1. Introduction

a. Incision

b. Locate and Externalize Testis

c. Lengthen and Mobilize Spermatic Cord by Dividing Cremasteric Fibers

d. Locate and Separate Hernia Sac

e. Ligate and Reduce Hernia Sac

2. Dissection

a. Create Tunnel into Scrotum

b. Create Pouch for Testis

c. Bring Testis Through Tunnel and into Scrotum

d. Suture to Secure Testis in Place

3. Reposition Testis Within Scrotum

4. Closure

5. Circumcision

6. Post-op Remarks

Cryptorchidism is a condition in which one or both testicles fail to descend to its normal position in the scrotum. The testicle may reside in the retroperineum, in the internal inguinal ring, in the inguinal canal, or even at the external ring. The exact cause is unknown but several risk factors have been linked to this condition such as premature birth, low birth weight, family history, Down syndrome, alcohol use, and cigarette smoking. Undescended testis occurs in approximately 30% of preterm infants and 1-3% of term infants. Diagnosis is made during examination at birth or shortly thereafter, and timely recognition and management of this condition prevents adverse consequences. The goal of treatment is to relocate the undescended testicle to its proper location in the scrotum. Treatment before 1 year of age lowers the risk of complications such as infertility, testicular cancer, inguinal hernia, and testicular torsion. Treatment can be hormonal, surgical or a combination of both. Hormones such as hCG can sometimes induce descent of the testicle; however, surgery is the preferred option. Orchiopexy is the surgical procedure to free an undescended testicle and implant it in the scrotum.
 
Phimosis is the inability to retract the foreskin covering the glans of the penis. It may appear as a tight ring of the foreskin around the tip of the penis preventing full retraction. Phimosis can be physiologic or pathologic. Physiologic phimosis is seen in children born with tight foreskin at birth and separation occurs naturally overtime while pathologic phimosis is caused by scarring, infection or inflammation. A tight foreskin can interfere with the passage of urine as seen as ballooning of the foreskin during urination. This can lead to inflammation of the penis called balanitis or inflammation of the penis and foreskin called balanoposthitis. Physiologic phimosis does not require intervention and will resolve with daily gentle retraction while pathologic phimosis is treated with topical steroid cream or circumcision.
 
Here we present the case of a young male with an undescended right testicle and phimosis. The right testicle was located in the right inguinal area and was brought down into the scrotum. Circumcision was also done to resolve the phimosis.

<h4>CHAPTER 1</h4>

<p>Here, you are going to see quite a disparity on the size of the scrotum. You don't even have to touch it, and the lump that they're seeing is his testicle, that's up here, that's in here. The testicle probably goes in the belly and then goes down. we're going to have brought the ring that - we're going to try to bring the testicle to the scrotum. We're going to try. And if it, if it doesn't go down,
we might have to take it out because it can develop into cancer.</p>

<h4>CHAPTER 2</h4>

<p>Okay, cautery? Ah, it's right here. So I don't know whether we can bring his testicle down or not, we'll see. We'll find out how short - see what happens when the testicle is up in the belly, The - the one that doesn't grow or lengthen is the - artery, yeah the cord, the spermatic cord. So if, if you can't lengthen it, you can't bring the testicle down. Because young… Like I said the other day, they took a testicle out of a man with the same thing, and had developed cancer. So this is um… It's not even a testicle. Not yet sir. Yeah. Still there. Feel, I'm pulling on the scrotum. That might be where the testicle is. Right here, there it is. It's a good size testicle. Yes. Actually, it's near here - it's the, the testicle can go down right here. You could go right here. Yeah. I think we can bring it down. Hopefully.</p>

<p>So you can divide this attachment here, with the cautery right in here. Yeah, I think we can bring it down. It looks like a… There's the testicle, it's not a big. The testicle is smaller than this guy, see this guy is… There's a - the left side's testicle is uh - No. See, that's a small testicle compared to the other side. So it's underdeveloped, but at least it's better to have one and a half than one.</p>

<p>One and a half testicle - wait, these are, divide these cremasteric fibers. More chances of winning sir? Yeah. One and a half is better than, than one. But all you need is one. Isn't that a song, all you need is one? Something like that. All you need is love? Oh. Yeah. See, what we do now is we are mobilizing, we call this mobilizing the cord by dividing all these muscles we call cremasteric fibers. And by doing so, you make the cord longer so that it will go down to the scrotum with ease, without tension.</p>

<p>See, so far so good, we're doing good. Here, here, more. Wow, that's good. Now, the next thing is we're going to look for the sac, there's a hernia sac in here, and if we release that away from the cord, what will happen is the - the cord will be long enough for us to bring to the to the scrotum. Okay, good.</p>

