Laparoscopic Orchidopexy

This video will demonstrate a laparoscopic orchiopexy for a right undescended abdominal testicle. Laparoscopy is essential for the accurate diagnosis and optimal management of a non palpable undescended testicle. When this condition is diagnosed, one of 3 possibilities will be confirmed on laparoscopy. The first is an abdominal testicle, as seen on the left. In this case, laparoscopy is also used to treat the condition. The second is a blind ending vast as seen in the middle photo. This confirms the absence of a testicle precluding further exploration. The third possibility is the demonstration of a vast deference in testicular vessels exiting the deep ring as shown on the right. This warrants continuing with an inguinal exploration. When an abdominal testicle is found, a number of options are available to the surgeon, including a single-stage laparoscopic orchiopexy without vessel ligation, a one or two-stage Fowler-S Stevens procedure with vessel ligation, and the newer Shehata traction orchiopexy. In this 14 month old boy with a non palpable right testicle, an abdominal testicle was found just proximal to the deep ring. A single stage orchiopexy was performed. The procedure is performed using a single 5 millimeter trocar at the umbilicus for the camera and two lateral stab incisions on the right and left sides at or just below the level of the umbilicus for 3 millimeter instruments. The mobilization of the testicle starts with stretching the gubernaculum and clearly visualizing the vast deference. The gubernaculum is divided as far away as possible from the vase to untether the testicle. The vast should be kept in view at all times as this step is completed. The surgeon should also keep in mind the possibility of a long looping vass. Grasping the peritoneal edge to provide traction, the vas is then mobilized using blunt and sharp dissection with fine shears in a lateral to medial direction approaching the wall of the bladder. Next, the testicular vessels are mobilized by dividing the retroperitoneal attachments. This is where most of the length will be gained. If the mobilized testicle is able to reach the contralateral ring as shown here, it is likely to reach the scrotum without further mobilization. A darto's pocket is developed in the right scrotum. And a needle and sheath trochar is introduced from this pocket into the abdominal cavity. The point of entry should be between the epigastric vessels and bladder edge, just over the pubic tubercle. A full bladder actually aids in safe entry into the abdomen. Following entry into the abdomen, a 10 millimeter trochar is introduced through this sheath to dilate the tunnel. The testicle is then grasped by the gubernaculum and brought through the trochar, taking care to keep it oriented correctly with the vast medial and vessels lateral. It's fixed in the dartto's pouch using a slow absorbable suture. It is not necessary to close the deep ring, as the incidence of inguinal hernia after laparoscopic orchiopexy is extremely low. The outcome of the procedure is shown here. At 2 weeks, a tethering can be seen in the scrotum. At 2 years, this tethering is mostly resolved, and a testicle of normal caliber is easily visible and palpable in the right scrotum.