Laparoscopically assisted orchidopexy for the management of intra-abdominal testis

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摘要

The description of the laparoscopically assisted orchidopexy covers all aspects of the surgical procedure used for the management of intra-abdominal testis.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: dissection, vessel length, orchidopexy, closure.
Consequently, this operating technique is well standardized for the management of this condition.

媒體類型

刊物

2002-07

普通的

最愛

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數位出版

WeBSurg.com, Jul 2002;2(07).
URL: http://www.websurg.com/doi-ot02en225.htm

Laparoscopically assisted orchidopexy for the management of intra-abdominal testis

1. Introduction

The incidence of cryptorchidism is about 1% to 3% in male infants. In 20% of cases, the testis is non-palpable (Vaysse, 1994; Esposito et al., 2000). Laparoscopic exploration must be performed only where a non-palpable testis is identified. If laparoscopic exploration shows an intra-abdominal testis (IAT), a laparoscopically assisted orchidopexy (LAO) is indicated.
The laparoscopic procedure was first described by Cortesi et al. in 1977. In 1989, both Elder and Bloom advocated the use of the Fowler-Stephens laparoscopic orchidopexy. Nassar (1995), Kirsch et al. (1998) and Esposito et al. (2000) proposed a laparoscopically assisted orchidopexy without the sectioning of testicular vessels for an IAT.

2. Anatomy

• Topographic anatomy

Laparoscopic view of the pelvis:
1. Sigmoid colon
2. Bladder
3. Right deep inguinal ring
4. Vas deferens
5. Spermatic vessels
6. Cecum
7. Ileum
8. Rectum
9. Peritoneal reflection

• Local anatomy

1. Testis
2. Internal inguinal ring
3. Testicular vessels
4. Vas deferens
5. Gubernaculum testis
6. Epigastric vessels
7. Iliac vessels
8. Bladder
9. Umbilical vessels

• Physiopathology

1. Intra-abdominal phase
2. Canalicular phase
3. Scrotal phase
The development and the migration of the testis may be divided into 3 phases: intra-abdominal (1 to 7 months during gestation), canalicular (7 to 8 months) and scrotal (8 to 9 months). The failure of one or both of the testes to descend is called cryptorchidism.
The position of the cryptorchid gonad depends on the phase in which the migration ceases.

• Vasculature

1. Deferential artery
2. Superior vesical artery
3. Internal pudendal artery
4. Perineal artery
5. Internal spermatic artery
6. Posterior scrotal artery
7. Epididymal artery
8. Deep external pudendal artery
9. Superficial external pudendal artery
10. Femoral artery
11. External spermatic artery
12. Inferior epigastric artery

3. Indications

Surgical intervention is indicated for all kinds of intra-abdominal testis. Cardiac malformations are a contraindication (Chang et al., 2001).

4. Preop period

Medical treatment
Human chorionic gonadotropin injections or luteinizing hormone-releasing hormone therapy may be used to achieve descent of the testis. Dosage of testosterone is administered at the beginning and end of the treatment.

Clinical examination
Signs such as an empty scrotum or a non-palpable testis in the inguinal region, a potential hypertrophy of the contralateral testicle or the presence of a palpable structure at the external inguinal ring are used to assess the pathology. Precise examination of the external genital organs (penis, urethral duct, scrotum) is involved.

Diagnostic studies
Ultrasonography is carried out. Hormonal assays are recommended only for bilateral cryptorchidism. CT and MR scans are rarely done (Kirsch et al., 1998).

5. Operating room set-up

• Patient

- supine position;
- 20°/30° Trendelenburg position;
- gauze is placed under the scrotum to elevate it;
- the bladder is emptied before surgery;
- the entire abdomen, genitalia and upper legs are included in the operative field.

• Team

1. The surgeon stands on the side of the patient contralateral to the pathology.
2. The assistant stands opposite to the surgeon.
3. The scrub nurse stands on the side of the surgeon closer to the patient's feet.
4. Anesthesiologist

• Equipment

1. Anesthetic unit
2. Operating table
3. Instrument table
4. Laparoscopic unit
5. Electrocautery

6. Trocar placement

• Pneumoperitoneum

The first umbilical blunt tip trocar is introduced in open laparoscopy under direct vision, as is usually done in children. The peritoneal cavity is insufflated with CO2 up to a pressure of 8 mm Hg to 10 mm Hg with an inflow of 1 L to 1.5 L/min.

• Trocar placement

A: 5 mm, in the infraumbilical region
B: 3-5 mm, in the left iliac fossa
C: 3-5 mm, in the right iliac fossa
D: 5 mm, in the homolateral hemiscrotum
Trocar D is inserted late in the procedure.

7. Instrumentation

• Optical

1. Trocar A: 0° laparoscope

• Operating

1. Trocar B: atraumatic fenestrated forceps
2. Trocar C: curved scissors
3. Trocar C: needle holder
4. Trocar D: grasping forceps

8. Major principles

A laparoscopically assisted orchidopexy may be divided into 4 phases:
- dissection of the testicular vessels and vas deferens;
- controlling the length of the testicular vessels;
- orchidopexy;
- closure of the internal inguinal ring.

