Orchidopexy and Orchiectomy for Testicular Torsion 
In Resource-Limited Settings 
Richard Davis, Leahcaren Oundoh, Jason Axt 
 
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:  
 
Testicular 
torsion 
is 
a 
true 
surgical 
emergency. Unfortunately, in locations where access 
to surgery is poor, it usually presents beyond 6 hours 
after onset, the time when intervention would have 
saved the testicle. The peak age group for testicular 
torsion to occur is between ages 12 and 18, although 
it can appear at any age including infancy and well 
into adulthood.  
The anatomic condition that predisposes to 
testicular torsion is called the “bell clapper 
deformity.” With this condition, the testis can be 
thought of hanging within the scrotum the way a 
clapper hangs within a bell. It can then twist on itself. 
If the condition is recognized in time, the testicle can 
be untwisted and saved. This is variously known as 
“de-torsing” or “de-torting” the testicle and is usually 
accomplished through surgery. Since the problem is 
that the testicle can twist inside the scrotum, the 
solution is to tack the testicle to the walls of the 
scrotum with non-absorbable suture so that it cannot 
rotate inside the scrotum anymore. This is called 
orchidopexy, or orchiopexy. This is a different 
operation from Orchidopexy for Undescended Testis.  
 
Normal anatomy: The testis (Green) and epididymis (yellow) 
are supplied by the gonadal vessels, entering from above. The 
Tunica Vaginalis (grey) is a small fluid filled sac that does not 
occupy all of the scrotum. It is very difficult for the testis and 
epididymis to rotate on their blood supply. Courtesy of Craig 
Hacking, 
via 
https://radiopaedia.org/cases/bell-clapper-
deformity-diagram?lang=us  
 
 
Bell clapper deformity: The potential space of the Tunica 
Vaginalis extends up to where the blood vessels enter the 
scrotum. The testicle and epididymis can rotate within the 
Tunica Vaginalis, though this has not occurred in this 
illustration. 
Courtesy 
of 
Craig 
Hacking, 
via 
https://radiopaedia.org/cases/bell-clapper-deformity-
diagram?lang=us  
 
 
Bell clapper deformity with torsion: the testicle and scrotum 
have twisted within the Tunica Vaginalis and the blood supply 
is cut off. The testicle rides higher, and transversely, in the 
scrotum. 
Courtesy 
of 
Craig 
Hacking, 
via 
https://radiopaedia.org/cases/bell-clapper-deformity-
diagram?lang=us  
 
It is important to keep in mind the anatomy 
of the Tunica Vaginalis: this is a fluid-filled space 
that surrounds the testis: it surrounds it only partially 
in normal anatomy, but it surrounds it completely 
when the “bell clapper” deformity is present. The 
surface of this space originated in the peritoneum and 
has the same shiny appearance. The part that is 
Orchidopexy and Orchiectomy for Testicular Torsion 
In Resource-Limited Settings 
Richard Davis, Leahcaren Oundoh, Jason Axt 
 
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  
 
attached to the surface of the testis is called the 
visceral Tunica Vaginalis, and the part that is 
opposite it, that you must cut through to access the 
space, is called the parietal Tunica Vaginalis.  
If you are able to operate before testicular 
ischemia becomes irreversible, detorse and perform 
orchidopexy on the affected testicle and then perform 
orchidopexy on the contralateral one. Classically this 
will be within 6 hours or less of the onset of acute 
pain, although it is possible to preserve the testis even 
farther out. The following table estimates your 
chances of testicular salvage based on time since 
onset of symptoms:  
Duration of Torsion 
Salvage Rate 
<6 hours 
85-97% 
6-12 hours 
55-85% 
12-24 hours 
20-80% 
>24 hours 
<10% 
 
If the ischemia is irreversible, perform 
orchiectomy on that side and then orchidopexy on the 
contralateral side to prevent the same from 
happening on that side. This operation is shown here.  
Rarely, before edema has set in, the testicle 
can be de-torsed by external rotation. Remember in 
this case that the testicle should be twisted with its 
axis moving away from the body’s midline- a useful 
memory trick is to think of “opening a book.”  
 
