P123 TAPP - THE BEST APPROACH FOR INGUINAL HERNIA ASSOCIATED WITH ADULT CRYPTORCHIDISM: CASE REPORT AND LITERATURE REVIEW

Aim Cryptorchidism is a rare condition of adult male. The diagnosis is based on examination: impalpable testis and CT/MRI. The surgical correction of cryptorchidism is possible in childhood, but in adult orchiectomy is recommended, considering the malignancy risk. The association with hernia is uncommon. Material and Methods We report the case of a 23 years old male with left inguinal hernia and concomitant left cryptorchidism. MRI revealed the intra-abdominal left testicle, with reduced size and short vessels. Lab analysis were normal. We underwent laparoscopic exploration: the left testicle was small and had pelvic localization. A large inguinal hernia was also confirmed. We decided to perform laparoscopic TAPP (transaabdominal preperitoneal repair) and left orchiectomy. The evolution was uneventful and patient discharged 1st day postoperatively. Histology revealed testicular atrophy with no malignancy, also no spermatogenesis was present. No recurrence was found during follow-up. Results Cryptorchidism in adult is rare. The association with hernia is even more rare. The open management is not easy, often in pelvic/abdominal localization, the inguinal approach can be cumbersome. There is no standard of care for these cases, but we found the minimally invasive approach to be a good choice. Laparoscopic surgery has the advantage of enhanced exploration and orhidectomy can be easily performed. Associated with the orchidectomy, hernia cure can be facilitated by laparoscopic TAPP procedure. Conclusions In cases of concomitant hernia and cryptorchidism, we emphasize the idea of simultaneously cure hernia via laparoscopic TAPP procedure associated with orchidectomy as feasible and safe.

Spigelian hernia with bilateral undescended (impalpable) testis in a child: rare scenario

Spigelain hernia (SH) is rarely seen in children. Various mechanisms has been described for the co-existence with cryptorchidism. A 4 month old boy, a known case of bilateral impalpable testes and intermittent right lower abdominal swelling was brought to paediatric emergency with complaints of excessive cry, poor feeding and irreducible right lower abdominal swelling - the swelling was a little higher than the usual inguinal hernia. On exploration, SH was seen coming off the deep ring then turning around the conjoint tendon and dissecting between internal oblique and external oblique aponeurosis. The hernia contained oedematous but viable gut with compression over the testicular vessels. Gut was viable. The testes was mobilized and fixed into the scrotum. Left testis was impalpable for which nubbin excision was done at a later date. A SH in the lower abdomen may be confused with a high inguinal hernia. In acute obstruction, emergent exploration and reduction is the cornerstone of treatment.

Laparoscopy and the impalpable testes: diagnosis, treatment options and the literature

Background: Laparoscopy is the best available tool and method to manage impalpable undescended testes; management of the impalpable testis often pose a significant diagnostic and therapeutic challenge to a surgeon. The aim of this work was to elucidate and present the sensitivity and the value of laparoscopy, as a surgeon’s tool, for the diagnosis and treatment of the impalpable testis.Methods: From November 2015 to December 2018, 56 patients with 60 impalpable testes were operated upon by laparoscopic approach by a single surgeon. One-stage Fowler-Stephens laparoscopic orchidopexy was performed in 14 cases, while two-stage Fowler-Stephens laparoscopic orchidopexy was performed in 16 cases and Vessel-Intact Laparoscopic Orchidopexy (VILO) was done in 22 cases. In 2 cases vessel and vas was entering through deep ring and inguinal orchidopexy was done. Blind ending vessel/vas was noticed in 4 cases (vanishing/absent testes). Laparoscopic orchidectomy was required in 2 patients for nubin. No case of disorder of sexual dysfunction was (DSD) was found.Results: Laparoscopy was successfully completed in all the cases. 34 testicles were impalpable on right side, 18 on left side and other 4 cases (8 testicles) were bilaterally impalpable. Laparoscopic orchidopexy was carried out for 36 testes at the same. 16 needed a staged procedure. Orchidectomy was done in 2 cases/testes. In 4 cases testes was absent/vanishing. In 2 cases testes was canalicular, standard inguinal orchidopexy was done. The mean operative time was 48 minutes. Patients were allowed oral fluids 6 hours of the operation and were discharged at one day after the procedure. None of the patients had wound infection. Patients were followed up for a mean period of 12 months. At follow-up, all but one of the testes were well down in the bottom of the scrotum. In one patient, the testis was in a high scrotal position. All testes were of normal size, no atrophy was seen so far and no malignant change is suspected in any case so far. No severe morbidity or death was observed in our study.Conclusions: Laparoscopy offers surgeons a safe and reliable diagnostic and therapeutic option to patients with impalpable testes. No other imaging investigation is required, if well versed with basic laparoscopy. Intra-abdominal dissection allows more testes to be brought down to the scrotum. Even when open orchidopexy is being done for intra-canalicular testes in a child, it is advisable to be ready with laparoscopy if necessary, at the same time, in case open surgery fails to mobilize the testicular vessels adequately. The procedure is best viewed as laparoscopy-assisted; as Orchidopexy has to be done in a conventional manner.

