Orchidopexy for Undescended Testis 
Jason Axt, Muse Freneh, Leahcaren Oundoh 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Undescended testis is one of the most 
frequent surgical conditions encountered in children.  
Decline in fertility increases the longer the testis 
remains out of the scrotum > 8 months’ time. 
Therefore, we recommend orchidopexy for all truly 
undescended testis at 8 months to one year of age 
depending on the comfort and skill of your 
anesthetist. There is a slight increase in cancer 
potential in undescended testis, but this risk does not 
decrease after orchidopexy. However, testicular 
cancer is easier to detect, by palpation, in testes 
located within the scrotum. Orchidopexy at 8 months 
to one year of time is recommended for fertility 
preservation, potential cancer detection, and to avoid 
traumatic injury to a testis located over boney 
structures.   
In the instance of bilateral undescended testis, 
care must be taken to always preserve at least one 
functioning gonad.  If the first side of a bilateral 
orchidopexy goes well, we may perform bilateral 
orchidopexy in the same setting.  If there is any 
concern about blood supply or testicle viability, we 
defer the contralateral side temporarily to assure one 
side’s survival before placing the other side at risk. If 
there is hypospadias or any other indication of 
ambiguous 
genitalia 
along 
with 
bilateral 
undescended testis, orchidopexy should be only 
undertaken 
after 
chromosomal 
analysis 
and 
multidisciplinary discussion of gender assignment. 
Orchidopexy is increasingly difficult as age 
increases, particularly after puberty. We will offer an 
attempt at orchidopexy for post pubertal children 
primarily for social and aesthetic purposes if it can 
be easily done.  If extensive dissection is necessary 
however, we will perform orchiectomy if there is a 
normal contralateral testis. Therefore, every post-
pubertal child, and his parents, undergoing 
orchidopexy are explained the possibility of 
ipsilateral orchiectomy and consent is obtained. 
Testicular examination is an acquired skill 
and requires a relaxed child. One should stand to the 
side of the child, with the child’s legs gently bent, 
and knees spread. The parent should be at the head 
reassuring them. The examining hand should sweep 
downward from the abdomen following the inguinal 
canal, gently compressing tissue onto the superior 
pubic ramus and then laterally. 
 
Examine for testicle with a gentle inferior then lateral sweeping motion, 
in the direction shown by the green arrow. Traction on the scrotum 
may bring a “peeping” intrabdominal testis into a palpable position. 
The examiner’s hands should be warmed, and 
oil or soap can be used to reduce friction. One should 
feel and see a small pop as the examining hand slides 
over the inguinal testis. Alternately, gentle traction 
can be placed on the scrotum (gently pinching the 
gubernaculum) as the same motion is used with the 
examining hand. This will sometimes bring a 
“peeping testis” from an intrabdominal position 
below the pelvic brim rendering it palpable. Testis 
can also be ectopic, outside of the normal pathway of 
descent, or intrabdominal. An ectopic testis can be 
surgically addressed in the manner described here if 
it is near the canal. If a testis cannot be palpated, one 
should examine the patient under anesthesia. If the 
testis cannot be palpated in an anesthetized child, 
diagnostic laparoscopy should be performed to 
identify an intrabdominal testis vs. a vanishing testis 
that has atrophied due to intrauterine torsion. This 
procedure is described elsewhere in this Manual. 
Orchidopexy for Undescended Testis 
Jason Axt, Muse Freneh, Leahcaren Oundoh 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Undescended 
testis 
must 
also 
be 
differentiated from retractile testis due to a strong 
cremasteric reflex. In retractile testis there is usually 
a well-formed scrotum. If the testis can be reduced 
into the scrotum in a relaxed and warm child and 
remains there for 5-10 seconds, no orchidopexy is 
needed. The testicle likely resides in the scrotum 
during sleep and times of rest.  The testis should be 
examined for ascent in one year.  
Orchidopexy proceeds in the following steps:  
• Skin and Scarpa’s fascia incision 
• Incision of the external oblique aponeurosis, if 
necessary, and locating the testis 
• Dissection of the testis and spermatic cord away 
from adherent peritoneum, and ligation of the 
peritoneum 
• Creation of a Dartos pouch 
• Passage of the testis to the Dartos pouch  
• Skin closure, including securing the testis within 
the pouch if necessary. 
 
