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Laparoscopy for Inguino-scrotal Conditions in Children

Posted by : Dr. Rasik S. Shah, 26 Feb 2013 12:14 AM
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Laparoscopy for Inguino-scrotal Conditions in Children
Dr. Rasik Shah, Dr. Pankaj Shroff, Dr.Ravi Ramadwar

Laparoscopic surgery in children is indicated for a variety of inguino-scrotal conditions namely inguinal hernia, non palpable undescended testis and varicocele.

Laparoscopy for Inguinal Hernia:

Inguinal hernias in children are almost exclusively indirect type. Those rare instances of direct inguinal hernia are caused by previous surgery and floor disruption. An indirect inguinal hernia protrudes through the internal inguinal ring, within the cremaster fascia, extending down the spermatic cord for varying distances. The direct hernia protrudes through the posterior wall of the inguinal canal, medial to deep inferior epigastric vessels, destroying or stretching the transversalis fascia.

Approximately 1-3% of children have a hernia. For infants born prematurely, the incidence varies from 3-5%. If a loop of bowel becomes entrapped (incarcerated) in a hernia, the patient develops pain followed by signs of intestinal obstruction. If not reduced, compromised blood supply (strangulation) leads to perforation and peritonitis. Most incarcerated hernias in children can be reduced.

Laparoscopic repair of inguinal hernia in children remains controversial even today. 

In favour of open repair of Inguinal Hernia-
• Need of laparoscopic equipment and expertise, which translates into higher cost.
• Open repair is extraperitoneal compared to laparoscopic repair, which is transperitoneal.
• In laparoscopic repair of inguinal hernia, controlled general anesthesia is required as compared to open surgery which can be completed by laryngeal mask and caudal block. 
• There is reported higher rate of recurrence in the literature in reference to the suture technique of laparoscopic repair of inguinal hernia.
• More time consuming compared to open repair.

In favour of laparoscopic repair of Inguinal Hernia-
• It is possible to inspect the opposite inguinal ring and if open, it can be repaired in the same operation. The incidence of contralateral patent processus vaginalis ranges between 10-30 %. The life time incidence of development of the contralateral hernia is approximately 15 %. So by performing laparoscopic repair one can avoid future possibility of second surgery.
• As repair is done under magnification, the incidence of injury to vas and vessels is less compared to the open surgery.
• As repair is done at the internal ring, the highest point where sac meets the peritoneum, recurrence is less likely to occur by leaving behind or missing the hernial sac. 
• The disruption of lymphatics and venous drainage is less in laparoscopic repair compared to open surgery and hence scrotal edema is less after the laparoscopic repair. The disruption of venous drainage is one of the causes of testicular atrophy, so incidence of testicular atrophy is less after laparoscopic repair.
• The laparoscopic anatomy always remains the same and there is no struggle to find the hernial sac even in patients who present with the communicating hydrocele. 
• In the published literature, the incidence of higher recurrence rate after laparoscopic repair of inguinal hernia is associated with “Only suture closure of the internal ring”. To tackle this higher recurrence rate the authors advocate IDES technique (Incision, Dissection, Excision and Suture). The incidence of recurrence rate with this technique in the hands of authors remains at 0 % in the series of 180 cases (unpublished data). 
• The access trauma with laparoscopic inguinal hernia repair is less than the open surgery.
• Inguinal hernia in girls have higher incidence of bilaterality (upto 60%) and in laparoscopic repair both sides can be repaired in the same operation with the same trocar placement.
• In girls with inguinal hernia there is a 1% incidence of male pseudohermaphordite (testicular feminization syndrome) and this can be easily diagnosed laparoscopically. In open repair it is recommended to evaluate the patient by performing Barr body, Ultrasound and Karyotyping before surgery. This can be avoided if the repair is performed laparoscopically.

“Author recommends - IDES laparoscopic repair in patients with inguinal hernia and communicating hydrocele.”

Laparoscopy for Undescended Testis:
The undescended testis is a condition where the testis cannot be manually manipulated into the base of the scrotum. In arrested descent, they may be found any where along the path of descent from the kidneys to the internal inguinal ring. Undescended testes occur in approximately 3% of term boys and in up to 33% of preterm boys. The majority of testes descend within the subsequent 3 months, resulting in an incidence of 0.8% undescended at 1 year. The testis is unlikely to descend after this time.

