In the era of minimally invasive surgery, there is a growing amount of evidence and support for the role of laparoscopy in the management of cryptorchidism. There has been a tremendous improvement in technology and laparoscopic technique over the past few years. Laparoscopy has been proven to be a safe and effective alternative to open exploration for the nonpalpable testis in experienced hands. This chapter outlines indications, preoperative considerations, and description of our laparoscopic approach to the nonpalpable testis, and postoperative results and potential complications.
Indications and contraindications
Cryptorchism or undescended testis (UDT) is a commonly encountered pediatric disorder, especially in preterm infants. The latest American Urological Association (AUA) guidelines recommend referral to a pediatric urologist for surgical management of UDT at 6 months of age (corrected for gestational age). The rational for waiting is twofold. First, spontaneous descent may occur as a result of gonadotropin surge within 2 to 3 months of life. Second, anesthetic risks are increased in younger infants. Indications for correction of UDT include risk of progressive infertility, testicular malignancy, testicular torsion, associated inguinal hernia, and potential social implications for both the child and family. Orchiopexy is preferably done at 6 months and before 12 months because of potentially unfavorable histologic changes after that time period.
UDT is further classified as palpable or nonpalpable, which requires a thorough history and physical examination. The palpable inguinal or high scrotal testis is traditionally approached via a small inguinal incision or occasionally through a scrotal approach (Bianchi technique). In the case of a nonpalpable testis, diagnostic laparoscopy is indicated if examination under anesthesia reveals a truly nonpalpable testis. Further surgical management is dictated by intraoperative findings and the surgeon’s preference and expertise. In this chapter, we focus on the therapeutic laparoscopic management of UDT of a nonpalpable testis.
It should be noted that in a patient with bilateral nonpalpable testes, evaluation for disorder of sexual development should be performed before any surgical management.
Absolute and relative contraindications to laparoscopic surgery should be considered, including but not limited to insufficient expertise of the surgeon, peritonitis or abdominal wall infection, extensive previous abdominal or pelvic surgery, significant cardiopulmonary disease, coagulopathy, and risk associated with anesthesia.
Patient preoperative evaluation and preparation
The clinical finding of a unilateral nonpalpable testis will ultimately reveal one of four scenarios:
Atrophic (“vanishing”) testis
High canalicular (“peeping”) testis
Agenesis of the testis
A common physical examination finding that may suggest vanishing testis or agenesis, although not predictive or definitive, is hypertrophy of the normally descended contralateral testis. Hormonal therapy is no longer recommended owing to low response rates and lack of evidence for long-term efficacy and will not be discussed. We do not recommend ultrasound or other imaging modalities in the management of unilateral nonpalpable testis because imaging will not affect decision making or patient management owing to low sensitivity and specificity. To date, only laparoscopy can unequivocally diagnose the presence or absence of a unilateral intraabdominal testis. There is still some controversy in regard to the initial surgical approach to nonpalpable testes. While most advocate for exploratory laparoscopy as the initial and ultimate approach, as presented by Igarashi et al., some clinicians encourage inguinal or scrotal surgical exploration and proceeding with laparoscopic exploration if the testis was not extraabdominal. We believe the best course is laparoscopic exploration for two reasons: (1) visualization of the retroperitoneum is much better than any other access, and (2) if the child needs two-stage Fowler-Stephens orchiopexy (FSO), inguinal exploration may compromise some collateral blood supply.
Parents are advised of the standard laparoscopic operative risks of bleeding, infection, general anesthesia, hernia, air embolus, and injury to intraabdominal or retroperitoneal viscera or vessels. Informed consent for orchiopexy specifically includes the risks of testicular atrophy and injury to the vas deferens or gonadal vessels. The potential for conversion to an open procedure, the need for orchiectomy, the need for a staged procedure, and the potential finding of agenesis or vanishing testis are also discussed.
Operating room configuration and patient positioning
The operating room configuration traditionally includes one monitor at the foot of the bed to allow adequate visualization of the pelvis by all members of the surgical team ( Fig. 39.1 ). In a modern operating room equipped for laparoscopic and robotic-assisted surgery, multiple monitors may be positioned as desired by the surgical team. The surgeon stands on the side contralateral to the affected testis.
