Diagnostic peritoneoscopy (laparoscopy) can be used in infants and children for evaluation of a contralateral inguinal hernia in a patient with a known unilateral inguinal hernia.1,2 In addition, laparoscopy has been preferred for approximately 10 years by selected specialists for evaluation of undescended testes that are not palpable.3-8
EVALUATION OF THE CONTRALATERAL INGUINAL REGION
Inguinal herniorrhaphy is the most frequent surgical procedure performed by pediatric surgeons. However, what to do about the contralateral inguinal region at the time of repair of a known unilateral inguinal hernia has been the subject of controversy for 40 years. The concept of routine bilateral inguinal herniorrhaphy in children with a known unilateral hernia was first proposed by Rothenberg and Barnett in 1955.9 In their series, 12 children were under the age of 1 year and all had bilateral inguinal hernias. Of 37 children over the age of 1, 65% had bilateral inguinal hernias. Also, in their report, physical examination was not a reliable factor for determining whether a contralateral hernia was present.
In 1962, Sparkman reviewed literature reports of 918 children who had undergone herniorrhaphy and found that 57% had bilateral hernias noted on routine contralateral exploration.10 However, from the same review, he found that in children who initially underwent unilateral repair, development of a second hernia on the contralateral side ranged from 4% to 34% (mean: 15.8%). Gilbert and Clatworthy reviewed 164 patients and reported a 60% incidence of bilaterality regardless of age.11 Moreover, they also noted that physical examination did not reliably predict a contralateral hernia.
Advantages for exploration of the opposite side during repair of a known inguinal hernia are as relevant today as they were in the 1960s. A substantial number of children will be found to have a patent processus vaginalis on routine contralateral exploration. Thus, a second operation and considerable anxiety will be prevented if an existing contralateral hernia is repaired at the time of the first operation. The surgeon also is spared having to perform another operation with a second anesthesia at a later time. In addition, the substantial increase in cost both to the family and third-party payers for a second procedure will be avoided.
Figure 1. In this 3-year-old child, there was a known right inguinal hernia (right). At laparoscopy, an equally large left inguinal hernia was documented (left). Note the vas deferens (solid arrows) and the testicular vessels (open arrows) coursing through the internal opening of the hernia sac.
Figure 2. In this 6-month-old infant, there was a known right inguinal hernia (right). However, at laparoscopy, there was no evidence of a hernia on the left side (left) and unnecessary contralateral exploration was avoided. The vas deferens (solid arrow) and testicular vessels (open arrow) are best seen on the left side.
Disadvantages to routine bilateral exploration in boys include the potential for injury to either the vas deferens or testicular vessels. A pathological review of inguinal hernia sacs submitted for examination in 313 children documented five instances (1.6%) of segments of the vas deferens being identified on microscopic examination.10 In another report, 2% of 160 boys routinely examined for as long as 20 years were found to have some degree of testicular atrophy on the side of the hernia repair.12 A final disadvantage is the feet that, when performed routinely, many children will undergo unnecessary exploration of the contralateral inguinal region.
Because of the advantages and disadvantages for routine bilateral exploration, several diagnostic modalities have been used to determine whether the contralateral side should be explored.13'15 One maneuver is to insert a Bakes dilator through the known inguinal hernia sac into the peritoneal cavity and probe the contralateral region to determine if a patent processus vaginalis exists. Unfortunately, this technique is difficult to master and is not entirely reliable.
Herniography is another diagnostic procedure performed by radiologists in which dye is injected into the peritoneal cavity. The child is placed in the upright position until the contrast medium gravitates into the lower pelvic area after which a radiograph will determine if contrast fluid is within the contralateral inguinal sac. Disadvantages to this technique include pain with injection, gonadal radiation, and the requirement of an experienced radiologist for performance and interpretation. However, Kieswetter and Oh found it to be a satisfactory method to reduce the incidence of unnecessary contralateral exploration.14
A final technique is the use of pneumoperitoneum to detect a clinically occult contralateral hernia. In a random review of 64 patients in whom this procedure was used, Harrison and his colleagues found that contralateral hernia repair was required in only five patients (8%).15 Follow-up to 5 years revealed only one false-negative examination. Nevertheless, this 8% occurrence appears low for the true incidence of bilateral inguinal hernias in the pediatric population.
Because of the advantages of repair of a contralateral patent processus vaginalis when present and the disadvantages of performing unnecessary inguinal exploration when a hernia is not present and because of the unreliability and disadvantages of the previously mentioned tests, diagnostic peritoneoscopy is being performed to accurately evaluate the need for contralateral inguinal exploration. This diagnostic portion of the operative procedure requires only about 10 minutes and allows the surgeon to know if contralateral exploration should be performed.
A 3-mm incision is made within the depths of the umbilicus, and the umbilical fascia is incised under direct vision. A 3-mm cannula is then inserted into the abdominal cavity and pneumoperitoneum created through the cannula. A blind puncture with a Veress needle for creation of the pneumoperitoneum is not used as it is considered more likely to injure abdominal viscera and major vessels in infants and children.
A 2.7-mm telescope with a 30° viewing lens then is inserted through the cannula, and each inguinal region is assessed. The presence of a hernia on the known side is documented, and the contralateral inguinal region also is inspected. If a contralateral patent processus is present, then hernia repair is performed using an open inguinal crease incision in a standard fashion (Figure 1). However, should a contralateral hernia not be found, an unnecessary exploration will be avoided (Figure 2).
Having completed the laparoscopy, the telescope and cannula are removed. The umbilical fascia is closed with 3-0 absorbable suture, and the skin is approximated with 5-0 absorbable sutures. Bupivacaine is injected into the umbilical tissues for postoperative analgesia. Following endoscopy, either unilateral or bilateral inguinal hernia repair is performed in a standard fashion.
