Ann R Coll Surg Engl 1998; 80: 69-71

SURGICAL TECHNIQUE

A simple alternative technique of

Key words: Cryptorchidism; Orchiopexy

Medial displacement of the testicular vessels consti- This procedure was later rationalised by Fowler and
tutes an important principle for a successful opera- Stephens in 1959 (3). In our view, obliteration of the
tion for high undescended testis. Prentiss's spermatic triangle by medial displacement of the gonadal
manoeuvre involving division of the fascia transver- vessels forms a useful and essential fifth principle of
salis attempts to achieve this objective but has not operation for high undescended testis, when the testis lies
found favour with surgeons because it is more at the level of the deep inguinal ring. Prentiss et al. (4)
invasive. A simple alternative procedure of re-
routing the testicular pedicle behind the fascia described this principle in 1955 and recommended
ligation and division of the inferior epigastric artery and
transversalis is described. The technique has been
reported earlier and this paper aims to illustrate the incision of the fascia transversalis to bring the cord
steps with the help of intraoperative photographs. medially in a straight course. The internal ring is closed
This method serves as a fixation procedure owing to and the fascia transversalis is approximated. Prentiss et al.
the 'button-hole' effect of a small pathway and may be (5) later reported results in 75 patients. They compared
combined with other techniques of scrotal fixation the initial level of the testis with the level after standard
such as formation of a dartos pouch and suturing. dissection and after division of inferior epigastric vessels,
the posterior wall of the inguinal canal and retroperitoneal
dissection. The average gain with inguinal dissection
alone was 2.0 cm increasing to 5.5 cm after division of
The principles of the present-day operation for unde- inferior epigastric vessels, the posterior wall of the
scended testis were described by Bevan at the end of the inguinal canal and retroperitoneal dissection. We aim to
last century. Four basic principles advanced by Bevan are: illustrate, with intraoperative photographs, a simple, less
1 Complete excision of fascial coverings from vas and invasive altemative procedure that allows the safe
testicular vessels; inclusion of the spermatic triangle principle in routine
2 Repair of associated hernia; orchiopexy for high undescended testis. The technique
3 Extraperitoneal dissection and has been reported elsewhere (6). Advantages of the new
4 Fixation of testis in the scrotum (1). technique are:
However, as Bevan himself subsequently noticed, in a 1 A shortened route of testicular pedicle by obliteration
few cases of high undescended testis, the testis could not of the spermatic triangle permitting placement of the
be brought down to the base of the scrotum with these testis in the scrotum without tension;
steps alone. He recommended ligation of the testicular 2 Preservation of the integrity of the posterior wall of
artery, as in most instances the testis would survive owing the inguinal canal and inferior epigastric vessels;
to collateral circulation from the artery to the vas (2). 3 Safeguard against retraction of the testis owing to the
button-hole effect of a small opening;
Correspondence to: Mr K Ayub, Departnent of Urology, Box 4 It may serve as a complete procedure on its own or in
43, Addenbrooke's NHS Trust, Hills Road, Cambridge combination with an additional procedure for fixation
CB2 2QQ of the testis to the scrotum.
70 K Ayub and M P L Williams

Figure 1. The gubernaculum at the lower pole is divided. Figure 2. The cremasteric fascia is divided to look for a
hernial sac.

Figure 3. Despite retroperitoneal mobilisation the testis Figure 4. An artery forceps is passed behind the fascia
only comes as far as the neck of the scrotum. transversalis and inferior epigastric vessels.

Figure 5. The testis is held in the artery forceps and Figure 6. The testis now lies in a low scrotal position.
guided behind the fascia transversalis.

Technique are dissected free from the surrounding tissues. The deep
ring is opened laterally and the vas and vessels are further
The approach is through an inguinal skin crease incision. freed retroperitoneally and any restricting bands are
The external oblique is divided in the line of its fibres. divided. A small opening is then made in the fascia
The processus and tunica vaginalis are dissected free from transversalis above the pubic tubercle and an artery
the cremaster and the gubemaculum at the lower pole is forceps is passed behind the fascia, bringing its tip out
divided. The cord is dissected free up to the intemal ring. of the deep ring. The testis is held in the tip of the forceps
The coverings of the cord are then divided longitudinally. by its tunica. By withdrawing the forceps the testis is
Almost invariably a hernial sac is found (7) and pulled behind the fascia transversalis and out of the small
herniotomy is performed. The vas and testicular vessels hole. The testis may be followed with the little finger of
 Alternative technique of orchiopexy 71
the contralateral hand to ensure straightening of the route References
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route, yet has not found favour universally because it is
more invasive. The alternative procedure illustrated is a Received 2 July 1997
simple one-stage procedure that allows the safe inclusion
of the medial displacement principle in a routine standard
procedure for the undescended testis which lies at the
deep ring.