Indications and contraindications
The need to surgically remove an intraabdominal testicle or gonad is a rare event in children and is limited to gonadectomy in patients with gonadal dysgenesis and other forms of differences in sex development (DSD), older patients with undescended testicles, or patients with inadequate testicular volume, and patients in whom orchiopexy is not feasible.
The decision to perform orchiectomy is individualized at the time of laparoscopic surgery for a nonpalpable or known intraabdominal testicle. Intraabdominal testicular nubbins or testes that are small and of poor consistency are likely to be removed. In cases of testes that atrophy after a first-stage Fowler-Stevens procedure or that cannot adequately be mobilized, the decision to remove the testis may be made.
Patient preoperative evaluation and preparation
The preoperative evaluation of a child who may undergo a laparoscopic orchiectomy consists essentially of physical examination and, in selected cases, imaging and serum studies. The physical examination is aimed at determining the location of the testes: nonpalpable, intracanalicular, distal to the external inguinal ring, prescrotal, scrotal, or ectopic. In the case of a nonpalpable testis, the presence of a descended contralateral testis measuring more than 2 cm in length may portend an absent or a small intraabdominal testis that will be removed laparoscopically. In general, the finding of a nonpalpable testicle in a young child does not mandate preoperative imaging because diagnostic laparoscopy offers the most definitive assessment and treatment performed concurrently (i.e., orchidopexy or orchiectomy). A scrotal and groin ultrasound may be useful in obese boys, in whom the identification of a testis may be difficult or to assist in defining the nature of the small atrophic tissue found in the area. Pelvic ultrasound is useful in children with DSD to assess for Mullerian structures or the presence of an intraabdominal gonad.
No routine laboratory studies are required before surgery unless the patient has a predisposing medical condition or a testicular mass identified on imaging, or if a DSD is being evaluated. In addition, we do not advocate preoperative bowel preparation before laparoscopic surgery in children unless they have a longstanding history of constipation.
Operating room configuration and patient positioning
After the induction of general anesthesia, physical examination is repeated to confirm the absence of a palpable testis or the presence of an intrascrotal testicular nubbin. A Foley catheter or feeding tube may be placed to empty a distended bladder, but this may be deferred until the bladder distention is assessed laparoscopically. Similarly, an orogastric tube may be placed for gastrointestinal decompression at the surgeon’s discretion. A single dose of perioperative antibiotics is administered as per the author’s preference.
The patient is placed in the supine position with the arms tucked at the side to maximize surgeon comfort at the bedside and then is prepared from the xiphoid process down to the mid thighs, including the scrotum ( Fig. 40.1 ).
The camera port is placed through the umbilicus either in the midline or through a curvilinear incision in the inferior umbilical edge. In the small child the umbilicus can be opened directly in the vertical midline; in the larger child, two towel clamps placed on lateral sides of the umbilicus can be used to evert the umbilicus, and the vertical incision is made. In younger children a naturally occurring umbilical hernia may be present, into which a 5-mm trocar can be placed. In older children or adults, the Hassan procedure to gain abdominal access reduces the risk of injury to an intraabdominal organ.
Insufflation of the abdomen is maintained at a low rate (3 to 5 L/min) and pressure (8 to 12 mm Hg). A zero-degree or 30-degree laparoscope is introduced for diagnostic laparoscopy. When an intraabdominal testicle is visualized, additional working trocars (3 mm, 5 mm, or 10 mm for removal of a large testis) are placed under direct visualization at or just below the level of the umbilicus at the lateral rectus margin ( Fig. 40.2 ).