Page 14 - Laparoscopic Surgery Online Journal

Ved Bhaskar, Manash Ranjan Sahoo

vessel clipping followed several months later by extended the scrotum. Dissection was continued cranially as far as
inguinal or transabdominal orchidopexy. 7 In our current necessary to gain enough length of the spermatic vessels to
series, laparoscopic management of these testes yielded allow tension free orchiopexy (Fig. 2). Then the peritoneum
success in 48 of the 48 cases (100%). Orchidectomy was superior to the vas deferens was incised to gain additional
done for the remaining two patients as they had atrophied vasal length. Periodically the testis was moved toward
testes and they belonged to postpubertal age group. the contralateral internal ring as an average estimate of
In our series, technique consisted in sectioning the whether sufficient length had been attained to move it to
gubernaculum (when present), opening the peritoneum the scrotum (Fig. 3).
laterally to the spermatic vessels, and mobilizing the A neo-ring was then created just lateral to the medial
testicular vessels and the vas deferens in a retroperitoneal umbilical ligament. The endodissector was driven out of
position for 8 to 10 cm. In our technique the vas avoided the scrotal incision, guided by an index finger invaginating
going around the inferior epigastric vessels, thereby gaining the scrotum (Fig. 4). A small scrotal incision was made and
at least 2 to 3 cm of extra length. This route gives a direct a dartos pouch developed. A Kelly’s forceps was introduced
approach to the scrotum. So by using this neo-inguinal canal from the scrotal incision through this new ring into the
route we could mobilize all the testes to scrotum. The greater abdomen (Fig. 5), and grasped the testis, ensuring that only
degree of success with the laparoscopic procedure may be the gubernacular tissue was held (Fig. 6). It is inadvisable
because of the magnification used which may have led to to grab the vas or the advential tissues around the epididymis,
better preservation of small collateral vasculature. as this can crush the delicate blood supply
(Fig. 7). The neo-ring was narrowed using one or two
MATERIALS AND METHODS

This procedure was carried out in Department of General
Surgery, SCB Medical College, Cuttack over a period of
7 years from 2005 to 2012 using laparoscopic approach and
patients were followed up regularly. Then a retrospective
analysis after collection of all the data from medical records
was done. One important point to be noted here is that the
main author being a general surgeon usually got cases which
were of somewhat higher age group as compared to most
other studies which are conducted in pediatric surgery
departments. Most of the cases were postpubertal males in
whom testis was nonfunctional. They had mainly come for
psychological and cosmetic reasons.
A risk bond for surgery and a formal consent for
orchidectomy were taken in all cases. The bladder was
Fig. 1: Beginning of testicular mobilization
emptied using a urethral catheter. Diagnostic laparoscopy
was then performed through an optic port introduced
through 11 mm supraumbilical incision. The entire
abdomen was inspected and various anatomical landmarks
identified. The peritoneal cavity was insufflated with
carbon dioxide to a maximum pressure of 12 mm Hg.
If an intra-abdominal or ‘peeping’ testis was found, two
accessory working trocars 6 mm were placed at the level
of umbilicus in the midclavicular line on either side of the
abdomen under direct vision.
With gentle traction on the testis, using the harmonic
scalpel the most distal gubernacular attachment was divided
(Fig. 1). The peritoneum overlying the spermatic vessels is
then incised. This incision frees the testicular vessels from
the posterior peritoneal attachments and provides the
additional length for proper mobilization of the testis into Fig. 2: Mobilization continued
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