Introduction and Preoperative Considerations
If a testis has not descended into the scrotum by 6 months of age, surgical treatment should be considered. A child with bilateral nonpalpable testes should undergo evaluation for a disorder of sexual differentiation before operative intervention.
Orchiopexy is usually performed as an outpatient procedure between 6 and 24 months of age. A variety of approaches have been described to account for the spectra of testicular positions—ranging from high scrotal to high intraabdominal—that may be found at operation ( Table 114.1 and Fig. 114.1 ).
|Palpable testis, high scrotal position||Scrotal or inguinal orchiopexy|
|Palpable testis, inguinal position||Inguinal orchiopexy|
|Nonpalpable testis, contralateral testis enlarged (may represent in utero torsion with testicular atrophy)||Exploration to identify a remnant and orchiectomy of nonviable testis|
|Nonpalpable testis||Inguinal, laparoscopic, low ligation, staged Fowler-Stephens, or microvascular orchiopexy *|
* An algorithm for determining the approach to a nonpalpable testis is outlined in Fig. 114.1 .
In children younger than 2 years of age, the bladder extends well into the abdomen and can be injured during medial exposure of the spermatic cord or port placement in laparoscopy. Also, the peritoneum is more loosely attached to the anterior abdominal wall in children, and this space is more susceptible to emphysema with attempts to access the abdomen for laparoscopy.
Inguinal Orchiopexy (Open Technique)
An inguinal approach is commonly used for orchiopexy in a child with a palpable high scrotal or inguinal testis. Place the child in supine position. Consider a caudal block for postoperative analgesia in a young child or a local nerve block for an older patient. The major steps of the operation include (1) inguinal dissection, (2) delivery of testis and cord mobilization, (3) repair of the hernia defect, (4) creation of a dartos pouch, and (5) relocation of the testis.
Sharply incise the external oblique fascia from above. Use a knife or scissors to cut between the fibers that terminate at the external ring ( Fig. 114.2 ). Identify and avoid the underlying ilioinguinal nerve with its medial and lateral branches. Free the fascia from the conjoined muscle and the cremasteric fibers beneath it. Look for the ilioinguinal nerve and gently free it from the fascia. Separate the internal oblique muscle with scissors or a fine clamp to expose the floor of the canal.
Delivery of Testis and Cord Mobilization
Identify the testis within the tunica vaginalis. Pick up the overlying cremasteric fibers on either side with a fine smooth forceps ( Fig. 114.3 ). Peel them down and off the cord. Avoid injury to the external spermatic artery and vein, branches of the inferior epigastric vessels. Allow these vessels to drop to the floor of the canal. Maintain the dissection close to the tunica vaginalis and locate the communicating processus vaginalis. Excise gubernacular attachments and free the testis such that its only attachment is the spermatic cord.
Open the tunica vaginalis anteriorly and incise it proximally to the base of the cord ( Fig. 114.4 ). Remove the appendix testis and appendix epididymis if present. Note the size of the testis and inspect it for abnormalities. Gauge the length of the cord by pulling the testis over the symphysis. If it is too short, meticulously free remaining tunica vaginalis and cremasteric fibers from it.
If additional length is necessary to achieve a satisfactory scrotal position, open the internal ring by dividing the internal oblique muscles and more of the lateral spermatic fascia. Mobilize the cord into the retroperitoneum toward the kidney. Use a peanut dissector for medial dissection to avoid vascular injury. Minimize dissection about the vessels, vas, and cord structures to minimize the risk of testicular atrophy, particularly in infants. Usually, minimal cord dissection is necessary to achieve sufficient length for orchiopexy in testes found in the superficial inguinal pouch.
Repair of the Hernia Defect
Grasp the edges of the tunica vaginalis near the internal ring with fine forceps. Insinuate fine scissors or a small straight hemostat between the peritoneal lining of the hernia canal and the vessels and vas. The tunica vaginalis may appear to surround the cord. It is easiest to separate the vaginalis from vessels and vas just below the internal ring. Approach the dissection from both medially and laterally. As the structures begin to separate, divide the free edges of the sac to obtain better exposure and facilitate separation of the cord structures from the peritoneum. Finally, divide the posterior and lateral connections of the internal spermatic (transversalis) fascia to allow the cord to move medially.
Place mosquito clamps on its edges and complete division of the sac. Close the peritoneal opening with a purse-string suture. Suture ligation may also be adequate for a small hernia sac ( Fig. 114.5 ). It may be preferable to postpone this step until cephalad cord mobilization has been accomplished because subsequent retraction during retroperitoneal dissection may tear the repair.
