Keywords

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  • Perform an examination under anaesthetic (EUA) of the inguinal region to confirm the position of the testes

  • Expose the inguinal canal as described in Chap. F1 (Fig. 1).

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Fig. 1

  • In most cases, the undescended testis will be apparent at the superficial inguinal ring.

  • Delivery of a canalicular testis is aided by windowing the canal (see Chap. F1), with extension into the superficial inguinal ring.

  • Use toothed forceps to lift the spermatic cord from the inguinal canal.

  • Hold the testis in your non-dominant hand. Use artery forceps or finger dissection to create a window posterior to cord (Fig. 2).

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Fig. 2

  • The gubernaculum is divided by gently teasing the strands away from the testis with fine non-toothed forceps. Small vessels should be divided with bipolar diathermy (Fig. 3). Alternatively clipping and ligating these vessels (inferior epigastric.)

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Fig. 3

  • Elevate the testis superolateral to the incision and inspect the posterior surface of the cord for a hernial sac (Fig. 4).

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Fig. 4

  • Carefully dissect the vas and vessels off the sac as described in Chap. F02 (Figs. 5–7).

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Fig. 5

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Fig. 6

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Fig. 7

  • Use fine non-toothed forceps to tease away any adherent strands of tissue between the cord and sac to the level of the deep inguinal ring (Fig. 8).

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Fig. 8

  • Twist the sac, before transfixing and ligating with 3/0 Vicryl.

  • Divide lateral spermatic bands with scissors to allow the testis to be brought into the scrotum without tension.

  • Create a ‘tunnel’ into the scrotum by gently passing the index finger of your non-dominant hand from the medial end of the wound to the scrotum.

  • Use a scalpel to incise the scrotal skin over your finger, and iris scissors to create a dartos pouch (Figs. 9 and 10).

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Fig. 9

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Fig. 10

  • Pass curved mosquito forceps from the scrotal to the inguinal wound, guided and protected by your fingertip.

  • Grasp the testis by the tunica albuginea at its inferior pole and deliver into the dartos pouch, ensuring no twisting of the cord.

  • Use an absorbable 4/0 suture to ‘pex’ (an orchidopexy) the lower septum of the testis to the median raphe or alternatively, to close the neck of the dartos pouch around the spermatic cord.

  • Close the inguinal wound in layers and the scrotum with continuous 4/0 Vicryl.

FormalPara Tips

  • On occasion the dissection of the testicular vessels may need to be extended extra-peritoneally to gain adequate length.

  • If after extensive retroperitoneal dissection the cord remains too short to reach the scrotum, consider performing a two-stage procedure (fix the testis to the pubic tubercle initially).

  • Always ensure the spermatic cord is not twisted before delivering the testis into the scrotum – check position of the lateral sulcus.

  • The dartos pouch should be made inferior to incision, so that the testis is not fixed under the wound.

FormalPara Common Pitfalls

  • The superficial inferior epigastric vein traverses the medial end of the incision. Either retract it or coagulate and divide.

  • When ‘windowing’ the inguinal canal, avoid dividing the ilioinguinal nerve. Division results in loss of sensation over the upper medial thigh and anterior third of the scrotum.

  • Always inspect the gubernaculum to exclude a ‘looping vas’, which may be inadvertently divided.

  • Failure to ensure meticulous haemostasis during dartos pouch creation will result in scrotal haematoma.