Figure 9-2. A and B, In a patient with a very large tumor, the incision can be curved down on the medial end to extend down onto the proximal scrotum.
ered. We do this by passing the plastic Penrose drain around the cord twice and securing it tightly with a clamp (Figure 9-5). This should provide venous and lymphatic control without affecting the arterial inflow. In most cases, however, when the diagnosis is certain, it is preferable to simply ligate and divide the cord completely prior to delivering the testis.
The cord must be mobilized to well inside the internal inguinal ring before it is ligated. This requires applying traction on the cord and sweeping off the surrounding soft tissues. The vas deferens can be separated from the cord and tied separately. The remaining cord structures are then clamped in one or two sections and tied with a double 2-0 silk suture ligature (Figure 9-6). Care must be taken to ensure complete hemostasis before the cord stump is allowed to retract into the ring. To ensure this, it is wise to leave a long suture on the stump until just before wound closure. Finally, it is important that a large nonabsorbable suture be used on the stump so that the end can be easily identified from inside if the patient subsequently undergoes a retroperitoneal node dissection.
The testis is then delivered up into the inguinal incision from the scrotum. This requires blunt pressure from below and gentle traction on the distal cord (Figure 9-7, A). Once the testis is delivered, the gubernacular attachments to the inferior scrotum are divided (see Figure 9-7, B). Again, care must be taken to provide excellent hemostasis so that the patient does not develop a large postoperative scrotal hematoma.
If a diagnostic biopsy is planned, the wound should be carefully draped off, the tunica vaginalis
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