Indications for diagnostic and therapeutic laparoscopy are identical to the goals of open orchiopexy: Determine if a testicle is present and viable, and if so, relocate it into the scrotum. Historically, laparotomy was performed to localize an intra-abdominal testis or diagnose blind-ending vessels if cord vessels were not observed on initial inguinal exploration. This was most often accomplished with a high inguinal (i.e., Jones incision) or Pfannenstiel incision. It is now common practice, especially as the child grows beyond infancy, to proceed with diagnostic laparoscopy when the testicle is nonpalpable.

During diagnostic laparoscopy for the nonpalpable testis, there are three scenarios that are commonly encountered. If blind-ending vessels and vas deferens are present proximal to the internal ring, a vanishing testis is diagnosed and no further action is required. Approximately 10% of boys with nonpalpable testis are found at the time of diagnostic laparoscopy to have blind-ending vessels, indicating the absence of testicular tissue (20). If the vessels and vas deferens are present and appear to enter the internal ring, then inguinal or scrotal exploration is warranted. The final scenario includes the presence of an intra-abdominal testis, which can be located in a variety of positions. For an intra-abdominal testicle the surgeon will need to assess which therapeutic modality is the most appropriate for treatment. If the testicle appears to be atrophic or grossly abnormal, then orchiectomy should be considered. If the testicle appears relatively normal, the ability to mobilize it to the scrotum is assessed, based on the distance of the testicle to the internal inguinal ring and redundancy of the spermatic vessels and vas. Deciding whether to perform a single-stage procedure leaving the vessels intact or to perform a one- or two-stage Fowler-Stephens procedure in which the spermatic vessels will be transected is challenging as no specific set of criteria have been determined. As part of the decision-making process, intraoperative measurement of the distance between the testis and the internal ring, observation of the cord anatomy, or assessment of the ability of the intra-abdominal testicle to reach the opposite inguinal ring after dissection may be helpful. Bilateral laparoscopic orchiopexies can be performed simultaneously or at separate procedures, depending on perceived risk of atrophy.

Diagnostic Laparoscopy Technique. Inhaled NO2 should be avoided in order to avoid bowel distention, and an oral gastric tube should be inserted to decompress the stomach and maximize visualization in the abdomen. The patient is secured to the bed in the supine position at the level of the chest and low thigh with his arms tucked and the legs placed in a slightly abducted position. Securing the child to the table allows for Trendelenburg positioning. Prep and drape the patient for possible conversion to an open procedure. In the sterile field, a Foley catheter is placed to avoid potential bladder injury with trocar placement. Figure 101.2 demonstrates the preferred setup and trocar placement for performing laparoscopic orchiopexy.

Access into the peritoneum may be achieved via an open Hasson fashion at the umbilicus. Alternatively, Veress needle access to establish pneumoperitoneumin has been shown to be safe and efficacious in children of all ages (21). A 5-mm hidden infraumbilical incision is made in the skin, and scissor dissection is performed at approximately 15- to 20-degree cephalad angle through the umbilical fascia into the underlying adherent peritoneum.

For the umbilical camera port, a 5-mm Step trocar will accommodate a 5-mm camera with a 0-degree lens. The child is placed in Trendelenburg position, and the abdomen is insufflated at 1 to 2 L per minute to a pressure of 10 to 12 cm H2O. General survey of the abdomen is undertaken, inspecting the peritoneal structures for injury that might have occurred during port placement. Next, attention is focused on the evaluation of the pelvis. If an instrument is needed to aid in the inspection, a 5-mm port is placed on the ipsilateral side of the nonpalpable testis, lateral to the rectus and just caudal to the level of the umbilicus. An atraumatic instrument may then be used to sweep the bowel cephalad. Placement of an additional trocar on the contralateral side (lateral to the rectus and just caudal to the umbilicus) is reserved for the need of an additional working port.

In the case of unilateral undescended testicle, the internal ring of the descended testicle is examined first to gain an appreciation of the anatomy. Possible findings on inspecting the affected side of the “nonpalpable” testicle may include blind-ending vessels, cord structures entering the internal ring, or an intra-abdominal testis. Note the status of the processus vaginalis; most undescended testicles are associated with a patent processus.

Blind-ending gonadal vessels indicate the absence of a testicle. This is the result of in utero testicular torsion that is either an intra-abdominal or intrascrotal event. Vessels will have a “horse tail” appearance; they diverge, do not exit the internal ring, and do not supply obvious testicular tissue (Fig. 101.3). If found during exploration, no further investigation is warranted and the procedure is terminated. It is important to note that the finding of a blind-ending vas deferens during laparoscopy is insufficient to conclude the absence of testicular tissue. Further cephalad inspection toward the aortic origin of the gonadal vessels is then necessary.

Cord structures may be visualized entering a closed internal ring or a patent processus vaginalis (Fig. 101.4). In the instance of a closed internal ring, a groin or scrotal exploration may be performed. If a patent processus vaginalis is present, the laparoscope may be used to inspect the inguinal canal via an antegrade approach. Alternatively, gentle manual retrograde pressure can be placed over the inguinal canal in an attempt to push groin contents (viable testicle versus nubbin)
intra-abdominally. In the instance of a nubbin or testicular remnant, laparoscopic orchiectomy is performed. This is accomplished by either clipping or dividing the cord contents or using a 5-mm instrument designed to seal and divide smaller vessels (i.e., LigaSure or harmonic scalpel). The specimen is grasped and removed from the contralateral 5-mm port. This incision can be widened as needed by spreading the fascia with any clamp while under direct vision from the camera port.

There are three minimally invasive reconstructive options to address an intra-abdominal testicle: (a) primary laparoscopic orchiopexy, (b) one-stage laparoscopic Fowler-Stephens orchiopexy, and (c) two-stage laparoscopic Fowler-Stephens orchiopexy. Laparoscopic orchiectomy is reserved for an intraabdominal nonviable testis (atrophic nubbin) or a testis that cannot be brought into the scrotum based on an extreme ectopic location or limiting vas or vessel length.

The initial measured distance of the testicle from the internal ring will determine which laparoscopic approach should be utilized and is therefore a predictor of success. “Peeping testes” or those located in close proximity to the internal ring (<2 cm away) can usually be mobilized into the scrotum in a single stage without dividing the testicular vessels (Fig. 101.5). It is important to counsel parents that intra-abdominal ectopic testes and those located >2 cm from the internal ring are at increased risk for surgical failure.

Following abdominal access, insufflation, and additional trocar placement, as outlined earlier, attention is focused on the ipsilateral testicle and internal ring. Fig. 101.6 demonstrates the surgical “map” needed to mobilize a triangular flap of peritoneum demarcated by the testicular vessels laterally and vas deferens medially. The preliminary goal is to create two continuous peritoneotomies parallel to the testicular vessels and vas in order to mobilize the testicle on a well-vascularized peritoneal pedicle.