ORIGINAL ARTICLE

The unidirectional testicular tunneller: a simple, safe and noveldevice for orchidopexy in patients with palpable undescendedtestes

Jonathan Evans • Chryz Cosgrove •

Simon Huddart • Anthony Lambert

Accepted: 25 April 2012 / Published online: 12 May 2012

� Springer-Verlag 2012

Abstract

Purpose Inguinal orchidopexy is already considered a

safe procedure, this paper describes a simple new surgical

instrument designed to make the operation easier, simpler

and quicker, whilst reducing tissue trauma, in particular to

the deep ring. The result of its use in two centres is

presented.

Methods A unidirectional testicular tunneller has been

developed comprising a head, shaft and eye. At operation,

following testicular mobilisation, the tunneller is passed

through the groin incision into the scrotum and a dartos

pouch created by cutting against the head of the instrument.

This allows more of a ‘‘no-touch’’ technique with less back

and forth movement through the inguinal canal. The testis

is attached to the eye of the instrument and pulled into the

scrotum before fixation.

Results From November 2000 to December 2011, two

surgeons operated on 592 boys using the instrument. 93

procedures were bilateral. All operations proceeded with-

out incident and a healthy testis was safely and

permanently placed in the scrotum. There were no com-

plications related to the use of the tunneller. All were

treated as day cases.

Conclusion The instrument described in this paper sim-

plifies inguinal orchidopexy, improves procedural safety and

is felt to reduce surgical trauma. In view of these advantages

and the absence of complications related to this instrument,

its use in inguinal orchidopexy is recommended.

Keywords Orchidopexy � Unidirectional � Testicle �Tunneller

Introduction

Undescended testes are seen with relative frequency, with

1–2 % of boys\1 year old being affected. This congenital

abnormality may present either unilaterally (90 %) or

bilaterally (10 %) [1–3]. Evidence suggests an increasing

risk of malignancy and sub-fertility in boys who undergo

orchidopexy late in childhood [4].

Inguinal orchidopexy is, as one would expect from its

incidence and associations, common; the principles of the

surgical technique are well established and orchidopexy for

inguinal testis is one of the commonest operations per-

formed in boys. Traditionally, a finger is placed through the

groin wound into the scrotum to facilitate the formation of

a dartos pouch. Cutting against that finger creates the

pouch. The forceps is then passed from the scrotal incision,

cephalad into the groin wound, to retrieve the testis from its

proximal location [5]. A novel approach for testicular

tunnelling has previously been reported, suggesting that the

passage of a digit and surgical clips through the tissues of

the inguinal canal is likely to be more traumatic than the

single passage in one direction of a tunneller [6].

Presented at the International Surgical Society, Adelaide, Australia,

2009.

J. Evans (&) � C. Cosgrove � A. Lambert

Ministry of Defence Hospital Unit Derriford, Derriford Hospital,

Plymouth PL6 8DH, UK

e-mail: j.t.evans@me.com

A. Lambert

e-mail: anthony.lambert@nhs.net

J. Evans � C. Cosgrove � A. Lambert

Directorate of Surgery and Renal Services, Derriford Hospital,

Plymouth PL6 8DH, UK

S. Huddart

University Hospital of Wales, Cardiff, UK

123

Pediatr Surg Int (2012) 28:693–696

DOI 10.1007/s00383-012-3103-9

This paper describes a surgical instrument specifically

designed by the senior author to improve the safety of this

procedure and reduce the trauma of testicular tunnelling

during this operation.

The use of laparoscopic orchidopexy in abdominal testis

has been described [7]; however, its use in inguinal, pal-

pable testis is limited.

Other techniques have been described for inguinal

orchidopexy, especially in patients with low palpable

undescended testis. These techniques include various

approaches such as high scrotal (Bianchi) and low trans-

scrotal mid-raphe as well as the traditional inguinal

approach. Early reviews of these techniques have been

reported as successful [8]; however, a traditional two-

incision approach is still used.

Method

A specifically designed unidirectional testicular tunneller

(UTT) (Fig. 1) was used in two centres by surgeons who

perform paediatric inguinal orchidopexy. The instrument

comes as a single size, single use pack. The shaft is man-

ufactured from stainless steel and the head is anodised

aluminium. The head of the instrument measures 10 mm in

diameter and 15 mm length, with the overall instrument

measuring 240 mm.