Testicular torsion occurs in the direction shown by the Red 
arrows, like the closing of a book. When de-torsing the testicles, 
either before or during surgery, remember to rotate them in the 
direction shown by the Green arrows, as if opening a book. 
Source:https://commons.wikimedia.org/wiki/File:Human_scro
tum(human_genitalia).jpg  
 
Scrotal ultrasound is often performed in this 
setting, sometimes before the surgeon is called; it 
will show diminished or absent blood flow within the 
testis. We feel this modality is somewhat useful, 
although in a patient with characteristic history of 
acute onset scrotal pain, and a high-riding, tender and 
swollen scrotum, we would not defer operation, 
especially if it is possible to do so within 6 hours of 
onset. Certainly the operation should not be delayed 
while waiting for the ultrasound; it is better to 
explore than to miss the diagnosis within the 6 hour 
window. The main differential diagnosis, acute 
epididymo-orchitis, has a more gradual onset of pain. 
The ultrasound, in this case, will show hyperemia of 
the testicle and increased vascular flow. Other items 
on the differential diagnosis include testicular 
rupture due to trauma and testicular tumor. As 
always, a careful history is helpful: of all of these 
entities, only testicular torsion will have a history of 
sudden onset pain without trauma.  
There is a related clinical entity, usually 
occurring in neonates, called extravaginal torsion: 
this occurs when the testicle and spermatic cord twist, 
within the scrotal skin, at a site that is proximal to the 
tunica vaginalis. This is due to lack of attachment of 
the tunica vaginalis to the scrotal skin itself. This 
occurs usually in utero before the tunica vaginalis is 
fixed to the scrotal wall, or soon after birth in the 
neonatal period- the boy is born with one, possibly 
two infarcted testes. For this reason, an acutely red 
and tender scrotum in a neonate should be explored 
without delay. 
Scrotal 
exploration, 
orchiectomy 
and 
orchidopexy occur in the following steps.  
• Exploration of the affected testis 
• Orchidopexy or orchiectomy as appropriate 
• Exploration of the contralateral testis and 
orchidopexy 
• Fascia, then skin closure 
 
Steps: 
1. The patient or his parents should be consented for 
unilateral orchiectomy if a necrotic and dead 
testis is found. The surgeon should be prepared 
to explore and affix the contralateral side if this 
is the case.  
Orchidopexy and Orchiectomy for Testicular Torsion 
In Resource-Limited Settings 
Richard Davis, Leahcaren Oundoh, Jason Axt 
 
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  
 
2. Anesthesia can be general or spinal. It would be 
difficult to perform this operation under local 
anesthetic.  
3. The approach will be trans-scrotal, with a single 
skin incision and two separate incisions through 
the Dartos fascia, as shown below.  
 
In this picture, the scrotal skin is Black and the Dartos fascia is 
Dark Blue. The Dartos Fascia covers each testicle separately 
and has a septum between the two testicles. The parietal (outer 
layer) Tunica Vaginalis is Light Blue and the testicle, covered 
by the visceral layer of the Tunica vaginalis, is Yellow. The 
incision is shown by the Dotted line.  
 
4. Make a skin incision through the midline of the 
scrotum, where there is often a raised “raphe” of 
skin. The incision should be generous, to allow 
complete visualization and safe performance of 
the orchidopexy.  
 
Make a generous incision in the midline of the scrotum, using 
the “cut” mode on the diathermy to avoid bleeding. 
5. Open the affected side first, by squeezing the 
affected testicle into the skin incision with your 
non-dominant hand and opening over its surface 
using the diathermy. When you enter the Tunica 
Vaginalis, there will be a rush of fluid, blood- 
stained if the testicle is ischemic. 
 
