Laparoscopy for Contralateral Patent Processus Vaginalis

(CPPV) and Non-Palpable Testis

George W. Holcomb, III, M.D., MBAChildren’s Mercy Hospitals and Clinics

Kansas City, Missouri

The Child with a Unilateral Hernia

What about the other side?

J.Ped. Surg. 29:970-974, 1994J.Ped. Surg. 29:970-974, 1994

J.Ped. Surg. 31:1170-1173, 1996J.Ped. Surg. 31:1170-1173, 1996

Urology 51:480-483, 1998Urology 51:480-483, 1998

Unilateral Hernia

• Unilateral hernia repair only

• Bilateral exploration and repair

• Goldstein Test

• Unilateral hernia repair and diagnostic laparoscopy

• Laparoscopic hernia repair

Options

Unilateral Hernia Repair Only

Advantages

• Repairs known disease

• No contralateral incision or complications

Disadvantages

• 10 - 30% return for contralateral repair

Unilateral Hernia Repair with Diagnostic Laparoscopy

Advantages• Selects contralateral

repair for those with CPPV

• Less than 1% false-positive contralateral explorations

Disadvantages• Uncertain which

child with CPPV will return with symptomatic hernia

Bilateral Exploration and Repair

Advantages

• 10 - 30% have CPPV

• Avoids need for possible second anesthesia and operation

Disadvantages

• 70 - 90% do not have CPPV

• ? Increase injury to spermatic cord

Contralateral InspectionContralateral Inspection

Ambiguous Findings

Geiger, JD - J Pediatr Surg 35:1151-1154, 2000

Study

May 1, 1992 - To evaluate the role

of diagnostic laparoscopy in the

child less than age 10 years with a

known unilateral inguinal hernia

IPEG 2005

JLAST 16:650-653, 2006

May 1, 1992 – January 1, 2003

Total Number of Patients 1870

Known Bilateral Hernia 194

No lap.; Tech. Reasons 73

Total Number Scoped 1603

1603 Patients

Unilateral hernia Bilateral disease

960 643

(60%) (40%)

1603 PatientsPhysical Exam

• #Patients suspected on #Patients suspected on exam to have CPPVexam to have CPPV

• #Patients with CPPV#Patients with CPPV

446

192

(43%)

1603 PatientsPhysical Exam

• #Patients suspected on exam not to have CPPV

• #Patients without CPPV

1157

706

(61%)

Laparoscopy for CPPV1603 Patients

• 643 with CPPV

• 55 (8.5%) positive Goldstein test

Diagnostic Laparoscopy

• Allows surgeon to know which child needs contralateral repair

• Takes 3-5 minutes to accomplish

• Performed through known inguinal hernia sac

• No complications to date

The Parental Perspective Regarding The Contralateral Inguinal Region in

a Child With a Known Unilateral Inguinal Hernia

George W. Holcomb, III, MD, MBA,Kelly A. Miller, MD, Beverly E. Chaignaud, MD,

Stephen B. Shew, MD, Daniel J. Ostlie, MD

Children’s Mercy HospitalKansas City, Missouri

APSA 2003J Pediatr Surg 39:480-482, 2004

Parental Perspective

• Management of the contralateral inguinal region in a child with a unilateral inguinal hernia has been debated for 50 years

• Parental views regarding this issue have not been sought

Methods

• Prospective study with IRB approval

• November 2001 – February 2003

• All patients less than 10 years of age with a unilateral inguinal hernia seen by the senior surgeon (GWH) were eligible for study

Methods

Methods

Methods

• Motives for parents’ decision

• Last 113 patients requesting contralateral inspection (either exploration or laparoscopy)

Results No. of parents choosing this option Repair the known unilateral hernia only 12

Repair the known unilateral inguinal hernia and explore the contralateral region with CPPV repair if indicated

13

Repair the known unilateral inguinal hernia, perform laparoscopy through the known hernia sac and repair the CPPV if one is found at laparoscopy

142

Total 167

J Pediatr Surg 39:480-482, 2004J Pediatr Surg 39:480-482, 2004

ResultsParents’ reasons for wanting to evaluate

the contralateral side

• 90 parents: convenience

• 21 parents: concerns about a second anesthesia

• 1 parent: thought there was a hernia on the other side

• 1 parent: 2 previous children with BIH – wanted contralateral

explorationJ Pediatr Surg 39:480-482, 2004J Pediatr Surg 39:480-482, 2004

Conclusions

• When given information about the possibility of a CPPV on the opposite side, over 90 percent of the parents in this study requested evaluation and repair, if needed.

• The vast majority of those desiring contralateral evaluation preferred using laparoscopy as opposed to a contralateral incision

Conclusions

• Most of those desiring contralateral inspection did so for reasons of convenience as opposed to concerns about returning for a second operation and anesthetic

J Pediatr Surg 39:480-482, 2004J Pediatr Surg 39:480-482, 2004

? ? Questions ? ?

Laparoscopy For The Non-palpable Testis

Non-palpable Testis

• 10 percent of undescended testes

• Difficulty with orchiopexy is the length of testicular vessels

• Ultrasound unreliable for location

• Laparoscopy used to determine location/presence/absence of testis

• Viability of testis with staged orchiopexy based on collateral vessels around vas deferens

Non-palpable Testis

Non-palpable Testis

Laparoscopy

Blind ending Attenuated Testisvessels; no testis vessels; no

testis

No further Inguinal Viable Atrophied exploration exploration toneeded excise remnant Orchiectomy

Single stage Staged orchiopexy orchiopexy (vessels ligated

initially)Holcomb, et al: Laparoscopy for the Nonpalpable Holcomb, et al: Laparoscopy for the Nonpalpable Testis. Am Surg. 60:143-7, 1994.Testis. Am Surg. 60:143-7, 1994.

Non-palpable TestisDiagnostic Laparoscopy

• Blind ending vessels and vas• No further therapy

Non-palpable TestisDiagnostic Laparoscopy

• Attenuated vessels -No testis

• Inguinal exploration to excise remnant

Non-palpable TestisDiagnostic Laparoscopy

• Intra-abdominal testis

• Staged procedure vs one stage laparoscopic orchiopexy

Non-palpable TestisStaged Orchiopexy

• One 5 mm umbilical cannula

• Two 2.5 mm stab incisions

CMH Experience1998 – 2005

Group 1Standard lap. orchiopexy

31 orchiopexies/ 22 pts

93.8% success

Group 2Single or 2-stage FS

orchiopexy

30 orchiopexies/23 pts(8 one stage, 22 two stage)

83.3% success

61 laparoscopic orchiopexies/ 45 patients

CMH Experience1998 - 2005

Group 1

(2/32) – 6.3%

Group 2

(4/24) – 16.7%

Atrophy

Prospective Randomized Trial1 Stage vs 2 Stage F.S. Laparoscopic Orchiopexy

• Non-palpable testis

• Can not reach contralateral internal ring

• Pilot study - 30 patients

www.centerforprospectiveclinicaltrials.com

www.cmhcenterforminimallyinvasivesurgery.com