Orchiectomy Scar

Superficial Inguinal Ring
Figure 9-3. The spermatic cord (C) can be seen exiting from the superficial inguinal ring, formed by the edges of the external oblique aponeurosis (EO).
Penrose Drain
Figure 9-4. The ilioinguinal nerve can be seen in the inguinal canal (straight arrow) after the external oblique aponeurosis has been incised and reflected (curved arrows).
Clamp Sperm Cord
Figure 9-5. A Penrose drain is wrapped around the cord and secured tightly with a clamp to provide venous and lymphatic control.

Figure 9-6. The spermatic cord (C) is clamped and then divided and doubly ligated with silk suture.

opened, and the testis examined. Biopsy is performed, and in the case of benign disease, the testis can be returned to the scrotum. We would generally perform a "bottleneck" procedure, everting and suturing the tunica vaginalis together behind the epididymis to avoid potential hydrocele formation in this situation. In most cases, the testis is simply removed, the scrotum is irrigated, and the wound is closed. A single figure-of-eight suture can be placed to obliterate the internal inguinal ring if it seems capacious, to avoid possible hernia. The external oblique fascia is closed with an absorbable suture, taking care to avoid injury to the ilioinguinal nerve. The subcutaneous tissues and skin are approximated in the usual way. This is an ideal situation for using tissue sealants rather than suture material for the skin (although the cost is still somewhat prohibitive).

Patients who have had prior scrotal surgery and who present with a testicular mass may have alterations in lymphatic drainage. Although these patients may have an increased risk of inguinal node metastasis, the initial approach should still be radical inguinal orchiectomy.7

A testicular prosthesis may be placed into the scrotum at the time of inguinal orchiectomy if the patient wishes. Such prostheses are available from a number of companies (now often called silicone carving blocks). They should be fixed to the lower dartos fascia with a single suture (to help keep them in a good position) and irrigated with antibiotic prior to closure.8 The patient must be warned that sometimes these prostheses become encapsulated and very hard over time, which makes them aesthetically less natural in texture. Nevertheless, some patients clearly prefer to have a prosthesis placed if possible.

Scrotal Orchiectomy

Figure 9-7. A, The mass is delivered into the inguinal incision from the scrotum. B, The gubernacular attachments are divided.

Scar Testicles

Figure 9-7. A, The mass is delivered into the inguinal incision from the scrotum. B, The gubernacular attachments are divided.

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