Surgery for Testis Cancer

Orchiectomy

Preoperative workup/counseling

Steps

  1. Shave inguinal area, prep/drape, give cefazolin for skin flora coverage
  2. Palpate external ring, make mark and mark ASIS, draw ~8-10cm line along langer lines from external ring laterally
  3. Make skin incision, divide deeper layers (can spread with hemostat), can use wheatlander as self-retaining retractor
  4. Identify fascia, clean off inferiorly to better define the layer for closure
  5. Make fascial incision with knife (not cautery) to prevent nerve injury - after making small incision, insert tenotomy scissors, spread tips along fascial fibers, spread under fascia to elevate off muscle, then cut to external ring
  6. Use debakeys to move cremaster fibers off overlying fascia, try to protect ilioinguinal nerve
  7. Can use fingers to bluntly encircle entire cord, then wrap x2 with penrose drain and clamp with tonsil clamp
  8. Push testicle from scrotum into inguinal region - may need to extend skin incision towards scrotum
  9. Divide all testicular attachments, taking care not to injure testicle or punch hole through skin, then take down cremasteric attachments until testicle and cord freed to internal inguinal ring
  10. Create two cord packets, clamp each packet separately proximally, then clamp entire cord distal to the clamps, and divide cord between the proximal/distal clamps (curved mayo scissors), then hand off specimen
  11. Tie off each packet x2 with 2-0 silk - usually use on a taper needle, can also use free tie, leave tails long to rescue if bleeding still present, leave at least one long tail to identify if RPLND needed in the future
  12. Check hemostasis including inside scrotum, irrigate field
  13. Close fascia with 2-0 or 3-0 vicryl or PDS, close scarpa layer with 3-0 vicryl, then close skin with 4-0 monocryl and dermabond

Retroperitoneal Lymph Node Dissection

Open RPLND

Chylous Ascites

Sources