ORIGINAL ARTICLE

Incidence and management of the inguinal hernia duringlaparoscopic orchiopexy in palpable cryptoorchidism:preliminary report

Mario Riquelme Æ Arturo Aranda Æ Carlos Rodriguez Æ Julio Cortinas ÆGerardo Carmona Æ Mario Riquelme-Q

Accepted: 29 December 2006 / Published online: 8 February 2007� Springer-Verlag 2007

Abstract During the laparoscopic approach of unde-

scended testis, an associated inguinal hernia is a fre-

quent finding that must be treated at the same time.

The objective of this presentation is to show the inci-

dence and management of the inguinal hernia that

were found during laparoscopic orchidopexy, reporting

how the scar tissue will join the edges of the canal and

the parietal peritoneum will grow above. Between

January 1999 and December 2002, 31 patients with 33

palpable and nonpalpable undescended testes were

treated by laparoscopic orchidopexy. Patients were

between 6 months and 9 years. We used four ports,

and 2 mm instrument. When an associated inguinal

hernia were found we only removed the membranes of

the processus vaginalis and did not close the defect. All

cases were treated by the same surgeon. The average

surgical time was 50 min that included the orchiopexy

and the treatment of the associated inguinal hernia. We

found inguinal hernia in 23 cases (69.9%). We did not

find any inguinal hernia in the opposite side of the

undescended testis. In two patients with bilateral

undescended testis that were approached in two stages

3 months later we confirmed the closure of the hernia

defect. These 23 patients have 21.5 months average

follow up and confirm no recurrence. With an average

follow up of 21.5 months, we found no inguinal hernia

in any of the patients. A larger volume study with

longer follow up is needed to confirm that there is no

need for closure of the internal inguinal ring during

laparoscopic orchidopexy.

Keywords Orchiopexy � Laparoscopic orchiopexy �Cryptorchidism � Inguinal hernia � Laparoscopic

hernioplasty

Introduction

Inguinal hernia is the main congenital malformation

associated to cryptorchidism. During the third month

of gestation the processus vaginalis extend down to-

ward the scrotum and follows the gubernaculum, which

extends from the testicle in the retroperitoneum to the

scrotum. During the seventh month, the testicle des-

cends into the scrotum, where the processus vaginalis

forms a covering for the testicle and the serous sac in

which it resides (tunica vaginalis) [12].

At about the time of birth, the portion of the pro-

cessus vaginalis between the testicle and the abdominal

cavity obliterates, leaving peritoneal cavity separate

from the tunica vaginalis, which surrounds the testicle

[20]. If the process of obliteration in not complete, a

variety of anomalies can occur. Most true cases of

Presented at the IPEGs 12th annual congress for endosurgery inchildren, in Los Angeles, CA, USA, March 2003.

M. Riquelme (&) � A. Aranda � J. Cortinas �G. Carmona � M. Riquelme-QGeneral Surgery, Pediatric Surgery Department,Christus Muguerza Hospital,Centro Medico Conchita C1-4 and San Jose Hospital,15 de Mayo 1822 Pte, Monterrey NL 64060, Mexicoe-mail: cima_riquelme@hotmail.com

C. RodriguezAnesthesia Department,Christus-Muguerza Hospital and San Jose Hospital,Monterrey, Mexico

A. ArandaChildrens Hospital Los Angeles,Los Angeles, CA, USA

123

Pediatr Surg Int (2007) 23:301–304

DOI 10.1007/s00383-007-1876-z

undescended testicles (90%) are associated with a

patent processus vaginalis, except retractile testis [3,

16]. If an overt hernia is present, expeditious hernia

repair with orchiopexy at the age of presentation is

undertaken. Otherwise, the hernia should be repaired

at the time of orchiopexy. A man with an untreated

undescended testicle and an occult inguinal hernia may

present at any time with symptoms and complications

typical of any inguinal hernia [9, 10, 11, 15].

During the laparoscopic approach of undescended

testis, an associated inguinal hernia or processus vagi-

nalis is a frequent finding that must be treated at the

same time [5, 18].

Most of the papers about the laparoscopic treatment

of inguinal hernia in children, rarely report the finding

of another anomalies as undescended testis; and most

of the works about laparoscopic orchiopexy do not

have any mention about inguinal hernia or its man-

agement in the same procedure. But a few articles, that

include one large series of inguinal repair management

without closure of the internal inguinal ring during

orchiopexy. And a multi-institutional analysis that re-

port their cases without post-orchiopexy inguinal her-

nia formation, also without closing the inguinal ring,

and a overall risk of hernia formation less than 1% [1,

4, 7, 8, 17, 19].

The objective of this presentation is to show the

incidence and management of the inguinal hernia that

were found during laparoscopic orchiopexy.

Materials and methods

IRB approval was obtained from the Ethics and re-

search committee of Christus-Muguerza and San Jose

Hospitals.