<p>Okay, here it is, now we're going to separate that. There's usually a space that you can find to get the sack away from the cord, but just by doing this maneuver here, just push this. And then eventually you'll see the It's also your own maneuver sir? sac. Hmm? Your own maneuver? Yeah. Get the, there. Starting to separate. That's the vas. The vas still there? Okay, we'll get the vas away. I think that's where it is. I found it. I'm going to get that vessel, there is a little vessel. There. Yeah. Part of that. And also... The vas is here, so we're good. That's the cord - that's the sac... Spermatic vessels, so we're good. Like that, okay? That's easy. Now we can divide this. You can divide it here. You can sacrifice that little vessel. Go ahead. Straight? Yeah, like that. Hemostat?</p>

<p>Amazing. Hmm? Amazing. See how east that was, what I just did? Yes. You guys take so much trouble doing what I'm doing. You're painstakingly wasting time, and causing bleeding and all that, but I just did a very simple maneuver, you should never have seen in your whole life. Yes, and we use around ten hemostats. Huh? We use around ten hemostats to isolate the sac. What? What a waste. But look, look at this, I want to show you - Hemostat? - I want to show you the opening. Yes, I saw it. Yes. That goes in the belly. See, there? That goes in the belly. Like, see this? This goes in the belly. Amazing. That's the one. See, see it? Right there? We only used 3 hemostats. That's correct. I use ten. Ten? What a waste. And also it takes forever, takes so much time.</p>

<p>Hold this. Now you hold that, and now we going to separate this whole thing so we can ligate it like we normally do like a regular hernia. Now we can - now it becomes easy. Like this, see? Yeah, like that. And what you do then, is you just slowly peel this off like this, slowly peel this off, with this maneuver, very nice and easy. Yes. Nice and easy. Nice and easy. And here's this trick, a little trick with the gauze. Just look, what you do is just lean with the gauze, down, and you'll see the opening. A little bleeding there. Stop that. Yeah, there's a - I think we have a little bleeder in here. But we'll stop the bleeding with just pressure.</p>

<p>Okay, I obtained my objective, see? Now we can put a stitch there, like a 3-0 vicryl. From here, to there. Okay? Good. Perfect. Okay, tie that. Okay. Get in and catch that again. Go towards you. As far as far down as you can. As far down as you can reach, that's it. Like that. Perfect. Excellent. Okay, I'll just go over. It has to do, that's to separate the sack from the cord easily with the forceps. And that's like, one minute? Scissors? Yeah. Sometimes it takes three hours to do this. Yes. Three hours to do this procedure by many people? Including me. Including me, including me. By many people. By many people See? But see how easy it is, now we have that all the way. Oh, that's a good length. See the length, that's plenty of length. And you have all the tissues sir. Everything. It takes about three hours to do this procedure by many people.</p>

<h4>CHAPTER 3</h4>

<p>Then you go, create a tunnel. Tunnel. Like that. And you go to the base of the scrotum, and then you create a pouch. In the skin. We call that Dartos pouch. We make a pouch so you can create a new house for the testicle. And we do it without bleeding. Is there any bleeding? Okay. No. Okay, here we go. So we going to catch part of the testicle here that's safe, like this one, this gubernaculum. This is called the gubernaculum, you can grab this with a hemostat.</p>

<p>And watch it, the testicle is going to come down to his new house. Here's the testicle, and you slowly bring it down where it belongs into his new house. Here it comes. Yeah, you can stretch with a hemostat, get a hemostat and stretch that opening. Go in and stretch. There it comes. Stretch, stretch. It's going to come out easily. Yeah, that's good. Here it comes, there he is - hello! There's the testicle. And there's no tension, you see? There's no tension, and the blood supply looks great.</p>

<p>So now we get a - we suture this with a 5-0. Here's the dartos fascia. Right here. Okay, and suture this to the dartos fascia. The gubernaculum. Put about three stitches. The gubernaculum. Yeah, dartos. Good. Cut? Cut. Okay. Yeah, take - maybe excise that, trim that. Okay. That to that. Put one in between like, in between here.</p>

<p>I guess this has been another chapter of the book that you're going to write for me? Yes. Yeah, yeah. Catch that one and to this one, right here. Here. Yeah, to this. Right here. Okay, good. See, we have no tension whatsoever on that after we mobilized that testicle. Okay, now we're going to put - bring me the Adson. Do you have an Adson pickup? So what you do now is we're going to put his testicle in his house. Okay, by just lifting this up. Hello! There you go, put the 5-0 again, just close the skin.</p>