Laparoscopic orchidopexy and its outcome in the management of nonpalpable testis

Background: Management of impalpable testis represents a significant diagnostic and operative challenge. The aim of this work was to present the superior value of laparoscopy as a single tool for the diagnosis and treatment of impalpable testis.Methods: 51 patients with 58 nonpalpable were included in our study. Study design was case series. We have conducted this study at Surat Municipal Institute for Medical Education and Research, Surat. For each patient laparoscopy orchidopexy was performed and either testis or blind ending cord structure are searched for. The testis either brought down to the scrotum or removed depending on the condition. The patients were followed up for 12 months.Results: On diagnostic laparoscopy the number of testis found normal 54, followed by 3 hypoplastic and 1 atrophic. There were 8 testis found to be present at high intraabdominal (>2 cm from deep ring), 46 were present at low intra-abdominal (<2 cm from deep ring), intracanalicular 4. Postoperative complication included minor wound infection in one patient, none of them were diagnosed scrotal hematoma, port site hernia, and testicular atrophy.Conclusions: Laparoscopy seems to offer a safe and reliable diagnostic and therapeutic option to patients with nonpalpable testis. Intraabdominal dissection allows more testis to be brought down to scrotum. Laparoscopy clearly demonstrate the anatomy and provide visual information upon which a definitive decision can be made.

Role of Laparoscopy in Management of Nonpalpable Undescended Testis in Children

Background Normal testicular descent relies on a complex interplay of numerous factors. Any deviation from the normal process can result in an undescended testis (UDT). UDT is a common abnormality that carries fertility and malignancy implications. Aim of the Work The aim of this study is Evaluation of the role of laparoscopy in diagnosis and management of clinically impalpable testis. Patients and Methods Nineteen male patients were included in this study with twenty two non-palpable testes. All these patients were subjected to diagnostic laparoscopy & the subsequent decision was then based on the laparoscopic finding. There was no age limit for the procedure. The procedure was carried in Ain Shams University teaching hospital and El-mataria teaching hospital. Results The study included nineteen patients with twenty two non-palpable testes. Age at presentation was averaging 18.5 ± 12.5 months. Our study may present convincing evidence that laparoscopy has significant advantage over imaging procedures. Preoperative imaging proved inaccurate in determining testicular position in 10 of the 22 testes (45.5%) this is in agreement with many studies which reported that ultrasonography helped to identify only 45% of non palpable testis. Conclusion This study tried to assess roughly the effectiveness of laparoscopy as a diagnostic tool and treatment of non-palpable undescended testis. This study dealt with a very small number of patients and this issue still needs more researches to study all the benefits and disadvantage and shall need further study on a wide range of patients.

Crossed Testicular Ectopia in a 65-year-old man

Crossed testicular ectopia (CTE) is an extremely rare anomaly in which deviation of testicular descent results in unilateral location of both testes. It usually presents as an inguinal hernia on the side of a fully descended testis and an impalpable testis with undeveloped hemiscrotum on the contralateral side. Most often the diagnosis of CTE is not made until surgical exploration. Few reports are available regarding CTE in infants or younger children. Though the patients of CTE usually present at a younger age, we report a case of crossed testicular ectopia in a 65-year-old male who was admitted in the department of surgery, Shaheed Suhrawardi Medical College Hospital (ShSMCH) with right sided inguinal hernia. Journal of Surgical Sciences (2015) Vol. 19 (1) : 39-41

Five different cases of ectopic testes in children: a self-experience with literature review

BackgroundEmpty scrotum may be due to many reasons; besides true undescended testis these are monorchia, retractile testis, atrophy of testis due to torsion and ectopic testis. The location of testis in an aberrant site after passing through the inguinal canal and leaving it via external ring is a condition called ectopic testis. The most common aberrant locations of ectopic testes are superficial inguinal pouch (Denis Browne pouch), within anterior abdominal wall, perineum, femoral canal, contralateral scrotum (transverse testicular ectopia) and prepenile area.MethodsDescription of management of five different cases of ectopic testes over a period of 10 years’ experience in pediatric surgery have been done with review of the literature about this rarity.ResultsFive different cases of ectopic testes were as follows: infants 3 months of age with right ectopic testis in anterior abdominal wall near anterior superior iliac spine, 4 months of age with left perineal testis, 6 months of age with an ectopic femoral testis on left side, 8 months of age with transverse testicular ectopia on left side and 10 months of age with right true undescended testis and left perineal testis.ConclusionsSearch for ectopic sites of testes should always be in mind during examination of patients with empty scrotum. Early surgical repair of ectopic testes is recommended, as there is no chance of spontaneous correction to the normal location. Long-term follow-up is necessary due to relatively high incidence of infertility and malignant transformation. Surgeons should be aware of the rare possibility of transverse testicular ectopia in cases of inguinal hernia with impalpable testis on the contralateral side.

Impalpable Testis: Evaluation of Diagnostic and Treatment Procedures and Our Treatment Protocol

Introduction. The aim of this study is to present our treatment protocol for impalpable testis. Material and Methods. In a retrospective study we analyzed clinical data including diagnostic procedures, intraoperative findings, final diagnosis, treatment modality, and outcome of patients with impalpable testis who underwent surgery from January 2010 until December 2015. Results. Ninety-one patients were admitted under the diagnosis of impalpable testis. In 39 patients ultrasound detected testis in the inguinal canal and orchidopexy was done. In 25 patients (48.08%) laparoscopy showed the entrance of the spermatic cord into the inguinal canal. Open exploration of the inguinal canal was done, testicular remnant removed, and appropriate testicular prosthesis implanted. Twenty patients (20/52) underwent orchidopexy of the abdominal testis (46.51%), 4 of which underwent Fowler-Stevens procedure in two stages, and in 16 patients deliberation of the testis and spermatic cord was sufficient to place the testis into the scrotum. Conclusions. Excision of the testicular nubbin is highly recommendable, as well as implantation of the testicular prosthesis at the time of orchiectomy.