Between January 1999 and December 2002, 31 pa-

tients with 33 palpable and nonpalpable undescended

testes were treated by laparoscopic orchiopexy.

During the physical examination 12 (36.4%) were

nonpalpable and 21 (63.6%) were palpable testes. We

found only two patients that presented an associated

inguinal hernia during the physical examination. Pa-

tient age ranged between 6 months and 9 years (aver-

age 21.72 months), with weight ranges from 9 to 36 kg.

The patient is under general anesthesia with full

muscle relaxation and is placed in a supine position on

the operating table. All patients receive a urine cath-

eter at the beginning, and removed before starting the

procedure. The surgeon stands at the upper end of the

table, behind of the patient’s head, with the assistant to

his left and the scrub nurse to his right. The monitor is

placed at the lower end of the table.

Using the closed technique with the Veress needle,

the peumoperitoneum of 8–10 mmHg was created. We

used four ports (1 of 10 mm, 2 of 2 or 3 mm and 1 of

5 mm), 4 mm, 30� lens and 2 or 3 mm instrument in all

cases. The 5 mm trocar was placed in the umbilical

area, and the 2 or 3 mm trocars were placed in the mid-

clavicular line, slightly infraumbilical.

In all cases (Fig. 1) we usually open the peritoneum

of the internal ring to dissect the vas and testicular

vessels and pull the testis into the abdominal cavity

(Fig. 2) cutting the gubernaculum and then pull-trough

the testis to the scrotum, in addition to treat an asso-

ciated inguinal hernia we only removed the mem-

branes of the processus vaginalis (Fig. 3) in all the

cases, we did not close the defect with any sutures or

vascular clips (Fig. 4). All cases were treated by the

same surgeon and were filmed.

Results

The average surgical time was 50 min that included the

orchidopexy and the treatment of the associated

inguinal hernia.

We found inguinal hernia in 23 cases (69.9%), 16

(76.%) of the palpable testes and 7 (58.3%) of the

nonpalpable testes. We did not find any inguinal hernia

in the opposite side of the undescended testis.

In two patients with bilateral undescended testis that

were approached in two stages three months later we

confirmed the closure of the hernia defect (Fig. 5).

These 23 patients have 21.5 months average follow

up and confirm no recurrence.

We had one vascular injury that resulted in testicular

atrophy.

Discussion

Although our volume is small, we found a lower inci-

dence of inguinal hernia associated to undescended

testis, compared with other references.

Fig. 1 Indirect hernia

302 Pediatr Surg Int (2007) 23:301–304

123

The gold standard for inguinal hernia repair remains

high ligation of the processus vaginalis [13].

The advantages of laparoscopic orchidopexy are

active visualization of the structures providing easy and

safe high dissection of vas and vessels, therefore

eliminating the need of blind dissection of the trans-

inguinal approach. Also, there is no need of opening

the inguinal floor.

There are several laparoscopic techniques for pedi-

atric inguinal hernia repair, but most of them close the

internal ring and leave the processus vaginalis.

Recurrence with this approach are reported from 3.4 to

25% [6, 14]. Becmeur [2] follows the steps of open

technique, done laparoscopically, and reports 0%

recurrence. This supports the importance of resection

of the processus.

Laparoscopic approach of pediatric inguinal hernias

is described as the internal ring closure with sutures,

with or without the complete removal of the hernia sac.

The final result with this technique, is the separation of

the scrotal cavity from the abdominal space, leaving a

small opening for the vas deferens and spermatic ves-

sels.

We support the surgical technique that emphasizes

the resection of the processus vaginalis as the most

important step of pediatric hernia repair, even with-

out closure of the internal ring. By performing

this resection, the walls will be in contact and the

hernia space will be occupied by scar tissue and the de-

peritonealized area will close completely over the

internal inguinal ring. On the contrary, closing the ring

without the processus resection will not solve the

problem completely and will have a high index of

recurrence.

We report no post-operatively inguinal hernias after

laparoscopic orchidopexy, removing completely the

hernia sac during the procedure, without suture closure

of the internal ring with sutures.

With an average follow up of 21.5 months, we found

no inguinal hernia in any of the patients.

Testicular sizes were normal in all but one testis,

which had a vessel injury during the procedure and

became atrophic. This complication was one on the

first five cases, and no other complication is reported

after that. All scrotal positions were in the desired

place.

There is no technical difficulty encountered with the

processus vaginalis resection. This required basic lap-

aroscopic instruments. The processus vaginalis should

be completely excised in order to fulfill the goal of the

theory of this technique. Leaving parietal peritoneaum

without the processus. This is not possible on a trans-

inguinal approach.

Fig. 2 Orchiopexy

Fig. 3 Hernia sac resection

Fig. 4 Internal inguinal ring open, sac resected

Fig. 5 Original site of the internal ring

Pediatr Surg Int (2007) 23:301–304 303

123

A larger volume study with longer follow up is

needed to confirm that there is no need for closure of

the internal inguinal ring during laparoscopic orchi-

dopexy.

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