Orchiectomy: Difference between revisions

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== Radical Orchiectomy ==

* Video

* See [https://www.youtube.com/watch?v=trrsFrtqI3Q Video]

* Position: supine

* Preparation: abdomen above the umbilicus cranially, the bilateral mid-to-lower thigh caudally, and the external genitalia through to the perineum posteriorly

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** In circumstances in which a mass is too large to be delivered through the standard incision, the incision can be extended down along the anterior scrotum in a hockey-stick fashion.

* '''Step by step'''

** '''Dissect down to external oblique fascia and expose external inguinal ring.''' ~~Mark and then make incision with scalpel/cautery.~~ Dissect down through fat and Scarpa's fascia to expose the external oblique fascia overlying the inguinal canal. Tug on the testicle to facilitate identification of the inguinal canal. Continue to expose the external oblique fascia distally towards the external inguinal ring.

** '''General anesthesia and insertion of lines.'''

*** ~~'''~~Recall that anterior wall and floor (inferior wall) of the inguinal canal are formed by the external oblique fascia~~'''~~, the roof (superior wall) by the internal oblique and transversus abdominis, and the posterior wall by the transversalis fascia.

**'''Patient positioning, antiseptic preparation, draping.'''

** '''Open inguinal canal and identify ilioinguinal nerve.''' Use a knife to create a stab incision in the external oblique fascia in the area of the proximal cord. To release the ilioinguinal nerve, use metzenbaum scissors with closed tips pointed anteriorly to pass under the external oblique fascia from the knife incision to the external ring, staying as close to the underside of the fascia. Spread scissors when tips through external ring. Use metzenbaum scissors to extend fascial incision towards the external inguinal ring, small cuts at a time, taking care to identify and preserve the ilioinguinal nerve. Place mosquito clamp on lateral edge of external oblique fascia.

*** After induction of general anesthesia...

*** Trim hair overlying operative site, if needed.

*** Prepare surgical area and drape to expose the ipsilateral anterior superior iliac spine, pubic tubercle, and scrotum.

**'''Skin incision.''' Use marking pen to denote external inguinal ring and a 3-5cm transverse line extending laterally from this point, overlying the inguinal canal. Make an incision with scalpel/cautery.

**'''Dissect down to external oblique fascia and expose external inguinal ring.''' Dissect down through fat and Scarpa's fascia to expose the external oblique fascia overlying the inguinal canal. Tug on the testicle to facilitate identification of the inguinal canal. Continue to expose the external oblique fascia distally towards the external inguinal ring.

*** Recall that anterior wall and floor (inferior wall) of the inguinal canal are formed by the external oblique fascia, the roof (superior wall) by the internal oblique and transversus abdominis, and the posterior wall by the transversalis fascia.

** '''Open the inguinal canal and identify ilioinguinal nerve.''' Use a knife to create a stab incision in the external oblique fascia in the area of the proximal cord. To release the ilioinguinal nerve, use metzenbaum scissors with closed tips pointed anteriorly to pass under the external oblique fascia from the knife incision to the external ring, staying as close to the underside of the fascia. Spread scissors when tips through external ring. Use metzenbaum scissors to extend fascial incision towards the external inguinal ring, small cuts at a time, taking care to identify and preserve the ilioinguinal nerve. Place mosquito clamp on lateral edge of external oblique fascia.

*** '''Mobilize nerve, if identified.''' The ilioinguinal nerve courses parallel to spermatic cord, typically along the cephalad aspect of its anterior surface. Dissect the nerve using Debakey forceps and metzenbaum scissors. After the nerve has been adequately dissected, replace a mosquito clamp so that nerve is protected behind the clamp.

*** '''Recall, ilioinguinal nerve (L1) provides sensation to anterior scrotum''' (or mons pubis and labium majus)''', root of penis, and upper medial thigh'''

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** '''Divide gubernacular attachments.''' After delivering testicle, use sponge to sweep away as much gubernaculum as possible. Then, divide gubernaculum with cautery, taking care not to buttonhole the scrotum. Be liberal with hemostasis to reduce risk of scrotal hematoma.

