Figure 6.4. Point tenderness in a case of a twisted appendix epididymis.
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Williamson 1986). The autoantibodies so produced can then damage the contralateral testis, thereby impairing hormone production and spermatogenesis of this side as well. A delay in relieving the torsion of more than 6 hours increases the risk that ischaemic necrosis will take place.
Warn the patient (and if he is a child, warn his parents) that if the testis is found to be dead at exploration, the best thing to do is to remove it. This is done to reduce the likelihood of an autoimmune reaction affecting the normal contralateral testis, but also because this provides the best pain relief and prevents the potential complication of infection of the necrotic tissue (which could lead to subsequent abscess formation).
Under general anaesthesia, the scrotum is explored. We use a midline incision, since this allows access to both sides so that they may both be 'fixed' within the scrotum. In some cases the testis may already be black and obviously necrotic. The spermatic cord should be ligated with a transfixion stitch of an absorbable material and the testis should be removed. If the testis has twisted and appears to be viable, untwist it and wait for it to 'pink up.' Give it the benefit of the doubt. Wait 10 minutes, placing the testis in a warm swab. You can use this timing to fix the other side. If, after 10 minutes, the viability of the testis is in doubt, make a small cut with the tip of a scalpel. If the testis bleeds actively, it should be salvaged (close the small wound with an absorbable suture).
There is some controversy surrounding the best technique for fixation. Some surgeons fix the testis within the scrotum with suture material, inserted at two or three points. Those who recommend three-point fixation do so because they argue it reduces the risk of retorsion (Phipps 1987, Thurston and Whitaker 1983). Some use absorbable sutures and others nonabsorbable sutures. Those who use the latter argue that absorbable sutures may disappear, exposing the patient to the risk of subsequent retorsion. Indeed, in a literature review Kuntze et al. (1985) found that 15 of 16 patients with recurrent torsion had undergone previous orchidopexy using absorbable suture material, and they recommended the use of 2/0 or 3/0 nonabsorbable suture material. Those who use absorbable sutures argue that the fibrous reaction around the absorbable sutures used to fix the testis will prevent retorsion and that the patient may be able to feel non-absorbable sutures, which can be uncomfortable (though this should not occur if the sutures are placed medially, i.e., into the septum between the two testes). If you use suture fixation, these should pass through the visceral layer of the tunica vaginalis cov-