Journal of Minimal Access Surgery Medknow Publications ISSN: 0972-9941 EISSN: 1998-3921 Vol. 7, Num. 3, 2011, pp. 178-180

Journal of Minimal Access Surgery, Vol. 7, No. 3, July-September, 2011, pp. 178-180

Original Article

Route to neo-inguinal canal: Our experience

J Jacob Swaroop Anand, V Kumaran, G Rajamani, S Kannan, N Venkatesa Mohan, R Rengarajan, V Muthulingam

Department of Paediatric Surgery, Coimbatore Medical College and Hospital, Coimbatore-641018, Tamilnadu, India
Correspondence Address: J Jacob Swaroop Anand, 75/10, 1st Floor, 8th Cross, Thirumagal Nagar, Peelamedu Pudur, Coimbatore, India, dr.cjacob@gmail.com

Date of Submission: 04-Nov-2009
Date of Decision: 15-Apr-2010

Code Number: ma11042

DOI: 10.4103/0972-9941.83509

Abstract

Aim: The objective of this study was to stress the importance and value of this route to neo-inguinal canal creation for undescended testis management laparoscopically.
Materials and Methods: Data from the Department of Paediatric Surgery, Coimbatore Medical College, was taken. Retrospective study was undertaken for the period 2004 to 2008. Here the surgical technique and outcome of the treatment are recorded for children aged 1 year to 12 years.
Results: A total of 126 children underwent laparoscopic stage II surgery by this route (medial to the medial umbilical ligament). Right-sided undescended testis (UDT) was present in 76 (60%) patients. Left-sided UDT was present in 45 (35%) patients. Bilateral UDT was present in 5 (5%) patients. There were 90 (71%) patients aged less than 2 years and 36 (29%) patients aged more than 2 years. The eldest patient was 12 years of age. The overall hospital stay was 1 day. There were no complications seen in the follow-up. In all cases, the testis could not be brought down in a single stage.
Conclusion: Creation of neo-inguinal canal medial to the medial umbilical ligament and just lateral to the bladder has the advantage of gaining more length on the vessels and vas to bring the testis to scrotum. The laparoscopic management of undescended testis in stage II by this innovative new route is simple, less complicated and well tolerated.

Keywords: Medial, neo-inguinal canal, umbilical ligament, undescended testis

Introduction

The multitude of approaches to, and procedures for, nonpalpable testis attests to the management dilemma it presents. We report our preference for, and success with, diagnostic laparoscopy for the patient with nonpalpable testis, with extension of the procedure to laparoscopic orchidopexy by this route.

Materials and Methods

A retrospective study of 126 patients who underwent laparoscopic management of stage II UDT by this new technique was carried out.

Results

Out of the 126 patients, 76 (60%) were right sided and 45 (35%) were left sided. Bilateral UDT was present in 5 (5%) patients. The youngest patient was 1 year of age; and the oldest, 12 years of age. There were 90 (71%) patients below the age of 2 years; and 36 (29%), above the age of 2 years. Mean age was 2.4 years.

In all the patients, the testis was brought to the scrotum by using the route (medial to the medial umbilical ligament and just lateral to the bladder). In all the patients, the testis was impalpable and located intra-abdominally. The sizes of testis at the time of stage II ranged from 0.5 to 1 cc by volume. They all had undergone laparoscopic stage I surgery by Fowler-Stephens method. The time interval between the two stages is 6 months.

At a mean follow-up of 6 months, all testes were in a low scrotal position. There was no other intra-operative or postoperative complication. The 126 testes were in a dependent scrotal position with normal consistency, and none had atrophied (0%).

Surgical technique

The patient is positioned supine. There are a total of four ports being used. Three 5-mm ports on the anterior abdominal wall are used for the intra-abdominal dissection and creation of neo-inguinal canal. The umbilical port is inserted by means of open Hasson′s technique. The umbilical port is for the camera. Two accessory ports are placed at approximately the umbilical level on the mid clavicular line on either side of the abdomen. The fourth port is a 10-mm port, which is inserted in the scrotum [Figure - 1].

