6. SCROTAL AND GENITAL EMERGENCIES 131
ering the testis, through the tough tunica albuginea of the testis, and then through the parietal layer of the tunica vaginalis, which lines the inner surface of the scrotum. We find it easier to clip each suture, and to tie them only after all three have been placed. Tying them after each has been placed can make it difficult to insert the next suture.
Other surgeons have argued that the testis should be fixed within a dartos pouch (Frank and O'Brien 2002). The rationale behind this form of fixation is that suture fixation breaches the blood-testis barrier, thereby exposing both testes to the risk of sympathetic orchidopathia. Dartos pouch fixation should, in theory, avoid this potential risk. In a review of 387 patients who had undergone unilateral or bilateral orchidopexy, Coughlin et al. (1998) reported that the use of testicular suture material was strongly associated with infertility. Concerns have also been expressed about a possible increased cancer risk in testes that have been suture fixed (Frank and O'Brien 2002).
Many surgeons continue to use suture fixation, and indeed operative surgery textbooks still describe this technique for use in testicular fixation for torsion (Hinman 1998).
If you use dartos pouch fixation, open the tunica vaginalis, bring the testis out, and untwist it. Develop a dartos pouch in the scrotum by holding the skin with forceps, and dissecting with scissors between the skin and the underlying dartos muscle. Once you have started to develop this space, it can be enlarged by inserting your two index fingers and pulling them apart. Place the testis in this pouch. A few absorbable sutures may be used to attach the cord near the testis to the inside of the dartos pouch. This can help to prevent retorsion of the testes (which we have seen in testes that have been placed in a dartos pouch). The dartos may then be closed over the testis and the skin can be closed in a separate layer.
Whatever technique you use, remember to fix both testes since the bell-clapper abnormality, which predisposes to torsion, can occur bilaterally.