Staged orchiopexy—A new technique

Staged Orchiopexy-

A New Technique

By J. J. Corkery

M

OST MALDESCENDED TESTES can be successfully brought down and fixed in the scrotum by a single operation. In a very small proportion, despite the most extensive mobilization, the inadequate length of the testicular vessels makes it impossible to place the testis in the scrotum. In such cases, many surgeons anchor the testis to the pubic bone and 6-12 mo later reexplore the wound. It is my personal experience, reinforced by the published results of others (Snyder and Chaffin’; Gross and Jewett’; Persky and Albert-‘: Firor4) that at the second operation it is nearly always possible to place the testis satisfactorily in the scrotum. The second operation is, however, usually a difficult one due to the fibrosis which results from the first operation and which obliterates the fascial planes of the inguinal canal region. During the second mobilization the vas deferens is particularly liable to be damaged. The following technique reduces the hazards of the second operation. TECHNIQUE

After the testis has been mobilized fully its distal pole is anchored to the front of the pubis as low down as possible using two black silk sutures. (Fig. 1A). A sheet of reinforced Silastic* , .007 in thick, and with a narrow V cut out from the edges of the sheet nearest the anchoring sutures and the internal ring, respectively, is placed deep to the testis and spermatic cord. (Fig. 1B). The edges of the V at the pubic end are brought together in front of the anchoring stitches and sewn together with a running silk stitch (Fig. 1C). The sheet is then further trimmed and the silk suture line is continued up as far as the internal inguinal ring. The resultant Silastic pouch (Fig. ID) encloses the spermatic cord, epididymis, and most of the testis, leaving a tiny lower pole of testis exposed to the pubis to which it is anchored with the silk sutures. The anterior wall of the inguinal canal is sewn with interrupted black silk sutures and the wound is closed. At the second operation, 12 mo later, the black silk acts as a useful marker to define the anterior wall of the inguinal canal which is opened. The Silastic covering of the testis and spermatic cord is removed, and the mobilization of the testis and cord proceeds along orthodox lines. I have now performed this procedure on six patients. In one, the Silastic implant became infected and had to be removed. In the others, the procedure was entirely satisfactory in that in each of the five it was possible to bring the testis down into the scrotum at the second operation. I have noticed that at the sec-

*Obtainable 48640. From

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Hospital, requests:

Corporation,

Ladywood Mr.

Medical

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J. J. Corkery.

Products

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0 1975 by Grune & Stratton,

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Journal of Pediatric Surgery, Vol. 10, No. 4 (August), 1975

515

Fig.

1.

oblique either

end

anterior (B). ternal

(A)

The

testis

aponeurosis. is slipped

to the

(D)

The

oblique

(B)

(C) under

anchoring completed aponeurosis.

is anchored

Spermatic the stitches. Mastic

to the

pubis

cord.

(6)

A

(C)

The

V at

testis.

Excess pouch

sheeting (A).

(6)

(D)

Silastic the (A) Lower

with

two

sheet pubic

end

is removed pole

black

silk

sutures.

with

a

V-shaped

(A)

of

of

the

by

trimming

testis

sheet

exposed

is

(A)

sewn

along to

External

cut

out

with dotted

pubis.

(C)

at silk line Ex-

A

.*

c---__ --

--____

___

______

6

See legend facing page.

__--_______

-____

518

J. J. CORKERY

ond operation the fibrosis surrounding the Silastic membrane is probably more marked than one finds at a second-stage operation in which a Silastic sheet is not used. There is also more “capillary oozing.” However, the great advantage of the Silastic pouch is that, despite this extensive fibrosis and annoying ooze, one can confidently dissect in the inguinal canal in the certain knowledge that as long as the silastic pouch remains intact the spermatic cord, epididymis, and testis cannot be damaged. When the Silastic pouch is opened, prior to its removal, the testis and the cord will be found lying, undamaged, within it. SUMMARY

In a small proportion of cases two operations are necessary to bring an undescended testis successfully into the scrotum. A new technique is described in which a silastic pouch is constructed for the testis and spermatic cord at the first operation. This reduces the hazards to the testis and cord at the second operation. REFERENCES 1. Snyder WH Jr, Chaffin L: Surgical management of undescended testes: Report of 363 cases. JAMA 157:129, 1955 2. Gross RE, Jewett TC: Surgical experiences from 1222 operations for undescended testes. JAMA 160:634, 1956

3. Persky L, Albert DJ: Staged orchiopexy. Surg Gynaecol Obstet 132:43, 1971

4. Firor HV: Two Surg 102:598, 1971

stage

orchiopexy.

Arch