drain brought out through dependent scrotum]

Disposition:

The patient was taken to the PACU in stable condition. Scrotal support was applied. Swelling and ecchymosis were expected for [2–4 weeks]. The patient was discharged the same day.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Right/Left hydrocele — symptomatic
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left hydrocelectomy — Lord plication/bottle procedure
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General/spinal

INDICATIONS: .PTAGE-year-old male with *** hydrocele, *** symptoms. US: normal testis. Consent obtained.

FINDINGS: *** mL *** fluid. Sac *** (thin/thickened). Testis/epididymis normal.

PROCEDURE:
Supine. Scrotal prepped. *** cm transverse incision. Dartos/cremasteric divided. Sac delivered. Opened, *** mL drained. Testis/epididymis inspected — normal. [Lord plication: *** sutures placed radially, sac plicated behind testis.] [Eversion: sac everted/sutured behind testis running 2-0 chromic.] Testis returned. Hemostasis. Dartos 3-0 Vicryl. Skin closed. Scrotal support.

EBL: Minimal
COMPLICATIONS: None
DISPOSITION: Same-day discharge. Scrotal support. Swelling expected 2–4 weeks.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Hydrocele Aspiration and Sclerotherapy

For a patient with high surgical risk or preference for a minimally invasive approach, hydrocele aspiration and sclerotherapy were performed under local anesthesia. [X] mL of hydrocele fluid was aspirated with a [16-gauge] needle. [3% sodium tetradecyl sulfate / ethanolamine / polidocanol] [2–3 mL] was injected into the evacuated sac. The patient was instructed to change position every 5 minutes for 1 hour to distribute the sclerosant. Sclerotherapy has a [30–50%] recurrence rate and is not recommended as first-line treatment; it is appropriate for frail patients who are poor surgical candidates.

Charting Tips
  • Document testis inspection after sac drainage. The primary concern at hydrocelectomy is missing a testicular mass hidden by the hydrocele. Document 'the testis and epididymis were directly inspected and were normal in appearance with no mass palpated.' Missing a testicular malignancy is a serious adverse outcome.
  • Document the technique used (plication vs. eversion vs. excision). Lord plication has lower hematoma rates for thin sacs; the bottle procedure is preferred for large, thickened sacs. Document the sac characteristics and technique chosen to justify the approach.
  • Document drain placement if used. Scrotal hematoma is the most common complication. Document whether a drain was placed and why (large sac, oozing, bilateral). If no drain was placed, document that hemostasis was satisfactory.
Billing Tips
  • 55040 (unilateral hydrocelectomy, 5.31 wRVU) vs 55041 (bilateral, 8.33 wRVU). Use 55041 when both sides are repaired; do not bill 55040 twice for bilateral.
  • Global period is 90 days. Post-op scrotal edema management and wound checks are bundled.
  • Document hydrocele type: primary (idiopathic) vs secondary (due to epididymitis, trauma, tumor), as ICD-10 coding affects payer medical necessity review.
  • Concurrent ipsilateral varicocelectomy (55530) or orchiopexy is separately billable with modifier -51; document each procedure as distinct with its own indication.
  • Scrotal aspiration alone (55000) is not a hydrocelectomy. Do not use if a formal excision/plication was performed.
  • If the sac cannot be safely excised due to size and eversion/plication is performed instead, document the technique. The same CPT applies (55040/55041); document clearly.
  • Payer authorization may require ultrasound documentation of hydrocele for elective cases. Ensure imaging is in the chart before scheduling.