CHAPTER 31 Cryptorchidism
Step 1: Surgical Anatomy
♦ An indirect inguinal hernia is often associated with cryptorchidism, and the hernia sac is usually thin and fragile.
♦ The undescended testis may be located in the peritoneal cavity, in the inguinal canal (intracanalicular), emerging from the external annulus, in the superficial inguinal pouch, ectopic, or absent.
Step 2: Preoperative Considerations
♦ The optimal timing of operation is at about 1 year of age; however, some surgeons advocate as early as 3 to 6 months.
♦ If the testis is nonpalpable, a preoperative ultrasound may identify a testis in the inguinal canal, thus avoiding laparoscopy. Magnetic resonance imaging and computed tomography are rarely helpful in identifying intra-abdominal testes, and laparoscopy is generally the most appropriate next step if the ultrasound fails to reveal a testis.
♦ In the case of bilateral nonpalpable testes, a positive testosterone response to human chorionic gonadotropin stimulation and low serum levels of follicle-stimulating hormone and inhibin B and the presence of serum müllerian inhibiting substance confirm the presence of functioning testicular tissue.
♦ In general, hormonal treatment for cryptorchidism is not recommended; it has poor immediate results and possible long-term negative effects on spermatogenesis.
♦ A physical examination clue for true cryptorchidism is a hypoplastic scrotum on the ipsilateral side or both sides if the condition is bilateral (Fig. 31-1).
Indications for Operation
♦ Orchidopexy positions the testis where it can be easily examined; however, it does not minimize the risk of developing cancer.
Step 3: Operative Steps
Anesthetic Induction
♦ Tracheal intubation for laparoscopy or a laryngeal mask airway for groin exploration is preferred over mask ventilation. Some orchiopexies can be challenging and time consuming, and an adequate airway during anesthesia is essential.
Incision and Technique
♦ If the testis is palpable, the procedure is performed using a transverse groin incision. The incision is made approximately 1 cm longer than for repair of an inguinal hernia to allow for enhanced exposure.
♦ The incision is deepened to the level of the external ring, and the external oblique fascia is incised for a short distance to enable exposure to the upper spermatic cord.
♦ In general, the testis will be visible somewhere in the surgical field, or it can be pulled up into the incision by finding the peritoneal covering (tunica vaginalis) or the processus vaginalis (Fig. 31-2). At this point, an effort should be made to encircle the spermatic cord (and hernia sac if one is present) before opening the tunica vaginalis. The gubernacular remnant is divided, taking meticulous care to ensure that there is no long-loop variant of the vas deferens.
♦ If a hernia sac is present, it is carefully separated from the spermatic cord (Fig. 31-3), and a high ligation performed if possible. Absorbable suture is recommended. The ends of the sutures are clamped with a hemostat to allow countertraction on the peritoneal reflection, which allows easier cephalad dissection of the retroperitoneal testicular vessels.
♦ There is debate as to whether ligation of an associated hernia sac is necessary or whether simple division will suffice. It has become increasingly acceptable that peritoneal closure is not always necessary, as spontaneous closure occurs.
♦ Depending on the distance between the testis and scrotum, the spermatic cord may need to be skeletonized up the retroperitoneum to allow adequate length to bring the testis into the scrotum. Typically the length of the testicular vessels, rather than the vas deferens, is the limiting factor. There are fine investing layers around the testicular vessels that can be released to allow additional length, although this skeletonization process is associated with a later risk of ischemia and testicular atrophy.
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