Experience at Vanderbilt Children's Hospital
One hundred ninety-five children have undergone endoscopy for evaluation of the contralateral inguinal region since May 1, 1992. One hundred sixty-eight were boys and 27 were girls. Of the 195 children, 109 had unilateral hernias and 86 had bilateral hernias. Of the 80 boys under the age of 1 year, 45% had bilateral hernias and 55% had unilateral hernias. Of the 88 boys older than 1 year of age, 39% had bilateral hernias and 61% had only unilateral hernias. In the 1 1 girls younger than 1 year of age, 6 had bilateral hernias and 5 had unilateral hernias. In the 16 older girls, 10 had bilateral hernias and 6 had unilateral hernias. To date, no patient who has undergone unilateral hernia repair has returned with a missed contralateral inguinal hernia.
In the same study, the accuracy of both insufflation and physical examination was evaluated. Following anesthesia, 55 patients were suspected on physical examination to have bilateral inguinal hernias for which a contralateral exploration was indicated. However, at peritoneoscopy, only 31 (56%) had bilateral hernias. Of the 140 patients considered on physical examination not to have bilateral hernias and, therefore, in whom contralateral exploration would not be indicated, 80 (57%) had a unilateral hernia but a surprising 60 (43%) had bilateral involvement.
Insufflation was positive on the known side in only 129 patients (66%) and was positive on the contralateral side in only 23 of the 86 patients (27%) subsequently found to have a patent processus vaginalis by endoscopy. Therefore, neither physical examination nor insufflation proved to be an accurate means of selecting which patients should undergo bilateral repair.
ENDOSCOPY FOR EVALUATION OF THE NONPALPABLE TESTICLE
Approximately 10% of boys with an undescended testis will have a gonad that is not palpable. The testis may have undergone torsion during its descent into the scrotum, there may have been improper development of the testis, or it may have descended into the lower abdominal cavity but not through the inguinal canal. For this latter reason, diagnostic peritoneoscopy is a helpful adjunct to plan the surgical management of a boy with a nonpalpable testis.
Figure 3. Diagnostic laparoscopy was used in this 18-monthold infant with a nonpalpable right testis. An intra-abdominal testis was identified at laparoscopy. Note the vas deferens (open arrow) as it is coursing toward the intra-abdominal testis.
Standard orchiopexy usually is not possible in boys with an intra-abdominal testis. The reason is that standard orchiopexy relies on the main testicular artery and vein to be of sufficient length to reach into the scrotum. However, with an intra-abdominal testis, the vessels are short and cannot be mobilized sufficiently to reach into the scrotum. Therefore, an alternative orchiopexy (Fowler-Stephens orchiopexy) was developed to overcome this difficult problem. The testicular artery and vein are ligated and divided, and the testis is transferred to the scrotum now being nourished by collateral vessels along the vas deferens. This technique has been successful in approximately 60% to 70% of patients.3 The concept of a two-stage Fowler-Stephens orchiopexy was first proposed in 1982 by Duckett.3 The reasoning was that ligation of the testicular vein and artery during the first stage would allow augmentation and development of collaterals to nourish the testis and would thereby improve the chance for a successful outcome when the second-stage orchiopexy was performed. Therefore, the two-stage Fowler-Stephens operation was developed and has been used successfully for the past 10 years for these difficult cases. With the advent of modern endoscopic techniques, it is now possible to lígate the testicular artery and vein laparoscopically rather than having to make a lower abdominal incision. The second-stage orchiopexy is performed 6 to 9 months later through inguinal crease and scrotal incisions.
Figure 4. The testicular vascular leash appeared to be short and could not reach into the scrotum in this boy with a nonpalpable right testis. Therefore, a two-stage FowlerStephens orchiopexy was planned. At laparoscopy, the initial stage was accomplished by endoscopically placing a clip (open arrow) across the testicular vessels. Note the testicle (solid arrow) on the right side of the photograph.
The technique of diagnostic laparoscopy for evaluation of the nonpalpable testis is similar to that for the contralateral inguinal hernia. However, a 5-mm telescope and cannula generally are used as this larger telescope provides better visualization and evaluation of the size of the testicular vessels and the status of the intra-abdominal testis if present.
If an intra-abdominal testis is found (Figure 3), and the testicular artery and vein are not of sufficient length to reach into the scrotum with standard orchiopexy, then a 10-mm lower abdominal incision is made through which a cannula and endoscopic clip applier are inserted. The testicular vessels are ligated endoscopically, thereby allowing augmentation of the secondary blood supply along the vas deferens (Figure 4). The outpatient procedure is then terminated, and the patient returns 6 to 9 months later for a standard Fowler-Stephens orchiopexy.
Experience at Vanderbilt Children's Hospital
Our experience using initial endoscopy for evaluation and management of boys with nonpalpable testis recently has been reported elsewhere.8 This was a combined report from the pediatric surgical and urological services. Thirty-five boys were evaluated over a 4-year period beginning in 1988. Eleven were found to have an intra-abdominal testis of which seven could be brought into the scrotum using a standard single-stage orchiopexy. However, four had short testicular vessels, and in these patients, a two-stage Fowler-Stephens orchiopexy with initial endoscopic clip ligation was used with 100% success. In the remaining patients in whom an intraabdominal testis was not found, testicular atrophy was thought to have occurred either for hormonal reasons or due to prenatal torsion.
Diagnostic peritoneoscopy can be used through 3mm and 5-mm umbilical incisions for the evaluation of the contralateral inguinal region for children with a unilateral inguinal hernia and for the evaluation of boys with a nonpalpable testis. No complications have been noted in patients undergoing diagnostic laparoscopy, which affords an excellent chance to define a better management strategy for these patients.
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