Laparoscopic Evaluation

As mentioned, laparoscopy has proven itself to be an excellent localization and diagnostic tool (23-26). It is useful in patients with bilateral undescended testicles as well as in cases of unilateral undescended testicles. It also has been helpful in allowing the surgeon to plan subsequent therapy (i.e., to decide whether orchidopexy or testicular removal is indicated). Motility of the testis and its vas deferens as well as the vascular supply can be assessed on laparoscopic diagnosis.

Diagnostic laparoscopy requires general anesthesia and the patient should be secured to the operating table to allow the bed to be manipulated to all extremes. Patient preparation and draping must be suitable for an open exploration should it be required. A Foley catheter and an oral gastric tube are placed. A supra- or infra-umbilical skin incision is made and the peritoneum is accessed via an open technique. In children, the use of Veress needle insufflation has been abandoned at most centers. Likewise, true Hasson access is cumbersome.

In the young child, the peritoneum can be controlled and a trocar easily dilated into place under direct vision. Holding sutures placed in the fascia are helpful in elevating the fascia and peritoneum prior to peritoneotomy.

Laparoscopic photograph. (B) Diagram of the right internal ring with a patent processus vaginalis.

FIGURE 1 ■ Left: Laparoscopic photograph. Right: Diagram of the normal right internal ring.

Laparoscopic photograph. (B) Diagram of the right internal ring with a patent processus vaginalis.

FIGURE 1 ■ Left: Laparoscopic photograph. Right: Diagram of the normal right internal ring.

The InnerDyne® Radial Dilating Stepa introducer system is helpful but not mandatory (27,28). In most cases, 5 mm access is more than adequate. Alternatively, 2 or 3 mm needlescopic ports and access can be used (27,29,30). The abdomen is insufflated to 14-15 millimeters of mercury pressure, the peritoneum is inspected to ensure proper positioning at which point the working cannulas can be placed as needed. The patient should already be in Trendelenburg position; however, if further exposure is needed in the pelvis further Trendelenburg positioning is helpful along with some lateral tilt. This will expose each internal ring, which can then be inspected. If the rings are difficult to visualize, and there is a descended testicle, traction on that descended testicle will very easily make the spermatic vessels more prominent at which point the opposite groin can be examined in a similar location. A number of findings are possible (see box).

■ The vas and testicular vessels appear normal and exit a closed internal ring (Fig. 1). The groin can be explored for a descended remnant. Alternatively, an open inguinal approach can be used. These nubbins do need to be removed as approximately 10% contain viable germ cells and ostensibly could be at risk for undergoing malignant change (31-33).

■ The vas and testicular vessels appear normal and exit an open internal ring (Fig. 2). Oftentimes, gentle pressure over the groin pushes a canalicular (peeping) testicle or nubbin into the abdomen (Fig. 3). If the gonad is not pushed back into the abdomen, the groin must be explored and again this can be done by either open or laparoscopic techniques (34).

■ The blind-ending vessels are clearly identified and have a "horsetail" appearance. A blind-ending vessel is often in direct proximity to a blind-ending vas. These findings are pathognomonic for the vanished testicle and the procedure can be terminated. Most would agree that only in the case of a prominent nubbin being noticed would intervening tissue have to be removed (Fig. 4).

aTyco International, Inc., Princeton, NJ.

FIGURE3 ■ (A) Laparoscopic photograph of the right internal ring in a patient with a peeping testicle. (B) With external pressure on the inguinal canal, the peeping testicle can be visualized.

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Analyzing the existing data, 50% to 60% of all cases of nonpalpable testicles are identified as an intra-abdominal testicle or peeping testicle, 30% as an atrophic nubbin, and 20% as an absent or vanished testicle. A testicle located within 2 cm of the internal ring or is proven to be peeping in about 38% of cases and those testicles are usually normal in size with a normal vessel leash, vas, and epididymis. Testicles located higher in the abdomen are either along the normal path of descent, 44.8%, or are in an ectopic site in 7.1% (35).

When the testicle is not clearly identified just with placement of the camera alone, either small probes or working instruments are ideal to improve exposure. Because therapeutic maneuvers will be required in about 90% of cases, moving on to cannula

■ The blind-ending vas is seen without blind-ending vessels in vicinity. The testicular nubbin is always in proximity to the blind-ending vessels; and hence, the laparoscopic exploration must be carried ros-trally seeking those findings.

■ An intra-abdominal testicle is located (Fig. 5).

FIGURE5 ■ (A) Laparoscopic photograph of the right groin in a child with a low abdominal undescended testicle. (B) Diagram of the right groin in a child with low abdominal undescended testicle.

FIGURE5 ■ (A) Laparoscopic photograph of the right groin in a child with a low abdominal undescended testicle. (B) Diagram of the right groin in a child with low abdominal undescended testicle.

FIGURE6 ■ Diagram of the cannula placement for a right laparoscopic orchidopexy.

For primary laparoscopic orchidopexy, maximal exposure of the inguinal and groin area is obtained by placing the table in steep Trendelenburg with the bed tilted contralateral to the undescended testicle.

Cautery is used for this maneuver, as there can be rather prominent vascula-ture in the gubernaculum. Care must be taken to identify a long looping vas, which unusually can be encountered.

If the testicle can be placed across the abdomen to the opposite groin, then usually there is sufficient ability for the testicle to be placed in the ipsilateral hemiscrotum.

placement and placement of working instruments is probably most expedient. Correct placement of the working cannula is shown in Figure 6. During working cannula placement, insufflation is increased to 20 mmHg pressure, which can then be decreased to 10-15 mmHg.