<h4>CHAPTER 4</h4>

<p>Right there. You made it easy. One minutes to isolate the sac, one minute! I told you there's a space between the two structures, I told them, right? And this is how to find it with the forceps, and you have to do it this way and that way, and this way and then before you know it, you're done. I'm going to need Michelle's pictures for that. Okay, now we're going to close the external oblique, and then you can close. Yeah. There. Yeah, that's the one. Pick the other one, the other side, yeah, see? No that, right there. No, no, no. That. See that? There's the - there's what I'm looking at. There. Okay. Yeah. Yeah, that's the one. This is the one where I dug into the femoral area, so you don't want to do that. Yeah. Okay, sub-q.</p>

<p>So you talked to the mother about the circumcision? Yes. Yeah, good. Alright. They had? Okay. They agreed? Yes, the mother agreed, yes. She said we'd do what's best for her son. It's okay. Already said that, that's fine. See that looks nice, see the scrotum now? It looks almost even now. We enlarged the scrotum somewhat by our tunneling.</p>

<h4>CHAPTER 5</h4>

<p>Okay, all we need to do is maybe just a slit, I don't know, we'll see. 3-0 chromic is what we'll be using for the circ. If not, we can use the 5-0. 5-0. Well we still have 4-0, you can use the same 4-0. Vicryl, vicryl is fine. Okay. This is called phimosis because the end is tight, and you can't open it to exposed the head of the penis, you have phimosis. Okay, let's see. It's best to cut this frenulum. Okay. Okay, good. Now you divide.</p>

<p>Put a stitch right - Is that okay, or? You want to - yeah, just stitch it. Is this 4-0? Yeah, fine. You want to trim more? It's up to you. You cut, you cut this first if you want. Go through here up to here. Okay, put a Stitch. He's making a lot of noise. Okay, stitch. Hemostat? Go ahead, cut.</p>

<p>In your opinion sir, why do people - what is the significance of circumcision? Circumcision? Yes. Mostly hygiene. But if you can pull your foreskin beyond the crown - corona, you don't need circumcision. No, no need to circumcise. If you have phimosis, that's the only indication. Okay? Okay sir. Otherwise - you don't have to, like I said if you… This kid has phimosis, so at this age, part of the skin should have been pulling back so you can see the head of the penis, but he didn't have, so he has. Yeah. So, 1% of all males will have phimosis. 1%, only 1%, so only 1% require circumcision, and they don't even require, you know, removal of the skin. That's all they need in order for them to clean, and also have sex properly. Okay, cut.</p>

<h4>CHAPTER 6</h4>

<p>This case originally was diagnosed as having a hernia because he probably has, and it's well, but they didn't realize that this child had an undescended testicle because when I first saw him while he was on the table I noticed that this was a fully developed testicle, and the scrotum on this side was underdeveloped. And then when I started feeling, I could feel a mass right in here which turned out to be the testicle. So the testicle was stuck. It didn't go down far enough into the scrotum. It was right in here. So, it's a good thing, because it was stuck, that means the testicle didn't go to the belly, so - it wasn't - it was developing somewhat abnormally because it's smaller than the other side. So what we did was we - we released the hernia away from the spermatic cord structures. We lengthened the cord by two things, two ways. you lengthen the cord by cutting the - the cremasteric muscles, these are muscles around the cord, and then we lengthen the cord by stripping the hernia sac away from the - from the cord structures, and then when you do that, the cord structures start to go down, and you can see where the vas deferens goes medial, and the vessels go lateral. And then we're able to bring it down into the scrotum without any tension. What I mean by no tension is that you're not stretching the blood vessels. Because if you do it in tension, you can stretch the blood vessels and then - phew! When the kids start walking, then they, it will disrupt, and then the testicle dies.</p>

<p>So in this case we were able to do a - Then we also noticed that he has phimosis of his, on the penis. He was not circumcised so he can't pull back on the tip of the foreskin because it was tight with a ring, it has a tight ring. We call it preputial ring, which is called phimosis. So we circumcised him so he can stay clean.</p>

<p>Thank you.</p>

Watch the full-length procedure of an orchiopexy and circumcision performed during a surgical mission in the Philippines with the World Surgical Foundation.

DOI
Publication Date	N/A
Article ID	268.7
Production ID	0268.7
Volume	N/A
Issue	268.7
https://doi.org/10.24296/jomi/268.7

Orchiopexy and Circumcision

Procedure Outline

Table of Contents