Steps: 
1. No ultrasound or other workup is required.  In a 
healthy child one can proceed electively to 
operative repair.  
2. Orchidopexy can be performed under general or 
spinal anesthesia with sedation.  Often a caudal 
or ilioinguinal block is utilized for post operative 
pain control.  
3. The patient is placed supine with the knees 
slightly flexed and the hips externally rotated.  
The umbilicus and scrotum are prepared and 
draped into the operative field. 
4. Make a 1.5 cm incision through skin in an 
inguinal crease overlying the palpated cord (no 
diathermy is needed). Usually, the incision is 
about 1.5 cm lateral to the midline.  
 
A horizontal incision (Black line) is made 1.5cm from the 
midline (Blue line), through a skin crease, over the palpable 
cord. 
 
5. Scarpa’s fascia is identified and generously cut 
with scissors allowing access to plane above the 
external oblique. 
 
After skin incision, a fascial layer within the subcutaneous fat 
is found: Scarpa’s fascia. Once this is incised, the external 
oblique aponeurosis is revealed.  
 
Orchidopexy for Undescended Testis 
Jason Axt, Muse Freneh, Leahcaren Oundoh 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
6. Small retractors are used to clear overlying tissue 
from the external oblique fascia and the external 
opening of the inguinal canal. After sweeping 
away this tissue, the examining retractors are 
pushed downward to reveal the bulge of the cord 
structures 
or 
the 
fibrous 
tissue 
of 
the 
gubernaculum (if the testis is more proximal). 
 
Once the external oblique fascia is cleared, downward pressure 
with two retractors reveals a bulge representing the cord 
transiting the external opening of the inguinal canal.  
 
7. The cord structures or gubernaculum are grasped 
using a non-toothed grasper or hemostat and 
pulled through the incision. It should come up 
easily as fat is stripped. If the structure does not 
come up easily, it is not likely the cord / 
gubernaculum / testis. If it cannot be easily found, 
identify the external oblique as it creates the 
external inguinal ring and divide with scissors to 
open and fully examine the inguinal canal.  
 
The cord should come easily into the surgical wound once it is 
located and pulled gently.  
 
8. The cord and testis are now externalized. The 
gubernaculum if robust can be divided distal to 
the testis taking care not to injure a long looping 
vas deferens that might be in the gubernaculum.  
 
The gubernaculum testis will be a thickened structure on the 
opposite side of the testis from the spermatic cord. It is divided. 
Watch for the vas deferens, which may loop near to this 
structure.  
 
9. The hernia sac / investing peritoneum is carefully 
dissected from the cord. A small fraction of 
undescended testes will have a persistent 
Divided 
Gubernaculum 
Orchidopexy for Undescended Testis 
Jason Axt, Muse Freneh, Leahcaren Oundoh 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
processus vaginalis that could develop into a 
symptomatic hernia. 
 
Undescended testes will have attached peritoneum, similar to a 
hernia sac. Dissecting this peritoneum off the testicle and 
spermatic cord, all the way down to the internal ring, is the key 
to allowing the testicle to reach the scrotum without tension. In 
this photo, the spermatic cord is held within an Allis clamp on 
the right side of the photo and the forceps holds the thin 
peritoneum. It is quite clear in this photo that fully dissecting 
the peritoneum off the spermatic cord will give considerable 
length to the testis and cord.  
 
10. When the sac / investing tissue is dissected off 
the cord, the cord structures are verified by 
palpation. The vas deferens feels like a hard piece 
of spaghetti, the testicular artery and veins can be 
seen. An Allis clamp can be used to control the 
cord. 
 
As seen here, an Allis clamp surrounds the spermatic cord and 
its individual structures, including the vas deferens and blood 
vessels, all of which can be seen.  
 