As you incise through layers of the Dartos fascia surrounding 
the Tunica Vaginalis, the testis will become more clear. In this 
case, the dark red color of the ischemic tissue is seen. Continue 
until you enter the thin fluid filled space between the parietal 
(outer) and visceral (inner) Tunica Vaginalis lining the testis. 
 
6. Insert a hemostat into the Tunica Vaginalis space 
and use it and diathermy to enter the full length 
of the Tunica Vaginalis.  
 
Once you have entered the space around the testis, the shiny 
surface of the visceral Tunica Vaginalis confirms your location. 
Insert a hemostat clamp into this space and divide the parietal 
Tunica Vaginalis over it with diathermy. In this photo, the shiny 
Orchidopexy and Orchiectomy for Testicular Torsion 
In Resource-Limited Settings 
Richard Davis, Leahcaren Oundoh, Jason Axt 
 
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  
 
surface of the visceral Tunica Vaginalis is black because of the 
ischemic testicle underneath. 
 
7. If the testis is dark but not clearly necrotic, try to 
untwist it in the direction shown above, as 
“opening a book.” If there is any possibility it is 
viable, wrap it in a warm moist gauze and turn 
your attention to the other hemiscrotum, giving it 
time to declare itself.  
 
In this case, the testis is dark Red and even Black in some 
locations, clearly beyond salvage 
 
 
In this case, the testis is only dusky and actually appears to have 
some return of color (Left). It should be wrapped in a moist 
warm gauze (Right) and inspected again after inspection and 
pexy of the contralateral testis.  
 
 
Same case as above, after pexy of the contralateral testis. The 
questionable testis is inspected and a small incision is made in 
the visceral Tunica Vaginalis. As bleeding is seen, the decision 
is made to preserve this testis and it is pexied as well, as 
described below.  
 
8. If it is clearly necrotic, dissect the intra-scrotal 
spermatic cord away from the surrounding tissue 
at the superior aspect of the testis. Apply a right 
angle clamp to where the vessels enter. Amputate 
the testicle and suture-ligate the vessels, being 
careful to ligate them well to avoid a post-
operative scrotal hematoma. 
 
The intra-scrotal spermatic cord has been dissected proximally 
so that it can be safely ligated. If this maneuver is neglected, the 
ligature encircles an excessive amount of swollen tissue, and 
can slip off later leading to hemorrhage and a scrotal 
hematoma.  
 
Orchidopexy and Orchiectomy for Testicular Torsion 
In Resource-Limited Settings 
Richard Davis, Leahcaren Oundoh, Jason Axt 
 
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  
 
9. If the testicle is inflamed but not torsed, and the 
“bell clapper” deformity is not present, the 
diagnosis is acute epididymo-orchitis. Abandon 
the operation and close the Dartos fascia and the 
skin as described below.  
 
 
Epididymo-orchitis results in a swollen, hyperemic testicle as 
seen here. There may be patches of necrosis or abscesses within 
the testicle. In extreme cases, epididymo-orchitis can lead to 
necrosis of the entire testicle but there will be no torsion of the 
vascular pedicle. Consider also tuberculosis as a cause of 
epididymo-orchitis, especially if there is pus but it is not foul-
smelling.  
Source: https://doi.org/10.1177/11795476221146900  
 
10. Go now to the other side, squeezing the testicle 
gently with your nondominant hand and making 
another vertical incision in the Dartos fascia 
adjacent to your previous one, until you enter the 
Tunica Vaginalis, where there will be a rush of 
(hopefully non-bloody) fluid. Use a hemostat and 
diathermy again to extend the incision until all of 
the testicle is seen.  
 
Make an incision with the diathermy over the contralateral 
testis, dissecting through the tissue until the shiny surface of the 
visceral Tunica Vaginalis on the surface of the testis indicates 
that you have entered the space around the testis.  
 