Creation of a Dartos Pouch
Pass an index finger or a gently curved clamp into the scrotum along the usual course of testicular descent. Make a 2-cm incision with a scalpel through the scrotal skin ( Fig. 114.6, A ). Develop a pocket for the testis from below by freeing the skin from dartos fascia bluntly by 1 to 2 cm ( Fig. 114.6, B ). Make a small opening in dartos fascia while it is tensioned over a finger. Spread the incision with a clamp. Grasp the fascial edges with small Allis clamps ( Fig. 114.6, C ).
Relocation of the Testis
Pass an index finger through the inguinal incision and down the inguinal canal. Palpate the tip of a clamp passed through the scrotal incision. Pass a clamp over an index finger cephalad through the canal. Grasp the edge of the tunica albuginea or pass a suture through the tunica albuginea to grasp with a clamp. Carefully bring the testis down through the canal and out the scrotal incision. Take care to avoid rotating the cord. Some surgeons close the dartos fascia behind the testis ( Fig. 114.7 ). Others advocate for pexy of the testis in a dependent scrotal position within the pouch using an absorbable suture.
Suture the internal oblique to the shelving edge of the inguinal ligament over the cord with 3-0 or 4-0 synthetic absorbable sutures. Alternatively, approximate the internal oblique muscle with interrupted sutures.
Close the external oblique muscle with interrupted sutures from cephalad to caudad to create a new external ring ( Fig. 114.8 ). Do not make the ring too tight. Reapproximate the Scarpa fascia, close the skin with an absorbable 4-0 or 5-0 running subcuticular suture, and seal the skin with skin adhesive or appropriate dressing.
If the cord remains too short after freeing gubernacular attachments to the peritoneal reflection, consider bringing the testis directly into the scrotum with the Prentiss maneuver, which bypasses the obliquity of the inguinal canal.
Groin dissection may reveal a testis at or above the internal ring. Begin by lengthening the inguinal incision laterally. Elevate the skin at the upper end and open the lateral aspect of the internal ring by dividing the transversalis fascia. Place narrow Deaver retractors. With a Küttner dissector, bluntly develop the retroperitoneal space. Incise the external oblique fascia along the axis of incision and split the internal oblique and transversalis fascias. Look for the vas or spermatic vessels adherent to the peritoneum under the subserosal fascia and trace the vas to its proximal end (either to a testis or to a blind ending). If after thorough dissection and transposition the cord is still too short, consider an alternative procedure. Postoperative problems after inguinal orchiopexy are outlined in Table 114.2 .
|Postoperative scrotal swelling||Usually a sign of edema rather than infection or hematoma|
|Immediate progressive scrotal enlargement||Suggests uncontrolled bleeding and requires exploration|
|Testicular devascularization||Occurs during dissection of cord. Avoided by the use of loupes, fine instruments, and sequential dissection.|
|Division of vas deferens||More frequent in nonpalpable cases. Repair may be immediate or deferred until patient is postpubertal.|
|Inadequate testis position||Usually results from incomplete retroperitoneal dissection; can usually be corrected by a second operation.|
|Bladder injury||Avoid by draining bladder preoperatively. Managed with catheter drainage.|
|Late retraction of testis||Managed with repeat orchiopexy if inguinal.|
|Hydrocele||Thought to occur because of proliferation of tunica vaginalis remnants. May be ignored if small and asymptomatic. Large hydroceles may require transscrotal repair (see Chapter 123 ).|
|Testicular atrophy||Mild atrophy may be attributable to abnormal development rather than surgery. Orchiectomy may be advisable in the setting of profound atrophy caused by an increased risk of malignancy.|
A scrotal approach is reasonable in a child with a palpable testis in high scrotal position when minimal additional length is needed to achieve a favorable testicular lie. The primary operative steps include (1) scrotal dissection, (2) mobilization of the cord, and (3) relocation of the testis. An associated communicating hydrocele or hernia may be best addressed via an inguinal approach.
Place the child in supine position. Make a skin incision in a cephalad scrotal skin crease ( Fig. 114.9 ). Create a subdartos pouch through this incision before testicular mobilization. Use blunt and sharp dissection of the subcutaneous tissues to approach the testicle. Two factors facilitate mobilization of the skin incision to the inguinal region for cord dissection without entering the inguinal canal: (1) the high compliance of the scrotal skin and (2) the short distance from the external ring to the scrotum. If the testis can be manipulated into the scrotum, a vertical or transverse scrotal incision can be used.
