Orchiopexy

Orchiopexy surgically relocates an undescended (cryptorchid) testis into a dependent scrotal position and fixes it there. Surgery is considered if a testis has not descended by 6 months of age, and orchiopexy is usually performed as an outpatient between 6 and 24 months. Bringing the testis down improves fertility potential, allows self-examination and reduces (though does not eliminate) malignancy risk, and corrects the associated hernia. A child with bilateral non-palpable testes must be evaluated for a disorder of sexual differentiation before surgery. Cancer- and fertility-risk context is covered in the Testicular Cancer and Male Infertility topics; this page is the operative reference.

Indications and Timing

• Operate if the testis has not descended by 6 months; the window of 6–24 months balances anaesthetic safety against the benefit of early repair.
• Cancer risk — cryptorchidism raises ipsilateral testicular-cancer risk 4–6×, falling to 2–3× if orchidopexy is performed before puberty; the contralateral testis carries a small increase (RR ~1.74×).
• Fertility — after orchidopexy, paternity is ~96% with a unilateral and ~70% with a bilateral undescended testis; repair ideally before age 10.
• Adult cryptorchidism — a testis discovered post-pubertally is generally treated by orchiectomy when the contralateral testis is normal; after 50 years of age the operative risk exceeds the cancer risk, so surgery is usually not offered.
• Pediatric anatomy — in a child < 2 years the bladder extends into the abdomen (injury risk during medial cord exposure or port placement), and the loosely attached peritoneum predisposes to emphysema during laparoscopic access.

Choosing the Approach

The operation is selected from the pre-operative examination:

Examination	Approach
Palpable, high scrotal	Scrotal or inguinal orchiopexy
Palpable, inguinal	Inguinal orchiopexy
Non-palpable, contralateral testis enlarged (possible in-utero torsion with atrophy)	Exploration for a remnant; orchiectomy of a non-viable testis
Non-palpable	Diagnostic laparoscopy → inguinal, laparoscopic, low-ligation, staged Fowler-Stephens, or microvascular orchiopexy

A non-palpable testis is intraabdominal in 25–50% and absent/vanishing in 15–40% (atretic vessels and a blind-ending vas, usually at or just distal to the internal ring); blind-ending spermatic vessels confirm testicular absence.

Inguinal Orchiopexy (Open)

The workhorse for a palpable inguinal or high-scrotal testis. Position supine (a caudal block aids analgesia). The five steps:

1. Inguinal dissection — incise the external oblique fascia toward the external ring, identify and protect the ilioinguinal nerve, and free the cremasteric fibres.
2. Deliver the testis and mobilise the cord — open the tunica vaginalis and remove the appendix testis/epididymis, excise the gubernacular attachments, and gauge cord length by pulling the testis over the symphysis. If short, mobilise the cord into the retroperitoneum (a peanut dissector medially to avoid vascular injury), keeping dissection minimal to avoid atrophy.
3. Repair the hernia (patent processus vaginalis) — separate the sac from the vas and vessels just below the internal ring, then close it with a purse-string suture at the internal ring.
4. Create a dartos pouch — a 2 cm scrotal incision, blunt separation of skin from dartos over a finger.
5. Relocate the testis — bring it through the canal without rotating the cord and fix it dependently in the pouch.

Close the internal oblique to the shelving edge of the inguinal ligament (3-0/4-0 absorbable), fashion a new external ring (not too tight), and close skin with a subcuticular 4-0/5-0 suture. Troubleshooting: if the cord is too short, the Prentiss maneuver (which bypasses the obliquity of the inguinal canal) gains length.

Scrotal Orchiopexy

Reasonable for a palpable high-scrotal testis needing minimal extra length. Through a single cephalad scrotal-crease incision, create a subdartos pouch before mobilising the testis; the high compliance of scrotal skin and the short external-ring-to-scrotum distance allow cord dissection without entering the inguinal canal. Open the external ring/canal through the same incision if more length is needed, or convert to a standard inguinal approach. An associated communicating hydrocele or hernia is best addressed inguinally.