Standard pre-operative preparation, groin exploration and

testicular mobilisation were employed. When sufficient cord

length had been achieved, the UTT is easily passed through

the groin incision into the scrotum along the proposed route

of testicular descent (Fig. 2). By cutting against the head of

the instrument, a dartos pouch is created, avoiding the

requirement to cut against the surgeon’s finger (Fig. 3). The

UTT was manipulated through the scrotal wound (Fig. 4)

before the cauda epididymis is sutured to the eye of the

instrument (Fig. 5). In one straightforward easy movement,

the instrument is pulled through in the same direction,

delivering the testis into the scrotal wound, where it was

fixed in the dartos pouch (Fig. 6). The wounds are closed in

the standard fashion, after the instrument has been detached.

A ‘‘button-hole’’ effect is important in retaining the

strength of the deep ring and this is retained, if not

improved. A finger will, in the traditional method, remain

in situ during the formation of a dartos pouch, however,

because the head of the UTT instrument is only 15 mm in

length and on a narrow shaft; the deep ring is allowed to

return almost back to native shape following the passing of

the head. This protects this valuable ‘‘button-hole’’ effect

and the integrity of the deep ring.

The surgeon is able to operate using his/her dominant

hand on both sides. This is achieved by positioning him/

herself on the side being operated on and once the tunneller

Fig. 1 The unidirectional testicular tunneller

Fig. 2 The tunneller is passed through groin wound into scrotum.

The shape of the tunneller head can be seen here in the scrotum

Fig. 3 Formation of dartos pouch by cutting against tunneller head

whilst the surgeon’s assistant holds it in place. The surgeon is able to

stretch the skin over the head of the instrument and cut using his

dominant hand on both sides as he/she does not need to have a finger

in the scrotum to create the pouch

694 Pediatr Surg Int (2012) 28:693–696

123

is in position in the scrotum, utilising the surgical assistant

to hold the instrument in place. This frees up both of the

surgeons hands to create the dartos pouch instead of using

the finger of one hand inside the scrotum.

Ethical approval was not required as there was no ran-

domisation and was not part of a study, an instrument was

introduced to assist the operation.

Results

From November 2000 to December 2011, 592 boys, mean

age 5 years 3 months (range 6 months–16 years 1 month),

underwent inguinal exploration by one of two surgeons.

There were 93 bilateral and 499 unilateral procedures. 592

patients underwent inguinal orchidopexy using the method

described above.

There were no problems related to the use of the UTT

and no post-operative complications in this series of

patients. All were day case procedures and proceeded

without incident, and a healthy testis was safely and per-

manently placed in the scrotum. No complications resulting

in an overnight stay or review by the operating surgeon

were noted in any of the cases.

Discussion

Any modification to an established surgical technique that

reduces surgical trauma helps increase a ‘‘no-touch’’

approach and improves safety, should be encouraged. The

passage of a digit through the groin wound into the scro-

tum, cutting against that finger to create a dartos pouch and

the subsequent passage of the forceps in the opposite

direction before pulling the testis into the scrotal wound is

felt by the authors to be traumatic and cumbersome. There

are also potential safety implications during the creation of

the dartos pouch, particularly when there is a requirement

to cut with the non-dominant hand. A modification to the

procedure, reducing the manipulation of the tissues, was

developed, alongside the development of a unidirectional

testicular tunneller.

Initially, a technique for testicular tunnelling was estab-

lished using a vascular tunneller (Impra Tunneller, Bard Ltd,

UK) [2]. Using this tunneller, it was felt that there would be a

reduction in the trauma of tunnelling, as the instrument is of

smaller dimensions than the surgeon’s finger and is passed in

only one direction. This is in contrast, in the traditional

technique, to the passage of a digit in both directions fol-

lowed by the forceps, to retrieve the testis from the groin and

position it in the scrotum. Based on the necessity for trans-

location of the mobilised testis from the groin to the scrotum,

a new instrument was developed. The UTT was designed,

comprising a leading head, a shaft and an eye for the

attachment of the testis (Fig. 1) [9, 10]. This size is based

upon the average volume of a pre-pubertal testis of a boy

between 1 and 4 years, the typical age of orchidopexy.

The stages of inguinal orchidopexy include testicular

mobilisation, tunnelling and dartos pouch fixation. The

UTT described in this paper removes the previously

described necessity to pass a finger, and then the forceps in

two directions, through the groin. This simplifies the tun-

nelling procedure and thus reduces surgical trauma, both by

enabling a smaller incision to be made and reducing the

tissue damaged during the tunnelling procedure, as the

head of the tunneller is smaller in diameter and shorter in

length than a finger and is on a narrow shaft. There is an

Fig. 4 Tunneller delivered through scrotal wound

Fig. 5 After orientating the cord and testis, the cauda epididymis is

secured to the eye of the tunneller with 3/0 silk sutures. The

instrument is then pulled from the groin out of the scrotum with the

testis attached. The testis is sutured into the dartos pouch in standard

fashion prior to cutting the retaining suture

Pediatr Surg Int (2012) 28:693–696 695

123

additional advantage to the surgeon as there is no longer a

requirement to cut against their finger placed in the scro-

tum. This is particularly important when the scalpel would

previously have been held in the non-dominant hand. The

use of the UTT enables the surgeon to operate with their

dominant hand, no matter which side of the patient was

being operated upon.

