Undescended Testicle in the Groin: How Is Inguinal Orchiopexy Performed?

Inguinal orchiopexy is planned when the testicle is palpable on examination in the inguinal canal or at its exit, but cannot be brought down into the scrotum by hand, or does not stay there once released. Most ectopic (misdirected) testicles are also brought into the scrotum through this approach.

• The groin approach is preferred because it gives full control over the entire length of the inguinal canal: the spermatic cord can be traced up to the internal ring, the hernia sac can be safely separated, and additional length can be gained, if needed, by freeing the vessels along the posterior abdominal wall. If the testicle is very close to the scrotum, the scrotal-only approach may be an option; this distinction is made on examination and under anesthesia.

The surgery is performed under general anesthesia, usually with a regional block added. The sequence is as follows.

• Groin incision: A 2–3 cm incision is made along a groin skin crease, and the anterior wall of the inguinal canal is opened.
• Locating the testicle: The testicle and its coverings are located within the canal; its size, its relationship to the epididymis, and the cord structures are assessed.
• Division of the gubernaculum and adhesions: The gubernaculum (guiding ligament) anchoring the testicle and the cremaster fibers are divided; the cord is freed from surrounding tissue.
• Separation and closure of the hernia sac: The open peritoneal extension is carefully separated from the vas deferens and vessels and ligated at the level of the internal ring. This step both gains length and repairs the hernia.
• Mobilization along the posterior abdominal wall: If length is insufficient, the tissue over the vessels above the internal ring is opened to free the cord further; if needed, the cord is rerouted beneath the inferior epigastric vessels to shorten its path.
• Fixation in the scrotum: Through a small scrotal incision, a pocket is created between the skin and the dartos muscle; the testicle is brought down from the groin into this pocket and placed without tension (the subdartos pocket).
• Closure: The anterior wall of the canal and the incisions are closed with dissolvable stitches; the skin is closed with a subcuticular suture.

• The key steps that gain length are separation of the hernia sac and, if needed, mobilization along the posterior abdominal wall; the testicle is never pulled into the scrotum under tension.

In the large majority of children with an undescended testicle, the peritoneal extension that descended along with the testicle has remained open. This sac is the part of the surgery that requires the most care: it can lead to an inguinal hernia later on, and it is one of the main structures that keeps the cord short.

• Separating the sac from the vas deferens and vessels without injury allows the cord to lengthen freely. This is why finding an accompanying inguinal hernia does not call for a separate operation; it is repaired in the same session, through the same incision.

Unilateral inguinal orchiopexy usually takes 30–60 minutes, and the child goes home the same day. In our practice, surgery is performed jointly by two pediatric urology specialists; for delicate steps such as mobilizing the cord, this means four hands working together.

For a testicle palpable in the groin, the reported success rate of inguinal orchiopexy in the literature is high; the testicle remains in the scrotum in the large majority of cases. Re-ascent of the testicle and atrophy (shrinkage) after surgery are rare but not zero.

• Other possible complications include wound infection, bleeding or hematoma, and very rarely, injury to the vas deferens. If the testicle was smaller than the other side before surgery, it may remain smaller afterward as well; this reflects the testicle’s own history rather than the surgery, and size is monitored until adolescence.