Editing Acute Scrotum (section)

===== Orchiopexy =====
*'''Technique'''
**'''Equipment'''
***Sutures
****3-0 Vicryl x 4
****4-0 PDS x 6
****4-0 chromic x 1
****If orchiectomy, 2-0 silk ties to ligate vas deferens and vessels
**Antibiotics
***Cefazolin
**Position: supine
**Incision: midline raphe, length of largest testicle that needs to be delivered
**'''Surgical plan[https://pubmed.ncbi.nlm.nih.gov/23217129/]'''
**#'''Outline an incision in the midline raphe.''' Incision should be large enough to deliver twisted testicle.
**#'''Dissect towards twisted testicle.''' Use scalpel to make skin incision. Continue to divide layers of scrotum towards testicle.
**#'''Deliver twisted testicle.''' Open the tunica vaginalis and deliver the testicle
**#'''Untwist the testicle.''' Ensure proper orientation with lateral sulcus being lateral. Feel spermatic cord to ensure no more twists
**##Median degree of rotation was 540° in orchiectomy testes and 360° when the testis was salvaged
**#'''Attempt salvage of twisted testicle.''' Wrap twisted testicle in warm saline
**#'''Deliver contralateral testicle.''' Repeat steps 2-3 on contralateral (healthy) testicle. Bring contralateral healthy testicle to midline incision.
**#'''Orchiopexy to reduce the risk of metachronous torsion.'''
**##Trim excess tunica vaginalis. Obtain hemostasis along the edge with careful fulguration.
**##Reapproximate tunica vaginalis. Evert tunica vaginalis and reapproximate edges behind testicle, in Jaboulay fashion, with running 3-0 Vicryl
**##Place three 4-0 PDS interrupted sutures through the everted tunica. Then place these sutures into the dartos of the posterior scrotal wall. Replace the testicle into the hemiscrotum and tie sutures.
**##Note that this method does not penetrate the blood-testis barrier with the suture needle and may reduce the risk of forming anti-sperm antibodies[https://pubmed.ncbi.nlm.nih.gov/23217129/]
**#'''Evaluate twisted testicle for salvageability.''' If not salvageable, divide vas and vessels separately with 2-0 silk ties. If salvageable, perform orchiopexy similar to above. In cases of orchiectomy, prosthesis placement is usually offered after complete healing or later in puberty
**#'''Reapproximate dartos.''' Use 3-0 Vicryl to reapproximate dartos.
**#'''Reapproximate skin.''' Use 4-0 chromic suture with horizonal mattress to reapproximate skin
**#'''Inject local anesthetic.''' Local anesthetic solutions containing epinephrine should never be used to anesthetize the penis, scrotum, or spermatic cord.[https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683&sectionid=45343633]
**#'''Apply dressing'''
*'''Post-operative follow-up'''
**Limit contact sports for 2 weeks or until pain free
**Perform wound check in 3-4 weeks
**'''Advise of risk to solitary testicle, consider'''
***'''Cup protector in high-risk activities (catcher in baseball team)'''
***'''Sperm banking in case other testicle is affected'''