Laparoscopy for Contralateral Patent Processus Vaginalis (CPPV by HC111210012649

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									 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
The Child with a Unilateral Hernia


   What about the other side?




                  J.Ped. Surg. 29:970-974, 1994
                  J.Ped. Surg. 31:1170-1173, 1996
                  Urology 51:480-483, 1998
           Unilateral Hernia
                Options

• Unilateral hernia repair only
• Bilateral exploration and repair
• Goldstein Test
• Unilateral hernia repair and diagnostic
  laparoscopy
• Laparoscopic hernia repair
Unilateral Hernia Repair Only

Advantages           Disadvantages
• Repairs known      • 10 - 30% return for
  disease              contralateral repair

• No contralateral
  incision or
  complications
   Unilateral Hernia Repair with
     Diagnostic Laparoscopy
Advantages                 Disadvantages
• Selects contralateral    • Uncertain which
  repair for those with      child with CPPV will
  CPPV                       return with
                             symptomatic hernia
• Less than 1% false-
  positive contralateral
  explorations
Bilateral Exploration and Repair
     Advantages         Disadvantages

• 10 - 30% have     • 70 - 90% do not have
  CPPV                CPPV
                    • ? Increase injury to
• Avoids need for     spermatic cord
  possible second
  anesthesia and
  operation
Contralateral Inspection
  Ambiguous Findings




Geiger, JD - J Pediatr Surg 35:1151-1154, 2000
            Study

May 1, 1992 - To evaluate the role
of diagnostic laparoscopy in the
child less than age 10 years with a
known unilateral inguinal hernia

                      IPEG 2005
                      JLAST 16:650-653, 2006
May 1, 1992 – January 1, 2003

Total Number of Patients   1870

Known Bilateral Hernia     194

No lap.; Tech. Reasons      73

Total Number Scoped        1603
          1603 Patients

Unilateral hernia   Bilateral disease
       960               643
     (60%)             (40%)
            1603 Patients
            Physical Exam
• #Patients suspected on
  exam to have CPPV           446


• #Patients with CPPV         192

                            (43%)
          1603 Patients
           Physical Exam

• #Patients suspected on
  exam not to have CPPV     1157

• #Patients without          706
  CPPV
                           (61%)
    Laparoscopy for CPPV
             1603 Patients

• 643 with CPPV

• 55 (8.5%) positive Goldstein test
     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
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 39:480-482, 2004
       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
                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
Methods
Methods
               Methods
• Motives for parents’ decision

• Last 113 patients requesting
  contralateral inspection (either
  exploration or laparoscopy)
                        Results
                                                No. of parents
                                               choosing this option

Repair the known unilateral hernia only                12

Repair the known unilateral inguinal hernia            13
and explore the contralateral region with
CPPV repair if indicated

Repair the known unilateral inguinal hernia,          142
perform laparoscopy through the known
hernia sac and repair the CPPV if one is
found at laparoscopy
Total                                                 167

                                     J Pediatr Surg 39:480-482, 2004
                  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 39:480-482, 2004
              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
             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 39:480-482, 2004
? ? Questions ? ?
Laparoscopy For The
 Non-palpable Testis
        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
         Non-palpable Testis


• Viability of testis
  with staged
  orchiopexy based
  on collateral
  vessels around vas
  deferens
               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.
Non-palpable Testis
Diagnostic Laparoscopy




 • Blind ending vessels and vas
 • No further therapy
         Non-palpable Testis
         Diagnostic Laparoscopy

• Attenuated vessels -
  No testis
• Inguinal exploration
  to excise remnant
       Non-palpable Testis
       Diagnostic Laparoscopy

• Intra-abdominal
  testis
• Staged procedure
  vs one stage
  laparoscopic
  orchiopexy
         Non-palpable Testis
          Staged Orchiopexy

• One 5 mm
  umbilical cannula


• Two 2.5 mm stab
  incisions
                CMH Experience
                  1998 – 2005
    61 laparoscopic orchiopexies/ 45 patients
           Group 1                  Group 2
Standard lap. orchiopexy   Single or 2-stage FS
                              orchiopexy

31 orchiopexies/ 22 pts    30 orchiopexies/23 pts
                           (8 one stage, 22 two stage)

        93.8% success      83.3% success
      CMH Experience
           1998 - 2005
                Atrophy

   Group 1               Group 2
(2/32) – 6.3%         (4/24) – 16.7%
Prospective Randomized Trial
           1 Stage vs 2 Stage F.S.
          Laparoscopic Orchiopexy

• Non-palpable testis

• Can not reach contralateral internal ring

• Pilot study - 30 patients
www.centerforprospectiveclinicaltrials.com
www.cmhcenterforminimallyinvasivesurgery.com

								
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