11. The sac structures are now divided and dissected 
from the cord toward the abdominal wall. If 
necessary to create adequate length, the external 
oblique aponeurosis can be sharply opened into 
the inguinal canal (if not already done). If there 
is still inadequate cord length to reach the upper 
scrotum, the epigastric vessels can be divided, 
and the cord further medialized.  
 
Orchidopexy for Undescended Testis 
Jason Axt, Muse Freneh, Leahcaren Oundoh 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Mobilized testis and spermatic cord. The peritoneum, dissected 
off the cord, is held by a fine hemostat in the top of the picture.  
 
 
A hemostat may be placed under the external oblique fascia 
which can be sharply divided using a pushed scissors to open 
the inguinal canal if more length is needed 
 
12. The dissected sac structures (peritoneum) are 
ligated and divided at the abdominal wall, taking 
care to preserve the cord structures. 
 
Once the peritoneum is completely dissected off of the cord 
structures all the way up to the internal ring, it is suture ligated.  
 
13. A 1 cm incision is made on the scrotum in a skin 
crease. 
 
An incision the size of the testis is made in the scrotal skin, but 
not through the Dartos fascia underneath.  
 
14. An inferior pouch is created in the space between 
the scrotal skin and the fascia just underneath it, 
Orchidopexy for Undescended Testis 
Jason Axt, Muse Freneh, Leahcaren Oundoh 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Dartos’ fascia. Open up much more space than 
you think the testis will occupy.   
 
Using a hemostat, bluntly create a space between the skin and 
the Dartos fascia underneath.  
 
15. A hemostat is passed from the inguinal incision 
under Scarpa’s fascia to the scrotal incision 
pushing it in deeply to make a wide path for the 
testicle. This is exchanged for a hemostat from 
the scrotal incision to the inguinal incision 
following the same path. Grasp the testis, make 
sure there are no twists to the cord, and draw it 
into the scrotum. 
 
The first hemostat is passed from the groin incision to the 
created pouch in the scrotal skin.  
 
The first hemostat then guides a second one in the opposite 
direction, that will be used to pull the testicle down into the 
newly created pouch.  
 
16. Absorbable suture is used to close the canal 
around the cord.  
Orchidopexy for Undescended Testis 
Jason Axt, Muse Freneh, Leahcaren Oundoh 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
17. The testis is placed in the Dartos pouch.  If the 
testis is under tension, additional sutures can be 
used to affix the testis to the inferior scrotal wall. 
(We only place these when testis is under tension, 
as there is concern that inflammation caused by 
suture material to the testis can affect fertility.) 
 
 
Make sure the Dartos pouch is large enough to accommodate 
the testicle, enlarging it if necessary. An absorbable suture is 
placed to close the canal around the cord. The testicle, having 
been passed to the scrotum, can be seen outside the scrotal 
incision in the lower part of the picture.  
 
 
The testicle is placed within the subcutaneous pouch in the 
scrotum. If there is no tension, no sutures are required to fix it 
in place.  
 
The scrotal skin is closed with running absorbable 
monofilament suture. 
 
Close the scrotal skin with the testicle now in its proper location.  
 
18. Scarpa’s fascia is closed with a single absorbable 
suture. The skin is closed with two interrupted 
absorbable sutures. The whole operation can be 
performed with a single 2-0 or 3-0 polyglactin 
suture.   
Orchidopexy for Undescended Testis 
Jason Axt, Muse Freneh, Leahcaren Oundoh 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The completed operation.  
 
Note 
The photos are of a right transinguinal orchidopexy 
on a 2-year-old child.  
 
Pitfalls 
• If the testis cannot be palpated prior to operating, 
the child should have diagnostic laparoscopy. 
• Carefully preserve the vas deferens and testicular 
vessels. 
• Divide external oblique and then epigastric 
vessels if there is inadequate length. 
• In the case of hypospadias and bilateral 
undescended testis or ambiguous genitalia, 
perform chromosomal analysis and involve 
patient, family, and other medical providers in 
surgical decisions. 
 
 
Jason Axt MD FACS FCS(ECSA) 
Muse Freneh MD 
LeahCaren Oundoh MBChB 
AIC Kijabe Hospital 
Kenya  
 
September 2023 