Diagnostic Laparoscopy and Laparoscopic Orchiopexy

Diagnostic laparoscopy defines gonadal anatomy for a non-palpable testis. Under anaesthesia, repeat the exam — a testis or remnant becomes palpable in up to 20% of cases, sparing intraabdominal surgery. Decompress the bladder (urethral catheter) and stomach (NG tube), position in 30° Trendelenburg, and place 3–5 mm working ports at McBurney's points, avoiding the transilluminated inferior epigastric vessels. Findings range from a cord entering the internal ring (a distal testis/remnant) to blind-ending vessels (a vanishing testis) or an intraabdominal testis.

Single-Stage Laparoscopic Orchiopexy

For an intraabdominal or high-inguinal testis not tightly tethered by its vessels — as a rule, a testis that reaches the contralateral internal ring can be placed in the ipsilateral scrotum. Raise a broad peritoneal flap (leaving an isthmus of peritoneum on the vas to protect the vasal collaterals), dissect the gubernaculum distally to preserve collaterals, gain length with the Prentiss maneuver (passing the testis behind the inferior epigastric vessels for a more medial cord position), and deliver the testis to a dartos pouch. Inspect for bleeding at a low insufflation pressure (~6 mm Hg) before closing.

Two-Stage Fowler-Stephens Orchiopexy

Indicated for an intraabdominal testis that lacks mobility because of short spermatic vessels or has a long looping vas. Stage 1: clip the spermatic vessels high (two 5-mm clips per bundle or a non-absorbable tie) without dividing them, so collateral flow develops from the deferential and external spermatic vessels. Stage 2 (6 months later): mobilise the testis on a broad peritoneal flap preserving the collaterals and place it in the scrotum. Testicular retraction is the commonest post-operative complication, and atrophy can follow arterial division or vasospasm from excess tension.

Other Approaches

• Open surgery for a non-palpable testis (when laparoscopy has not localised it) — a midline transperitoneal approach (for known high intraabdominal testes, e.g. prune-belly syndrome), a midline extraperitoneal approach, or an extended inguinal approach.
• Laroque incision — for a low intraabdominal testis with short tethering vessels; a fascial incision ~3 cm superior to the inguinal incision allows the vessels to be mobilised to the lower pole of the kidney, often permitting a primary intraabdominal orchiopexy and avoiding a Fowler-Stephens.
• High-ligation (open Fowler-Stephens) — for a high testis with a short main vascular cord but a long looping vas; the internal spermatic artery and vein are divided, leaving the testis reliant on the vasal-artery collaterals. A bleeding test (bulldog on the internal spermatic artery, a 3 mm tunical incision; brisk bleeding persisting for 5 minutes = adequate collateral) confirms safety before ligation. Testicular atrophy is the key adverse outcome.
• Low-ligation — for a low-lying testis tethered by a short main cord; ligate the spermatic vessels low, unfold the vasal loop, and preserve a continuous 1 cm strip of peritoneum over the vas, vessels, and collaterals (backbleeding confirms flow).
• Redo orchiopexy — counsel the family about a high atrophy risk; mobilise the cord en bloc leaving a plate of external-oblique fascia attached to protect its blood supply, with retroperitoneal dissection to gain length.
• Microvascular orchiopexy (autotransplant) — for a high intraabdominal testis (e.g. prune-belly) or one lost at prior surgery; anastomose a branch of the inferior epigastric artery to the spermatic artery with 10-0/11-0 nylon, keeping ischaemia time under 1 hour, with heparin and postoperative low-molecular-weight dextran.

Complications

• Early (open) — scrotal swelling (usually oedema; progressive enlargement suggests bleeding and needs exploration), testicular devascularisation (minimised by loupes and fine instruments), vas division, an inadequate final position (from incomplete retroperitoneal dissection — correct at a second operation), and bladder injury (drain the bladder pre-operatively).
• Late (open) — testicular retraction (repeat orchiopexy), a hydrocele from tunica vaginalis remnants (transscrotal repair if large), and testicular atrophy (orchiectomy for profound atrophy, given the malignancy risk).
• Laparoscopic — most intraoperative injuries occur at port placement (preperitoneal/omental emphysema, major-vessel or inferior-epigastric injury — leave the trocar to tamponade a major-vessel puncture, and bowel/bladder/ureteral injury). Testicular retraction is again the commonest specific complication.