After carbon dioxide insufflation at 6-12 mm Hg, the abdomen is inspected for a testis on the affected side. In younger age group, lesser CO ₂ pressure was used. Dissection proceeds by incising the peritoneum caudal to the vas deferens and then lateral to the collateral vessels [Figure - 2]. At the superior extent of dissection, the peritoneum overlying the collateral vessels is incised, taking care to avoid injuring the vassal vessels. Care should be taken to avoid cautery while dissection. This step serves to free the collateral vessels from the posterior peritoneal attachments, and it often provides additional length. After this is completed, one should be able to determine whether the collateral vessels are of sufficient length to allow placement of the testis in the dependent portion of the scrotum. The lengths of the vas and vessels are said to be adequate if the testis can be placed on the opposite deep ring.

The neo-inguinal canal is created medial to the medial umbilical ligament and just lateral to the bladder wall [Figure - 3]. The dissection should be done close to and just lateral to the pubic tubercle [Figure - 4]. Care should be taken to see that the bladder is empty; the child can be asked to pass urine just before surgery or bladder can be emptied on table with an infant feeding tube.

The testis is brought as far down as possible via a scrotal trocar 10 mm through the neo-hiatus, which is positioned medial to the medial umbilical ligament and just over the pubic tubercle. Orchidopexy is performed by placing the testis in a subdartos pouch created.

Discussion

The multitude of approaches ^[1] to, and procedures for, nonpalpable testis attests to the management dilemma it presents. When deciding which approach to use, one must consider the success rate of the procedure and the morbidity or potential morbidity. We report our preference for, and success with, diagnostic laparoscopy for the patient with nonpalpable testis, with extension of the procedure to laparoscopic orchidopexy by this route, when a testis is identified at, or proximal to, the internal inguinal ring.

This approach was supported by Cisek et al,^[2] who recently reported that localization via diagnostic laparoscopy aided in planning the approach to an nonpalpable testis in 66% of patients. Nevertheless, Kirsch et al.^[3] prefer the inguinal approach in all of these patients. Regardless of the open or laparoscopic approach to the impalpable testis, ^[4] there remains a subset of patients in whom short testicular vessels associated with a high abdominal testis do not allow testis placement in the scrotum without division of the vessels.

This scenario is not new, and all paediatric surgeons are familiar with the numerous procedures available to treat these patients, including staged orchidopexy, ^[5] transperitoneal or retroperitoneal orchidopexy via an extended inguinal or Pfannenstiel incision, Fowler-Stephens orchidopexy in 1 or 2 stages, ^[6],[7] microvascular transplantation and laparoscopic vessel clipping ^[7],[8] followed several months later by extended inguinal or trans-abdominal orchidopexy. ^[9] In our current series, laparoscopic management of these testes yielded success in 126 of the 126 patients (100%).

In our series, the main criterion was that the vas avoided going around the inferior epigastric vessels and medial umbilical ligament, thereby gaining at least 2-3 cm more length. This route gives a direct approach to the scrotum. The greater degree of success with the laparoscopic procedure in our series may have been associated with leaving a wider peritoneal window intact when laparoscopy was done. Another potential explanation is that magnification used during laparoscopy may have led to better preservation of small collateral vasculature. We were able to reach the dependent scrotal area in all the 126 cases; none of the testes were at high-scrotal or mid-scrotal level. This is one other striking feature of our series.

When all reported series of laparoscopic orchidopexy are combined, the success rate is 96% with or without division of the spermatic vessels, which is comparable to the 97% success rate without division of the vessels for the Koop procedure. Although the number of patients in our series is relatively small, our excellent success rate makes this a sound alternative to the routine Fowler-Stephens procedure in patients with an abdominal testis.

Conclusion

The magnification and wide mobilization of laparoscopy likely allow better preservation of the collateral vascular supply, accounting for the improved success rates. The overall success rate of 100% in our study is comparable to or exceeds that of open orchidopexy for abdominal testis. Creation of neo-inguinal canal medial to the medial umbilical ligament and just lateral to the bladder has the advantage of gaining more length on the vessels and vas to bring the testis to scrotum by avoiding going around the inferior epigastric vessels. The laparoscopic management of undescended testis in stage II by this innovative new route is simple, less complicated and well tolerated. The 126 testes were in a dependent scrotal position with normal consistency, and none had atrophied (100%).

References

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