9. Dissection

• Identification

The testis and the testicular vessels are identified. If the gubernaculum is present, it is divided using monopolar coagulation.

• Testicular vessels

1. Testicular vessels
The posterior peritoneum is opened close and laterally to the testis. A window is created behind the testicular vessels. The testicular vessels are mobilized from the posterior peritoneum for about 8 cm to 10 cm using blunt dissection. Finally, the vas deferens is mobilized from the posterior peritoneum.
Dissection should be careful in order to avoid lesions of the ureter or iliac vessels.

10. Vessel length

1. Vessel length
Before proceeding further, it is important to control the length of the testicular vessels to ensure a tension-free orchidopexy. This can be achieved by grasping the testis with a forceps and moving it to the level of the contralateral internal inguinal ring. If this maneuver is possible, a tension-free orchidopexy is feasible. If this is not possible, the testicular vessels must be dissected higher up.

11. Orchidopexy

• Dartos pouch

1. Dartos pouch
The scrotum is incised homolaterally and a dartos pouch is created as in an open orchidopexy.
Both laparoscopic and open surgical procedures are used to accomplish the orchidopexy. Excessive traction on the testicular vessels should be avoided, as this can provoke their rupture.

• Introduction of forceps

A forceps is introduced through trocar C. This is passed from the abdomen through the internal inguinal ring and into the scrotum. The tip of the forceps exits at the level of the scrotal incision created in the preceding step.

• Scrotal trocar D

1. Scrotal trocar D
From the outside, a trocar sheath is placed onto the forceps that now exits through the scrotal incision, and pushed into the abdominal cavity along the path followed by the forceps. It may be necessary to dilate the pathway. Once this is done, the first forceps is removed and a grasping forceps is introduced through the scrotal trocar.

• Pull-through of testis

1. Pull-through of testis
With the grasping forceps, the testis is now pulled down into the scrotum through the internal inguinal ring or through a medial neo-inguinal ring made by the surgeon. The testis is fixed in the scrotum with 2 separated stitches as in an open orchidopexy. The scrotal incision is closed.

12. Closure

One or more separated stitches are needed between the 2 muscular sides of the internal inguinal ring for closure. For this, 2.0 non-absorbable sutures are used. The pneumoperitoneum is desufflated, and the trocar incisions are closed with intradermic absorbable sutures.

13. Postop management

The patient may leave the hospital the day after surgery. The first shower should take place only 7 days after surgery. Postoperative check-ups are carried out 1 week, 1 month and 6 months after surgery. In case of scrotal edema at the first control, anti-inflammatory drugs should be administered for 5 days.
Normal activities may be resumed the day after surgery. Scrotal trauma (cycling, football, etc) should be avoided for 1 month following surgery.

14. Conclusion

In patients with non-palpable testes, a laparoscopically assisted orchidopexy is the first and the best procedure to adopt (Esposito et al., 2000). This procedure guarantees normal vascularization of the testis and possesses the advantage of being minimally invasive along with the accuracy of dissection that characterizes the laparoscopic procedure (Baker et al., 2001; Esposito et al., 2000; Fleet et al., 1999).

15. Reference

Baker LA, Docimo SG, Surer I, Peters C, Cisek L, Diamond DA, et al. A multi-institutional analysis of
laparoscopic orchidopexy. BJU Int 2001;87:484-9.
Chang B, Palmer LS, Franco I. Laparoscopic orchidopexy: a review of a large clinical series. BJU Int
2001;87:490-3.
Esposito C, Vallone G, Settimi A, Gonzalez Sabin MA, Amici G, Cusano T. Laparoscopic orchiopexy
without division of the spermatic vessels: can it be considered the procedure of choice in cases of
intraabdominal testis? Surg Endosc 2000;14:658-60.
Flett ME, Jones PF, Youngson GG. Emerging trends in the management of the impalpable testis. Br J
Surg 1999;86:1280-3.
Kirsch AJ, Escala J, Duckett JW, Smith GH, Zderic SA, Canning DA, et al. Surgical management of
the nonpalpable testis: the Children's Hospital of Philadelphia experience. J Urol 1998;159:1340-3.
Lindgren BW, Darby EC, Faiella L, Brock WA, Reda EF, Levitt SB, et al. Laparoscopic orchiopexy:
procedure of choice for the nonpalpable testis? J Urol 1998;159:2132-5.
Nassar AH. Laparoscopic-assisted orchidopexy: a new approach to the impalpable testis. J Pediatr
Surg 1995;30:39-41.
Poppas DP, Lemack GE, Mininberg DT. Laparoscopic orchiopexy: clinical experience and description
of technique. J Urol 1996;155:708-11.
Vaysse P. Laparoscopy and impalpable testis--a prospective multicentric study (232 cases). GECI.
Groupe d'Etude en Coeliochirurgie Infantile. Eur J Pediatr Surg 1994;4:329-32.

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