A patent processus vaginalis or true hernial sac will be present 90% of the time. The undescended testis found in 0.8% of males can be palpable (80% - most at inguinal canal) or  non-palpable (20%). Testes that can be manually brought to the scrotum are retractile and need no further treatment.

Parents should know the objectives, indications and limitations of an orchiopexy: testis could not exist (testicular vanishing syndrome) even after descend can atrophy that it cannot be fixed and removal is a therapeutic possibility. To improve spermatogenesis (producing an adequate number of spermatozoids) surgery should be done before the age of two. Electron microscopy has confirmed an arrest in spermatogenesis (reduced number of spermatogonias and tubular diameter) in undescended testis after the first two years of life. In all palpable undescended testis, the standard open orchiopexy is recommended. In all clinically non-palpable undescended testis laparoscopy is recommended.

Timing of Laparoscopy: 
In a newborn, if the testis is not palpable then the recommendation is to wait for atleast 6 months for the testis to descent naturally. If testis does not descend in first six months of life then it is unlikely to descent on its own and needs surgical management.Currently the recommended age for a child to undergo orchiopexy is around the age of one year. But if the operating surgeon and the anesthesiologist are comfortable, laparoscopic orchiopexy can be safely performed any time after the age of 6 months.

Advantages of laparoscopy in undescended testes:
• Diagnostic and therapeutic – Gold standard for non-palpable undescended testis
• Precise and thorough intra abdominal dissection possible
• Both testes can be managed simultaneously with relative ease

Laparoscopy for Varicocele in children:
Varicocele is defined as an abnormal dilatation of testicular veins in the pampiniformis plexus caused by venous reflux. Venous reflux into the plexus pampiniformis is diagnosed using Doppler colour flow mapping in the supine and upright position.

It is unusual in boys under 10 years of age and becomes more frequent at the beginning of puberty. It is found in 15%-20% of adolescents, with a similar incidence during adulthood. It appears mostly on the left side (78%-93%). Right-sided varicoceles are usually noted only when bilateral varicoceles are present and seldom occur as an isolated finding.

Varicocele develops during accelerated body growth by a mechanism that is not clearly understood. Varicocele can induce apoptotic pathways because of heat stress, androgen deprivation and accumulation of toxic materials. Severe damage is found in 20% of adolescents affected, with abnormal findings in 46% of affected adolescents. Histological findings are similar in children, adolescents and in infertile men. In 70% of patients with grade II and III varicocele, left testicular volume loss was found. Several authors reported on reversal of testicular growth after varicocelectomy in adolescents. However, this may partly be attributable to testicular oedema associated with the division of lymphatic vessels. In about 20% of adolescents with varicocele, fertility problems will arise. Improvement in sperm parameters has been demonstrated after adolescent varicocelectomy.

Varicocele is mostly asymptomatic and is classified into 3 grades: 
Grade I - Valsalva positive (palpable at Valsalva manoeuvre only), 
Grade II - palpable (palpable without the Valsalva manoeuvre), 
Grade III - visible (visible at distance)
The size of both testicles should be evaluated during palpation to detect a smaller testis.

The recommended indication criteria for varicocelectomy in children and adolescents are:
• Varicocele associated with a small testis
• Additional testicular condition affecting fertility
• Bilateral palpable varicocele
• Pathological sperm quality (in older adolescents)
• Varicocele associated with a supranormal response to LHRH stimulation test
• Symptomatic varicocele
• Repair of a large varicocele physically or psychologically causing discomfort may be also considered. 
Other varicoceles should be followed-up until a reliable sperm analysis can be performed. 

Potential benefits of appropriate diagnosis and treatment of varicocele in children and adolescents
• Normal sexual function
• Preservation of fertility

Therapy:
Surgical intervention is based on ligation or occlusion of the internal spermatic veins. Ligation is performed at different levels:
• Inguinal (or subinguinal) microsurgical ligation
• Suprainguinal ligation, using open or laparoscopic techniques

The advantage of the former is the lower invasiveness of the procedure, while the advantage of the latter is a considerably lower number of veins to be ligated and safety of the incidental division of the internal spermatic artery at the suprainguinal level. For surgical ligation, some form of optical magnification (microscopic or laparoscopic magnification) should be used because the internal spermatic artery is 0.5 mm in diameter at the level of the internal ring. The recurrence rate is usually less than 10%. Lymphatic-sparing varicocelectomy is preferred to prevent hydrocele formation and testicular hypertrophy development and to achieve a better testicular function.
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