Laparoscopy for Contralateral Patent Processus Vaginalis (CPPV by HC111210012649


									 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

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

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

• No contralateral
  incision or
   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
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
Contralateral Inspection
  Ambiguous Findings

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

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

          1603 Patients
           Physical Exam

• #Patients suspected on
  exam not to have CPPV     1157

• #Patients without          706
    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

• Parental views regarding this issue have
  not been sought
• 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
• Motives for parents’ decision

• Last 113 patients requesting
  contralateral inspection (either
  exploration or laparoscopy)
                                                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
 Parents’ reasons for wanting to evaluate
           the contralateral side
• 90 parents: convenience
• 21 parents: concerns about a second
• 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
• 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

• The vast majority of those desiring
  contralateral evaluation preferred using
  laparoscopy as opposed to a contralateral

• 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
               Non-palpable Testis
Blind ending         Attenuated                       Testis
vessels; no testis   vessels; no

No further           Inguinal       Viable            Atrophied
exploration          exploration to
needed               excise remnant                   Orchiectomy

                     Single stage         Staged orchiopexy
                     orchiopexy           (vessels ligated
                         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
• Staged procedure
  vs one stage
         Non-palpable Testis
          Staged Orchiopexy

• One 5 mm
  umbilical cannula

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

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

        93.8% success      83.3% success
      CMH Experience
           1998 - 2005

   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

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