The use of a Foley catheter in the creation of a dartos pouch

has previously been described [11, 12] to distend the scrotal

sac, stretch parietal layers and enable quick bloodless dis-

section. Whilst that expansion is not possible with this device,

it offers the advantage of being able to cut down onto the

instrument directly whilst stabilising it with the other hand.

Various techniques are currently used for orchidopexy;

these include laparoscopic approaches [7], scrotal incision

only [13] and the use of a balloon catheter [11, 12] to assist

in the formation of the dartos pouch. The use of a tradi-

tional two incision orchidopexy remains an approach used

either primarily or as a back up, should orchidopexy not be

achieved by the alternative method [7, 13].

It is hard to quantify either the trauma caused to the

inguinal canal by the use of a digit to create a dartos pouch,

or the incidence of injury to the surgeon and as such we

recognise these are limitations of our experience. The

instrument’s use is limited to testes found extra-abdomi-

nally and at the external ring.

Conclusion

The instrument was simple to use, improved surgeon safety

and, it is felt that by the nature of its single pass through the

groin, was less traumatic for the deep ring and hence the

patient. In addition, it was possible for the surgeon to

operate with their dominant hand, no matter which side of

the patient was being operated upon.

In view of the perceived advantages and in the absence

of complications related to this instrument, its use in open

inguinal orchidopexy is recommended.

Acknowledgment We thank the Medical Illustration Department,

Derriford Hospital, Plymouth.

Conflict of interest The senior and corresponding author, Mr.

Anthony Lambert, was the developer of the instrument and holds the

patent for the Unidirectional Testicular Tunneller. The instrument is

available through Elemental Healthcare (insert contact) at a price of

£25 per single use pack (containing one instrument).

References

1. Sweeney DD, Smaldone MC, Docimo SG (2007) Minimally

invasive surgery for urologic disease in children. Nat Clin Pract

Urol 4(1):26–38

2. Swerdlow AJ, Higgins CD, Pike MC (1997) Risk of testicular

cancer in cohort of boys with cryptorchidism. Br Med J

314(7093):1507–1511

3. Hadziselimovic F, Herzog B, Barthold JS (1997) Treatment with

a luteinizing hormone-releasing hormone analogue after suc-

cessful orchiopexy markedly improves the chance of fertility later

in life. J Urol 158(3):1193–1195

4. Chilvers C, Dudley NE, Hough MH, Jacson MB, Pike MC (1986)

Undescended testis: the effect of treatment on subsequent risk of

subfertility and malignancy. J Pediatr Surg 21:691–696

5. Hutson JM (1998) Undescended testis, torsion and varicocele. In:

O’Neill Jnr JA, Rowe MI, Grosfeld JL, Fonkalsrud EW, Coran

AG (eds) Pediatric Surgery, 5th edn. Mosby, St. Louis

6. Lambert AW (2004) A novel technique for testicular tunnelling.

Ann R Coll Surg Engl 86(2):131

7. Abbas TO, Hayati A, Ismail A, Ali M (2012) Laparoscopic

management of intra-abdominal testis: 5-year single-centre

experience—a retrospective descriptive study. Minim Invasive

Surg 2012:878509

8. Cloutier J, Moore K, Nadeau G, Bolduc S (2011) Modified scrotal

(Bianchi) mid raphe single incision orchidopexy for low palpable

undescended testis: early outcomes. J Urol 185(3):1088–1092

(Epub 2011 Jan 21)

9. UK patent application number 0314689.1

10. International patent application number PCT/GB04/002688

11. Dalela D, Sinha RJ, Goel A, Sankhwar SN (2008) Balloon dis-

tension of scrotum: a step to facilitate creation of dartos pouch

during orchidopexy. Pediatr Surg Int 24(4):437–438

12. Al-Saied G (2008) Balloon inflation-created subdartos pouch

during orchidopexy: a new simplified technique. Pediatr Surg Int

24(10):1187–1190

13. Dayanc M, Kibar Y, Irkilata HC, Demir E, Tahmaz L, Peker AF

(2007) Long-term outcome of scrotal incision orchidopexy for

undescended testis. Urology 70(4):786–788

Fig. 6 The testis is sutured into the dartos pouch in standard fashion

prior to cutting the retaining suture and removing the device caudally

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