** '''Mobilize spermatic cord to the level of the internal inguinal ring.''' After division of the gubernaculum, mobilize the spermatic cord to the level of the internal inguinal ring until the peritoneal reflection is visualized.

** '''Dissect out and vas and gonadal vessels and ligate them ~~seperately~~.''' At the level of the internal inguinal ring, use a lauer to dissect the vas deferens and gonadal vessels. Ligate and divide them ~~seperately~~ to ensure a hemostatic tie on the vascular structures.

** '''Dissect out and vas and gonadal vessels and ligate them separately.''' At the level of the internal inguinal ring, use a lauer to dissect the vas deferens and gonadal vessels. Ligate and divide them separately to ensure a hemostatic tie on the vascular structures.

*** Use non-absorbable suture such as silk

*** First, tie and divide the vas deferens.

*** For ligation of the gonadal vessels, first use a ~~heavly~~ silk. Then use a 2-0 silk to suture ligate the cord in the area as proximal as possible in between the transected vas deferens. Pass the needle through the middle of the cord. Tie once. Bring suture around cord and tie. '''Leave a 1- to 2-cm suture tail on the stump of the gonadal vessels to facilitate identification at RPLND.''' Return this stay stump to the internal ring.

*** For ligation of the gonadal vessels, first use a heavy silk. Then use a 2-0 silk to suture ligate the cord in the area as proximal as possible in between the transected vas deferens. Pass the needle through the middle of the cord. Tie once. Bring suture around cord and tie. '''Leave a 1- to 2-cm suture tail on the stump of the gonadal vessels to facilitate identification at RPLND.''' Return this stay stump to the internal ring.

*** Individually ligating the vas deferens from the remainder of the spermatic cord facilitates retrieval of the distal spermatic cord stump during subsequent RPLND because the vas deferens is not taken as part of this specimen.

** '''Divide spermatic cord.''' Bring towel under cord to avoid blood and tumour cell spillage. Put top end of Debakey forceps under cord. Use knife to divide cord. Take slow cuts to ensure no bleeding.

