Radical inguinal orchidectomy

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Landmarks and incision Before the knife, the side is confirmed against the imaging, the markers have been sent, and a prosthesis has been discussed. The ASIS and the pubic tubercle, beside the pubic symphysis, are felt and marked. The incision, about 5 cm, lies between them along the line of the inguinal canal: over the internal ring laterally and running towards the external ring medially. One wound has to do two jobs, clamping the cord at the internal ring and delivering the testis whole, so it sits over the canal and never on the scrotum.
   where it bites: a scrotal incision contaminates the scrotum with tumour and changes the lymphatic drainage field.
2. Through the layers to the external oblique Each layer is named as it is met. The skin is opened with the scalpel. The yellow subcutaneous fat, Camper's fascia, is divided with diathermy, and deeper the pale membranous layer, Scarpa's fascia, is divided in the same line. Then the shiny external oblique aponeurosis comes into view, its fibres running down and in. That is where the superficial dissection stops.
   where it bites: going through the aponeurosis before it is cleaned and seen is how the nerve beneath it is cut.
3. Open the external oblique; isolate the ilioinguinal nerve The external oblique is nicked and opened along its fibres with scissors, down through the external ring, to show the spermatic cord in the canal. The ilioinguinal nerve lies on the cord under the aponeurosis. It is isolated, lifted off the cord and protected out of the way before anything is clamped or cut.
   where it bites: indiscriminate dissection or diathermy on the cord injures the ilioinguinal nerve.
4. Clamp the cord at the internal ring The cord is freed from the floor of the canal and traced up to the internal ring. A clamp goes across it there before the testis is handled, so the venous outflow of the tumour is controlled before the testis is squeezed or pulled.
   where it bites: delivering the testis before the cord is clamped handles a tumour with an open venous outflow.
5. Evert the scrotum and deliver the testis A finger from below everts the scrotum and the testis is delivered up into the wound whole, inside its coverings, with the cord. The gubernaculum is divided as the testis comes free. Traction is on testis and cord together, never on the mass. Where the ring is tight the external oblique is opened further rather than force applied, because a large tumour forced through a tight ring is how a tunica tears.
   where it bites: breaching the tunica or tearing the mass spills tumour cells into the wound and scrotum.
6. Second clamp; divide above both clamps With the testis held up out of the wound, a second clamp goes across the cord just above the first. The cord is divided above both clamps: the testis and cord are the specimen, and both clamps stay on the cord stump at the internal ring. Division at the ring is the oncological point of the route: a low division leaves tumour-bearing cord and lymphatics behind.
   where it bites: a low division leaves tumour-bearing cord behind in the remnant.
7. Transfix the stump; release the clamps slowly A transfixion suture is passed through the cord and tied below the top clamp, between both clamps, and the top clamp is removed slowly while the stump is watched. A second transfixion suture is then tied below the bottom clamp, at the internal ring, and the bottom clamp is removed slowly. The stump is watched until it is dry before it is allowed to settle: a stump released bleeding is the one that is lost in the canal. Some surgeons use a non-absorbable suture on the stump so it can be found at any later retroperitoneal surgery; that is a common practice, not a rule.
   where it bites: releasing a clamp on an insecure tie lets the stump retract bleeding through the internal ring.
8. Prosthesis, if consented A prosthesis is raised and consented before the incision, then placed when requested: the implant passes down the same inguinal route into the scrotal pouch, at the same operation or delayed until oncological treatment is complete. Delay is the usual choice where adjuvant chemotherapy or radiotherapy is likely, because infection threatens both the implant and the cancer pathway. The route never changes: a separate scrotal cut in a cancer case is forbidden.
   where it bites: never through a separate scrotal cut in a cancer case.
9. Close in layers; histopathology The nerve is laid back and the wound is closed in layers: the external oblique with a continuous 2-0 Vicryl, keeping the ilioinguinal nerve out of the suture line and re-forming the external ring without narrowing it; Scarpa's fascia with interrupted 3-0 Vicryl; and the skin with a subcuticular 4-0 Monocryl. Long-acting local anaesthetic goes into the wound. The specimen is sent whole and orientated by cord and testis, in a bag, because the histology of the entire orchidectomy specimen is the diagnosis; that is also why no biopsy is taken beforehand.
   where it bites: never biopsy a testicular mass trans-scrotally; the diagnosis is the histology of the whole orchidectomy specimen.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance