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

The Child with a Unilateral Hernia What about the other side? J.Ped. Surg. 29:970-974, 1994 J.Ped. Surg. 31:1170-1173, 1996 Urology 51:480-483, 1998

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

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 Inspection

Geiger, JD - J Pediatr Surg 35:1151-1154, 2000 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 Patients Physical Exam 446 192 (43%) #Patients suspected on exam to have CPPV #Patients with CPPV

1603 Patients Physical Exam #Patients suspected on exam not to have CPPV #Patients without CPPV 1157 706 (61%)

Laparoscopy for CPPV 1603 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 Hospital Kansas City, Missouri APSA 2003 J 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 J Pediatr Surg 39:480-482, 2004

Parents’ reasons for wanting to evaluate the contralateral side 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 39:480-482, 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, 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

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

Non-palpable Testis Laparoscopy Blind ending Attenuated Testis vessels; no testis vessels; no testis No further Inguinal Viable Atrophied exploration exploration to needed excise remnant Orchiectomy Single stage Staged orchiopexy orchiopexy (vessels ligated initially) Holcomb, et al: Laparoscopy for the Nonpalpable Testis. Am Surg. 60:143-7, 1994.

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

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

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

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

61 laparoscopic orchiopexies/ 45 patients CMH Experience 1998 – 2005 61 laparoscopic orchiopexies/ 45 patients 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

CMH Experience 1998 - 2005 Atrophy Group 1 (2/32) – 6.3% Group 2 (4/24) – 16.7%

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

www. centerforprospectiveclinicaltrials. com www www.centerforprospectiveclinicaltrials.com www.cmhcenterforminimallyinvasivesurgery.com