@@ Line 1: / Line 1: @@
 == Radical Orchiectomy ==
-* Video
+* See [https://www.youtube.com/watch?v=trrsFrtqI3Q Video]
 * Position: supine
 * Preparation: abdomen above the umbilicus cranially, the bilateral mid-to-lower thigh caudally, and the external genitalia through to the perineum posteriorly
@@ Line 12: / Line 12: @@
 ** In circumstances in which a mass is too large to be delivered through the standard incision, the incision can be extended down along the anterior scrotum in a hockey-stick fashion.
 * '''Step by step'''
-** '''Dissect down to external oblique fascia and expose external inguinal ring.''' Mark and then make incision with scalpel/cautery. Dissect down through fat and Scarpa's fascia to expose the external oblique fascia overlying the inguinal canal. Tug on the testicle to facilitate identification of the inguinal canal. Continue to expose the external oblique fascia distally towards the external inguinal ring.
+** '''General anesthesia and insertion of lines.'''
-*** '''Recall that anterior wall and floor (inferior wall) of the inguinal canal are formed by the external oblique fascia''', the roof (superior wall) by the internal oblique and transversus abdominis, and the posterior wall by the transversalis fascia.
+**'''Patient positioning, antiseptic preparation, draping.'''
-** '''Open inguinal canal and identify ilioinguinal nerve.''' Use a knife to create a stab incision in the external oblique fascia in the area of the proximal cord. To release the ilioinguinal nerve, use metzenbaum scissors with closed tips pointed anteriorly to pass under the external oblique fascia from the knife incision to the external ring, staying as close to the underside of the fascia. Spread scissors when tips through external ring. Use metzenbaum scissors to extend fascial incision towards the external inguinal ring, small cuts at a time, taking care to identify and preserve the ilioinguinal nerve. Place mosquito clamp on lateral edge of external oblique fascia.
+*** After induction of general anesthesia...
+*** Trim hair overlying operative site, if needed.
+*** Prepare surgical area and drape to expose the ipsilateral anterior superior iliac spine, pubic tubercle, and scrotum.
+**'''Skin incision.''' Use marking pen to denote external inguinal ring and a 3-5cm transverse line extending laterally from this point, overlying the inguinal canal. Make an incision with scalpel/cautery.
+**'''Dissect down to external oblique fascia and expose external inguinal ring.''' Dissect down through fat and Scarpa's fascia to expose the external oblique fascia overlying the inguinal canal. Tug on the testicle to facilitate identification of the inguinal canal. Continue to expose the external oblique fascia distally towards the external inguinal ring.
+*** Recall that anterior wall and floor (inferior wall) of the inguinal canal are formed by the external oblique fascia, the roof (superior wall) by the internal oblique and transversus abdominis, and the posterior wall by the transversalis fascia.
+** '''Open the inguinal canal and identify ilioinguinal nerve.''' Use a knife to create a stab incision in the external oblique fascia in the area of the proximal cord. To release the ilioinguinal nerve, use metzenbaum scissors with closed tips pointed anteriorly to pass under the external oblique fascia from the knife incision to the external ring, staying as close to the underside of the fascia. Spread scissors when tips through external ring. Use metzenbaum scissors to extend fascial incision towards the external inguinal ring, small cuts at a time, taking care to identify and preserve the ilioinguinal nerve. Place mosquito clamp on lateral edge of external oblique fascia.
 *** '''Mobilize nerve, if identified.''' The ilioinguinal nerve courses parallel to spermatic cord, typically along the cephalad aspect of its anterior surface. Dissect the nerve using Debakey forceps and metzenbaum scissors. After the nerve has been adequately dissected, replace a mosquito clamp so that nerve is protected behind the clamp.
 *** '''Recall, ilioinguinal nerve (L1) provides sensation to anterior scrotum''' (or mons pubis and labium majus)''', root of penis, and upper medial thigh'''
@@ Line 21: / Line 27: @@
 ** '''Divide gubernacular attachments.''' After delivering testicle, use sponge to sweep away as much gubernaculum as possible. Then, divide gubernaculum with cautery, taking care not to buttonhole the scrotum. Be liberal with hemostasis to reduce risk of scrotal hematoma.
 ** '''Mobilize spermatic cord to the level of the internal inguinal ring.''' After division of the gubernaculum, mobilize the spermatic cord to the level of the internal inguinal ring until the peritoneal reflection is visualized.
-** '''Dissect out and vas and gonadal vessels and ligate them seperately.''' At the level of the internal inguinal ring, use a lauer to dissect the vas deferens and gonadal vessels. Ligate and divide them seperately to ensure a hemostatic tie on the vascular structures.
+** '''Dissect out and vas and gonadal vessels and ligate them separately.''' At the level of the internal inguinal ring, use a lauer to dissect the vas deferens and gonadal vessels. Ligate and divide them separately to ensure a hemostatic tie on the vascular structures.
 *** Use non-absorbable suture such as silk
 *** First, tie and divide the vas deferens.
-*** For ligation of the gonadal vessels, first use a heavly silk. Then use a 2-0 silk to suture ligate the cord in the area as proximal as possible in between the transected vas deferens. Pass the needle through the middle of the cord. Tie once. Bring suture around cord and tie. '''Leave a 1- to 2-cm suture tail on the stump of the gonadal vessels to facilitate identification at RPLND.''' Return this stay stump to the internal ring.
+*** For ligation of the gonadal vessels, first use a heavy silk. Then use a 2-0 silk to suture ligate the cord in the area as proximal as possible in between the transected vas deferens. Pass the needle through the middle of the cord. Tie once. Bring suture around cord and tie. '''Leave a 1- to 2-cm suture tail on the stump of the gonadal vessels to facilitate identification at RPLND.''' Return this stay stump to the internal ring.
 *** Individually ligating the vas deferens from the remainder of the spermatic cord facilitates retrieval of the distal spermatic cord stump during subsequent RPLND because the vas deferens is not taken as part of this specimen.
 ** '''Divide spermatic cord.''' Bring towel under cord to avoid blood and tumour cell spillage. Put top end of Debakey forceps under cord. Use knife to divide cord. Take slow cuts to ensure no bleeding.