 
Here, the surgeon has not yet reached the surface of the testis 
with its characteristic shiny appearance. 
 
 
When the surgeon cuts through the parietal Tunica Vaginalis, 
reaching the space around the testis, there is a rush of clear 
fluid through a small hole. Insert the hemostat into this hole and 
elevate the parietal Tunica Vaginalis, allowing full entry into 
the space surrounding the testis.  
 
Orchidopexy and Orchiectomy for Testicular Torsion 
In Resource-Limited Settings 
Richard Davis, Leahcaren Oundoh, Jason Axt 
 
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  
 
11. Be sure that the testicle is not torsed and then use 
non-absorbable monofilament suture to tack it to 
the wall of the Tunica Vaginalis in three separate 
places, preventing torsion in the future.  
 
Place the posterior-most pexy stitch first, passing a 3-0 non-
absorbable suture into space where the testis will reside 
 
 
Finish the posterior pexy by passing the same suture through 
the posterior surface of the testis. Tie this suture to lay the testis 
within the Tunica Vaginalis space.  
 
Place two more sutures with the same material, attaching the 
visceral to the parietal Tunica Vaginalis on either side, leaving 
space for the Dartos Fascia to close and cover the testis.  
 
 
Schematic of a completed orchidopexy. Suture between the 
visceral Tunica Vaginalis (Yellow) and the parietal Tunica 
Vaginalis (Blue) prevents the testes from rotating within this 
space.  
 
12. Apply Allis clamps to both ends of the Dartos 
fascia and have an assistant pull the clamps 
gently. Close the Dartos fascia of both sides 
simultaneously by approximating them to the 
midline fascia, as shown below, using absorbable 
suture.  
Orchidopexy and Orchiectomy for Testicular Torsion 
In Resource-Limited Settings 
Richard Davis, Leahcaren Oundoh, Jason Axt 
 
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  
 
 
Allis clamps pulling the superior and inferior ends of both 
Dartos fascia incisions allows you to close both fascial 
incisions at the same time using a running absorbable suture.  
 
13. Close the skin in a simple running configuration 
using running monofilament absorbable suture.  
 
The appearance of the scrotum after closure of the skin layer.  
 
14. Wrap the testicle gently and not tightly with 
elastic bandage. 
 
Pitfalls 
• Missed diagnosis: The consequences of not 
operating when the patient needs an operation are 
usually far greater than the consequences of 
operating and finding some other, non-surgical 
condition. If there is any possibility that the 
diagnosis is testicular torsion, especially in a 
child or young man, do not hesitate to explore 
and do not place much weight on any doppler 
ultrasound findings.  
• The danger of leaving a dead testis, if one is 
found during a late exploration, continues to be 
debated. The concern for anti-sperm antibodies 
seems not to be as great as once thought. 
Nevertheless, as of this writing the most common 
recommendation is to completely remove a dead 
testis, especially in an adult. (In resource-rich 
settings, a prosthetic testis can be placed to give 
the scrotum a normal appearance.) The patient 
may be concerned that he will be infertile or 
impotent with only one testis, but he should be 
reassured that one is enough.  
• Be sure to dissect the cord contents free of 
surrounding tissue before ligating them and be 
sure that the ligature is well placed and tied. 
Bleeding from the gonadal vessels, especially the 
artery, will continue unopposed until the entire 
scrotum is full of blood and a tense scrotal 
hematoma is present. These usually require re-
exploration, as they can burst the wound or even 
endanger the scrotal skin itself if the pressure 
becomes very high.  
• Be sure that the testis is completely detorsed 
before performing orchidopexy. Remember that 
it rotates like the opening pages of a book.  
 
Richard Davis MD FACS FCS(ECSA) 
Leahcaren Oundoh MBBS 
Jason Axt MD FACS FCS(ECSA) 
AIC Kijabe Hospital  
Kenya 
 
November 2023 
