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Paper text:
we report the case of a 25-year - old caucasian male who developed an acute right scrotum secondary to bile within peritoneal fluid that entered the scrotum through a previously undiagnosed communicating hydrocele . to the best of our knowledge ,
approximately 10 ml to 15 ml of bile was spilled during the procedure after inadvertent entry into the gallbladder during its dissection from the gallbladder fossa .
after the gallbladder was removed , the abdomen was irrigated until aspirated fluid was clear .
the right cremaster muscles were noted to be in spasm . a urologic consultation was obtained .
the patient 's complaints and examination were concerning for testicular torsion , and right scrotal exploration was performed 3 hours after completion of the laparoscopic cholecystectomy .
opening of the tunica vaginalis revealed 10ml of bile - stained fluid and a normal right testicle .
the tunica vaginalis and right testicle were irrigated with saline , and a communicating hydrocele was identified and ligated .
postoperatively , the patient noted immediate relief of pain , and examination revealed minimal tenderness in the right scrotum .
the total bilirubin value of the fluid drained from the scrotum was 10 mg / dl .
the patients ranged in age from 7 to 20 years of age and presented with symptoms between postoperative day 1 and 10 .
acute postoperative scrotum due to early hernia recurrence has also been described in an infant after an open inguinal herniorrhaphy .
yasumoto et al reported a case of a 10-year - old male who underwent open appendectomy for perforated appendicitis on postoperative day 1 following incision and drainage of a left scrotal abscess .
infarction of the upper pole of the right testicle causing acute scrotal pain has been reported after a laparoscopic total extraperitoneal inguinal herniorrhapy .
bile causes peritoneal signs on examination in some patients with cystic duct stump leaks after cholecystectomy .
although the mechanism of irritation is not fully understood , bile salt concentration and bacteria are thought to be possible causes of bile - induced abdominal pain .
the cause of acute scrotal pain in this case was due to bile within peritoneal fluid that entered the right scrotum through a communicating hydrocele .
the fluid entered the right scrotum after spillage occurred while the patient was in a reverse trendelenberg position with increased intraperitoneal pressure due to carbon dioxide insufflation .
the possibility of bile causing the patient 's pain was included in our differential diagnosis ; however , with no prior cases reported in the literature and our concern for testicular torsion , we felt urgent exploration was indicated .
future management of a similar patient may include the option of percutaneous aspiration of the hydrocele with laboratory examination to determine bile concentration .
if symptoms persist following aspiration , urgent scrotal exploration would be indicated to rule out testicular torsion .
the surgical literature is scattered with only a handful of reported cases of an acute scrotum developing after laparoscopic procedures .
an acute suppurative process associated with laparoscopic appendectomy is the most common cause described to date .
the patient 's symptoms completely resolved after urgent scrotal exploration with drainage of bilious fluid that entered via a communicating hydrocele . to the best of our knowledge ,
this is the first case of an acute scrotum due to bile after laparoscopic cholecystectomy . as the volume of minimally invasive procedures performed increases , so does the number of unusual complications that develop .
reporting of such uncommon disorders developing after minimally invasive procedures provides a reference that may potentially allow earlier recognition and treatment of similar complications by fellow surgeons in the community .
we report our experience with a patient that developed an acute right hemiscrotum immediately after undergoing an uncomplicated laparoscopic cholecystectomy for gallbladder dyskinesia . 
 the etiology of the acute scrotal pain was due to bile which was spilled into the peritoneum after entry into the gallbladder during dissection . 
 the bile obtained access to the right hemiscrotum via a communicating hydrocele . 
 to the best of our knowledge this is the first report of bile causing an acute scrotum following laparoscopic surgery . 
 a review of the current literature on the topic of the postoperative acute scrotum follows our case presentation .