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

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. Geiger, JD - J Pediatr Surg 35:1151-1154, 2000
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 Patients 1870
Known Bilateral Hernia 194
No lap.; Tech. Reasons 73
Total Number Scoped 1603

11. 1603 Patients
Unilateral hernia Bilateral disease
(60%) (40%)

12. 1603 Patients Physical Exam
446
192
(43%)
#Patients suspected on exam to have CPPV
#Patients with CPPV

13. 1603 Patients Physical Exam
#Patients suspected on exam not to have CPPV
#Patients without CPPV
1157
706
(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. Methods

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

22. Results
J Pediatr Surg 39: , 2004

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

30. 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.

31. Diagnostic Laparoscopy
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

36. 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

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

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

39. www. centerforprospectiveclinicaltrials. com www