How is laparoscopic treatment of cryptorchidism performed?

Updated: Dec 17, 2020
  • Author: Joel M Sumfest, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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Answer

For the laparoscopic approach, place the patient in the supine Trendelenburg position and secure him to the operating table to allow tilting. Insert a bladder catheter and orogastric tube.

The authors use an open Hasson (mini-laparoscopic ["mini-lap"]) technique. Insufflate the abdomen with carbon dioxide at a low rate (1 L/min) until distension occurs. Initial pressures should be less than 7 mm Hg. Create a 5-mm umbilical camera port (newer 2- to 3-mm needlescopes are now available). In infants who are to undergo orchiopexy or orchiectomy, one or two 2-mm working ports need to be placed, usually lateral to the ipsilateral inferior epigastric vessels and at the midline below the umbilicus. Again, in patients with vanishing testis syndrome, the remnant is mobilized and removed via the ocular port. Laparoscopy is sufficient for the diagnosis of blind-ending spermatic vessels (see video below).

Laparoscopic management of the vanishing testis.

Jordan et al (1992) first described the technique of laparoscopic orchiopexy, and all modern techniques are similar. [67] It is necessary to decide early if a staged laparoscopic Fowler-Stephens orchiopexy is necessary. If the testis is farther than 4 cm from the internal ring, this should be considered. However, note that more than 90% of intra-abdominal testes can be brought down successfully without such extreme maneuvers. If the staged procedure is used, the first and second operations are separated by 6-9 months to allow collateralization of the deferential artery.

The peritoneum is incised around the internal ring and continued superiorly lateral to the vessels and medial to the vas deferens. A triangle of peritoneum is left between the vas and vessels distally. The vessels are carefully mobilized, and optical magnification with the laparoscopic approach is quite helpful in this regard. The testis is brought down after a subdartos pouch is created by passing a 12-mm radially dilating trocar into the peritoneum just lateral to the lateral umbilical ligament. Afterward, additional dissection of the vessels is necessary in some cases. Ensure that the cord is torsion-free as the testis is brought down. Standard scrotal fixation is performed. The 2-mm ports do not require closure, but the 5-mm umbilical port is closed to avoid omental herniation.


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