THERAPEUTIC LAPAROSCOPY

Laparoscopic Surgery for Unilateral Nonpalpable Testicles

The goal of therapeutic laparoscopy for a unilateral undescended testicle is either permanent fixation of the testicle in the scrotum or removal of a grossly abnormal testicle. The choice of surgical procedure is determined and our usual approach is summarized in the algorithm shown in Figure 7.

For primary laparoscopic orchidopexy, maximal exposure of the inguinal and groin area is obtained by placing the table in steep Trendelenburg with the bed tilted contralateral to the undescended testicle.

The open inguinal ring or the testicle is located and a peritoneotomy is made to either completely surround the open inguinal ring or to expose the gubernacular structures (Fig. 8). The authors prefer to leave the peritoneum between the vas and the vessels undissected and hence the peritoneotomy is extended along the spermatic vessel leash allowing for dissection rostral on the vascular cord structures. A peritoneotomy is likewise made over the vas deferens. To achieve sufficient mobility on the vas and vessels, eventually those two peritoneotomies need to be connected leaving a triangle of peritoneum in the area between the juncture of vas with vessels (Fig. 9). Ostensibly, this leaves the collateral circulation in that area undisturbed; and if one needed to proceed to single-stage Fowler-Stephens orchidopexy, then the results would be optimized by not having disturbed this area.

The testicular vessels, testicle, and vas are elevated on the "peritoneal pedicle." The testicle is then rostrally retracted inverting the processus vaginalis and the guber-naculums, and the gubernaculum is thinned and then cut across.

Cautery is used for this maneuver, as there can be rather prominent vasculature in the gubernaculum (Fig. 10). Care must be taken to identify a long looping vas, which unusually can be encountered (Fig. 11).

Current hemostatic modalities include Ligasure™b or Harmonic Scalpel™c. However, because cautery is minimally employed throughout the entire orchidopexy procedure, the expense of these additional instruments, we feel, is not justified.

The testicle is further freed, maximizing the length of vessels and vas.

If the testicle can be placed across the abdomen to the opposite groin, then usually there is sufficient ability for the testicle to be placed in the ipsilateral hemiscrotum (Fig. 12).

Elder has shown that vigorous dissection of the vas may be more related to testicular atrophy than vigorous mobilization of the spermatic cord. If length is inadequate bValleylab, Tyco Healthcare, Norwalk, CT. cEthicon, Cincinnati, OH.

FIGURE 7 ■ Algorithm outlining management of the impalpable undescended testicle.

FIGURE 7 ■ Algorithm outlining management of the impalpable undescended testicle.

FIGURE 8 m Laparoscopic photograph of a child with a peeping testicle; the appearance of the right groin as the peritoneum is opened FIGURE9 ■ Diagram of the peritoneal incisions. around the patent processes vaginalis.

FIGURE 8 m Laparoscopic photograph of a child with a peeping testicle; the appearance of the right groin as the peritoneum is opened FIGURE9 ■ Diagram of the peritoneal incisions. around the patent processes vaginalis.

The path that the testicle will take is medial to the inferior epigastric vessels and medial to the ipsilateral medial umbilical ligament but lateral to the bladder. The vessels are placed just over the top of the pubic ramus and down the inguinal canal.

after connecting the peritoneotomies and maximally dissecting vas and vessels, then the spermatic vessels can be divided. It is the authors' opinion that this scenario is best avoided; and hence, we make every effort to be sure that length will be adequate prior to proceeding this far with the dissection.

A number of techniques have been described for passing the testicle into the ipsi-lateral hemiscrotum, including the retrograde passage of a hemostat. A laparoscopic port can be primarily placed from below using a dilating trocar system or the path can be developed from within by passing a grasper into the hemiscrotum and then a dilating trocar system or step cannula used for the transfer. Lucent cannulas can be very helpful and prototype reusable lucent cannulas are in development.

The path that the testicle will take is medial to the inferior epigastric vessels and medial to the ipsilateral medial umbilical ligament but lateral to the bladder. The vessels are placed just over the top of the pubic ramus and down the inguinal canal.

A scrotal skin incision is made in the ipsilateral hemiscrotum and we prefer a subdartos pouch for fixation. In passing the testicle, a laparoscopic grasper is passed through the cannula into the abdomen grasping either the testicle or the gubernaculum

gubernaculum is exposed and is divided with cautery (same child as in Fig. 8). FIGURE 11 ■ Laparoscopic photograph of the appearance of a long looping vas deferens; the testicle is being retracted into the abdomen and the vas is noted coursing along the path of the gubernaculum.

gubernaculum is exposed and is divided with cautery (same child as in Fig. 8). FIGURE 11 ■ Laparoscopic photograph of the appearance of a long looping vas deferens; the testicle is being retracted into the abdomen and the vas is noted coursing along the path of the gubernaculum.

No limit to activities is necessary other than asking parents to prohibit the child from straddle activities for at least six weeks.

(Fig. 13). There are graspers which atraumatically grasp the testicle. The testis is then delivered through the port (Fig. 14). Should the vessels come under tension, then with the additional retraction, further dissection of vas and vessels can be accomplished above. Once the testicle is adequately mobilized to the level of the hemiscrotum, the pneumoperitoneum is immediately reduced and the internal surgical field is assessed for bleeding. The peritoneum in the area of dissection of the groin is not closed. In children, all port sites, 5 mm or greater, must be closed. The skin wounds can be injected with a long acting local anesthetic, adjuvant caudal anesthesia may also be beneficial.

The children are recovered from anesthesia and are discharged. In most cases, activity is somewhat diminished in the first 12 to 24 hours following surgery, but parents report that children very rapidly get back to normal activities.

No limit to activities is necessary other than asking parents to prohibit the child from straddle activities for at least six weeks.

In most cases, diet can be rapidly advanced.

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