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Laparoscopy for Contralateral Patent Processus Vaginalis (CPPV) and Non-Palpable Testis George W. Holcomb, III, M.D., MBA Children’s Mercy Hospitals and.

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Presentation on theme: "Laparoscopy for Contralateral Patent Processus Vaginalis (CPPV) and Non-Palpable Testis George W. Holcomb, III, M.D., MBA Children’s Mercy Hospitals and."— Presentation transcript:

1 Laparoscopy for Contralateral Patent Processus Vaginalis (CPPV) and Non-Palpable Testis George W. Holcomb, III, M.D., MBA Children’s Mercy Hospitals and Clinics Kansas City, Missouri

2 The Child with a Unilateral Hernia What about the other side? J.Ped. Surg. 29: , 1994 J.Ped. Surg. 31: , 1996 Urology 51: , 1998

3 Unilateral Hernia Unilateral hernia repair only Bilateral exploration and repair Goldstein Test Unilateral hernia repair and diagnostic laparoscopy Laparoscopic hernia repair Options

4 Unilateral Hernia Repair Only Advantages Repairs known disease No contralateral incision or complications Disadvantages % return for contralateral repair

5 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

6 Bilateral Exploration and Repair Advantages % have CPPV Avoids need for possible second anesthesia and operation Disadvantages % do not have CPPV ? Increase injury to spermatic cord

7 Contralateral Inspection

8 Ambiguous Findings Geiger, JD - J Pediatr Surg 35: , 2000

9 Study May 1, 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: , 2006

10 May 1, 1992 – January 1, 2003 Total Number of Patients1870 Known Bilateral Hernia194 No lap.; Tech. Reasons73 Total Number Scoped1603

11 1603 Patients Unilateral herniaBilateral disease (60%) (40%)

12 1603 Patients Physical Exam #Patients suspected on exam to have CPPV#Patients suspected on exam to have CPPV #Patients with CPPV#Patients with CPPV (43%)

13 1603 Patients Physical Exam #Patients suspected on exam not to have CPPV #Patients without CPPV (61%)

14 Laparoscopy for CPPV 1603 Patients 643 with CPPV 55 (8.5%) positive Goldstein test

15 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

16 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 Hospital Kansas City, Missouri APSA 2003 J Pediatr Surg 39: , 2004

17 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

18 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

19 Methods

20

21 Motives for parents’ decision Last 113 patients requesting contralateral inspection (either exploration or laparoscopy)

22 Results J Pediatr Surg 39: , 2004

23 Results Parents’ 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 exploration J Pediatr Surg 39: , 2004

24 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

25 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: , 2004

26 ? ? Questions ? ?

27 Laparoscopy For The Non-palpable Testis

28 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

29 Viability of testis with staged orchiopexy based on collateral vessels around vas deferens Non-palpable Testis

30 Laparoscopy Blind endingAttenuatedTestis vessels; no testisvessels; no testis No furtherInguinalViable Atrophied exploration exploration to needed excise remnantOrchiectomy Single stage Staged orchiopexy orchiopexy (vessels ligated initially) Holcomb, et al: Laparoscopy for the Nonpalpable Testis. Am Surg. 60:143-7, 1994.

31 Non-palpable Testis Diagnostic Laparoscopy Blind ending vessels and vas No further therapy

32 Non-palpable Testis Diagnostic Laparoscopy Attenuated vessels - No testis Inguinal exploration to excise remnant

33 Non-palpable Testis Diagnostic Laparoscopy Intra-abdominal testis Staged procedure vs one stage laparoscopic orchiopexy

34 Non-palpable Testis Staged Orchiopexy One 5 mm umbilical cannula Two 2.5 mm stab incisions

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36 CMH Experience 1998 – 2005 Group 1 Standard lap. orchiopexy 31 orchiopexies/ 22 pts 93.8% success Group 2 Single or 2-stage FS orchiopexy 30 orchiopexies/23 pts (8 one stage, 22 two stage) 83.3% success 61 laparoscopic orchiopexies/ 45 patients

37 CMH Experience Group 1 (2/32) – 6.3% Group 2 (4/24) – 16.7% Atrophy

38 Prospective Randomized Trial 1 Stage vs 2 Stage F.S. Laparoscopic Orchiopexy Non-palpable testis Can not reach contralateral internal ring Pilot study - 30 patients

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