After induction of general endotracheal anesthesia, administer prophylactic broad-spectrum antibiotics before making any incisions. Place a grounding pad. Secure the child to the operating room table in the supine position with the legs parted moderately or frog-legged. Repeat examination of the groin under anesthesia may identify a testis and obviate the need for laparoscopic evaluation. Pad all pressure points without elevating the extremities to an extent that will compromise exposure to the scrotum or pelvis.
Prepare and drape the child from the xiphoid process to the upper thighs including the scrotum. Placement of an orogastric tube for decompression may be considered. Place a small urethral catheter after the sterile preparation to decompress the bladder. The catheter may be removed once the bladder is emptied.
In the standard technique, three ports are usually sufficient to complete the procedure. Place the first 5-mm trocar in an immediate supraumbilical or infraumbilical position, as described later in the chapter. Increase the peritoneal pressure temporarily to 15 mm Hg for insertion of additional trocars under direct visualization, if desired. Diagnosis is made regarding the type of nonpalpable testis, and for patients with abdominal testis, additional ports are placed. Place the second and third ports, each 3 to 5 mm in size, at the level of the umbilicus in the midclavicular line ( Fig. 39.2 ). The vector of each trocar is toward the affected groin. Care should be taken to avoid the epigastric vessels. Placement of these ports just above the level of the umbilicus instead allows additional room for movement of instruments in the smaller infant. This configuration affords freedom for the surgeon and camera without compromising the triangulation needed for the laparoscopist to work efficiently.
Trendelenburg positioning with table rotation to the unaffected side will facilitate displacement of the bowel for safe visualization of the anatomy.
Single-site port placement
Depending on availability and the surgeon’s expertise, the laparoscopic endoscopic single-site (LESS) technique can be used and performed with a single infraumbilical incision. After confirmation of the nonpalpable abdominal testis by diagnostic laparoscopy (as described later), the camera is removed and the skin and fascial incisions are extended to allow insertion of the GelPoint (Applied Medical, Rancho Santa Margarita, CA). The inner ring is placed into the peritoneal cavity and secured in place. The port is then prepared by placing three trocars in a triangular fashion, and the post is secured in place on the ring in a standard fashion. The three ports can then be used to complete the operation as described later, identical to the classic technique ( Fig. 39.3 ).
Procedure ( )
Achieve peritoneal insufflation in children via a small semilunar incision in the infraumbilical or supraumbilical rim or by a transumbilical approach; excellent cosmesis results in each case. Dissect through the subcutaneous fascia to approach the rectus fascia. Place two hemostats on the fascia to facilitate lifting up and provide back pressure when placing a Veress needle. Obtain access to the peritoneum via direct blind puncture (Veress needle technique) or open insertion (Hasson trocar technique). Insert the trocar at a 45-degree angle toward the pelvis to minimize the risk of visceral injury. These techniques and respective precautions are described in detail elsewhere in the text, and the approach largely depends on the training and preference of the surgeon. After insertion of a 5-mm umbilical port, perform CO 2 insufflation at low flow to achieve a pressure of 12 mm Hg in infants and 15 mm Hg in older children. Use disposable or reusable blunt trocars. Defer placement of additional ports until the gonad has been identified and plans for therapeutic laparoscopy are in place.
With the evolution of single-port laparoscopy, we have now moved to perform orchiopexy in this manner. An Applied Medical GelPOINT mini port ( Fig. 39.4 ) is placed through one semilunar incision in the inferior border of the umbilicus. This allows access for three 5-mm instruments by which the procedure is completed in the standardized fashion. Although we are in the process of collating and publishing our experience, we can safely add at this time that the single-site laparoscopy allows us to do a safe procedure with excellent cosmetic outcomes.
After safely entering the peritoneal cavity, briefly inspect the abdominal and pelvic contents to rule out injury or obvious coincident disease. Rare adhesions are carefully dissected to facilitate exposure.
The inguinal ring may be more difficult to see in the child with a high abdominal testis because the anatomic landscape is less populated. The contralateral ring is a useful reference in that situation. The normal inguinal ring is marked by the confluence of the vas deferens (medial) and spermatic vessels (lateral) ( Fig. 39.5 ). Their relationship with the iliacs and ureter, as well as the obliterated umbilical artery and inferior epigastric vessels, is also noteworthy for the progression of the case.