Mobilization of Cord
Release the gubernacular attachments enabling identification of (1) the testis within the cremasteric fibers, (2) a patent processus vaginalis, and (3) the cord structures. Create a subdartos pouch by blunt dissection in caudal fashion just underneath the skin. During subsequent dissection, protect the ilioinguinal nerve (it is not routinely identified) before proceeding further.
Carefully separate the cremasteric fibers and hernia sac from the cord structures. Under traction, divide the hernia sac between hemostats and suture-ligate it ( Fig. 114.10 ).
Relocation of Testis
Relocate the testis into the subdartos pouch or suture tunica albuginea to either the scrotal septum or to the dependent scrotum. The pouch neck can be narrowed with simple interrupted absorbable suture to prevent ascent. Close the skin with a horizontal mattress or running subcuticular suture. Confirm that the testis remains in its new scrotal location. Apply skin adhesive as a dressing.
For children with a palpable scrotal nubbin, a transscrotal approach may be used to confirm the diagnosis of vanishing testis via identification of a dark, hemosiderin-laden tissue remnant.
When additional cord length is required, dissect further through the scrotal incision by opening the external ring and canal as necessary. If further length is still needed, a standard inguinal approach may be necessary. In a patient with a trapped testis after previous orchiopexy or hernia repair, the technique enables early identification of the testis and accompanying cord structures. Careful cranial dissection and en bloc fascial dissection may be required to obtain sufficient length in such cases.
Exploration for Nonpalpable Testis
A boy with a nonpalpable testis requires exploration to either identify an abdominal testis or remnant or to confirm absence of a testis on that side. This may be accomplished laparoscopically, intraabdominally, or by extending an inguinal incision. An intraabdominal testis is found in 25% to 50% of cases. An absent or vanishing testis—probably caused by prenatal or developmental vascular insult—is found in 15% to 40% of cases. Such cases are often characterized by atretic spermatic vessels and blind-ending vas, usually at or just distal to the internal ring. Having absent spermatic vessels warrants full exploration of the retroperitoneum to confirm the diagnosis of testicular agenesis. In other cases, abdominal exploration may reveal normal cord structures entering the internal ring and leading to a viable, nonpalpable inguinal testis. Inguinal exploration is indicated to confirm the presence of a distal viable or vanishing testis.
Diagnostic Laparoscopy for Nonpalpable Testis
Diagnostic laparoscopy is now widely used to define gonadal anatomy in patients with a nonpalpable testis.
Laparoscopy in Children: General Considerations
Laparoscopic surgery in children should be done under general anesthesia. After induction of anesthesia, it is essential to repeat the scrotal and inguinal examination. After the child is relaxed, a testis or remnant may be appreciated in up to 20% of cases, precluding the need for intraabdominal surgery. If a testis a palpated high in the canal, one may (1) proceed laparoscopically or (2) use a combined approach with a limited intraabdominal dissection (mobilizing vessels and vas) followed by inguinal orchiopexy.
A urethral catheter may be placed to decompress the bladder to avoid injury during port placement. A nasogastric tube may be placed to decompress the stomach, preventing depression of omentum into the route of the trocar.
If adhesions are anticipated because of a history of previous abdominal surgery, prepare the bowel both mechanically and with antibiotics. In such cases, have a standby table of laparotomy instruments available. Prep the genitalia and abdomen in case laparotomy is required ( Fig. 114.11 ).
Place the patient supine and secure him gently to the table. Insert a rolled towel under the lower back to create lordosis. Tip the table into a 30-degree Trendelenburg position to move the intestines out of the pelvis (return to a 30-degree tilt after introduction of the laparoscope). It may be helpful to rotate the table 30 degrees laterally toward the surgeon, raising the involved testis above intestine. Multiple laparoscopy access techniques have previously been described.
Localizing the Testis
Inspect the peritoneal cavity, especially the underlying bowel. Important landmarks are illustrated in Fig. 114.12 . Visualize the vessels and vas of the contralateral ring. Then visualize the ring on the cryptorchid side. Follow the vas laterally from its crossing of the medial umbilical ligament. Apply traction to the ipsilateral scrotum to make the vessels more apparent. One of seven anatomic arrangements ( Table 114.3 ) may be recognized.