Laparoscopic totally extraperitoneal exploration of intra-abdominal testis, orchidectomy and inguinal hernia repair in an adult patient
- Athira Gopinathan ,
- Balamurugan Ramachandran ,
- Sivamarieswaran Ramalingam and
- Padma Kannan
- General Surgery, SRM Medical College Hospital and Research Centre, Kancheepuram, Tamil Nadu, India
- Correspondence to Dr Athira Gopinathan; drathirag@gmail.com
Abstract
The presence of undescended testis predisposes to the development of an inguinal hernia due to the persistent processus vaginalis. This coexistence is not very rare in the paediatric population. Here, we report an adult man who presented with inguinal hernia and an intra-abdominal testis and successfully underwent an extended totally extraperitoneal (e-TEP) approach for extraperitoneal exploration of the testis in the left iliac fossa, and orchidectomy along with inguinal hernia repair. Review of the literature revealed only two case reports in which TEP has been used in the treatment of undescended testis in adults, and in both cases, the testes were intracanalicular. This case, as per our extensive bibliographical research, is the first reported case of an intra-abdominal testis, with descent arrested at the iliac fossa, explored using e-TEP along with inguinal hernia repair. Such minimally invasive procedures may be offered to the patients without the risks of intraperitoneal entry.
Background
Undescended testes, or cryptorchidism, is a rare but not unheard of occurrence in adulthood. Many authors have described laparoscopic methods to treat the same. In this article, we describe a case managed by an extended totally extraperitoneal (e-TEP) approach. The feasibility of e-TEP was considered, as it enables a better and bigger field to operate, a more flexible port placement, along with the advantages of a conventional TEP repair, which are no intraperitoneal contamination, less postoperative ileus, and fewer risks of bowel adhesions and visceral injury.
Case presentation
A man in his 20s came with swelling in the left inguinal region of 6 months’ duration, which was reduced when the patient lay down. Although the patient had noticed an empty scrotum since childhood, no medical advice was sought for the same. On examination, the patient was found to have a left-sided indirect inguinal hernia and an undescended testis on the same side, which was not palpable elsewhere.
Investigations
Sonographic evaluation revealed a shrunken intra-abdominal testis in the left iliac fossa near the iliac vessels, and an indirect inguinal hernia with omentum as content.
Treatment
This patient needed orchidectomy along with inguinal hernia repair. After induction of general anaesthesia, a 1 cm incision was made above and lateral to the umbilicus on the left side. Anterior rectus sheath was incised, and rectus muscle was retracted to expose the posterior rectus sheath, and the plane was developed using a balloon insufflator. A 10 mm trocar was introduced to this extraperitoneal space. Two more working ports, 5 mm each, were introduced in the infraumbilical region in the midline, and the landmarks were identified. During lateral dissection below the arcuate line, the shrunken testis was identified in close relation to the iliac vessels covered by peritoneal folds (see figure 1). While dissecting the overlying peritoneum, the indirect hernia sac also came into view which was adherent to the peritoneal covering of the testis (see figure 2). The testicular vessels and the vas deferens were found to join the testis at an angle; they were carefully clipped using metal clips (size 300) and divided, and an orchidectomy was done. An endobag (a custom-made sterile polythene bag) was introduced into the extraperitoneal space and the orchiectomy specimen was retrieved through one of the subumbilical ports, which was converted to a 10 mm port from the initial 5 mm, thereby minimising any possibility of contamination (see figure 3). This manoeuvre was important to prevent contamination of the synthetic mesh introduced in the extraperitoneal space and also in reducing possible tumour seedlings while handling. The inguinal hernia sac was pulled back into the peritoneal cavity and a polypropylene mesh was fixed in the preperitoneal space using tackers (see figure 4). The procedure was completed in 90 min with minimal blood loss. The additional equipment, which was used when compared with conventional TEP, was a polythene sterile cover and metal clips (size 300; four in number), which did not increase the procedure cost significantly.
Dissection of undescended testis from the peritoneal covering.
Mobilised testis after dissection.
Retrieval of orchidectomy specimen via the endobag.
Extraperitoneal placement of polypropylene mesh 44×26 mm.
Outcome and follow-up
The postoperative period was uneventful, and the patient was discharged on the third postoperative day. The histopathology report showed mildly atrophic testis with partial maturation arrest with no evidence of malignant change. The patient was followed up in the review outpatient department for a period of 6 months by means of periodical visits, and reported no complications or specific symptoms.
Discussion
The normal development and descent of the testis are a process that progresses early in the embryonic life until birth or immediately after birth, and are influenced by multiple hormonal and genetic factors.1 The incidence of undescended testes along with hernia is found to be 7% in the paediatric population,2 while the incidence of inguinal hernia in 1-year-old boys with undescended testes is as high as 90%.3 Such a clinical presentation is much less common in adults (about 0.23%),4 as the majority undergo surgical treatment in childhood. The rest of the patients may present with inguinal hernia, like our patient who was incidentally found to have an empty scrotum on the same side. A challenging situation arose when imaging showed an intra-abdominal testis close to the iliac vessels. A transabdominal preperitoneal (TAPP) or TEP repair was feasible, but we chose the latter, as it offered the advantages of minimal chance of peritoneal contamination, less ileus and cut-down on the possibility of bowel adhesions.5 The TEP procedure was modified to an e-TEP procedure, which provided a better and magnified view for dissection.
The undescended testis can be classified broadly as congenital or acquired. Congenital type may be intra-abdominal, intracanalicular, suprascrotal or ectopic testes.6 This occurs unilaterally in about 90% of the cases, and in 10%, it may be bilateral.7 8 Different studies quote the incidence on the right side as varying from 45% to 70%.9 10 Acquired forms are primary (those that cannot be manipulated into the scrotum or are unstable in the scrotum) or secondary to inguinal surgeries. Kaplan’s classification divided them into palpable and impalpable testes.11 The intracanalicular, intra-abdominal and absent testes fall into the impalpable variety, while others are in the palpable group. About 20% of the undescended testis are not palpable.10 12 The high position of the intra-abdominal testes is defined as being above the external iliac vessels.10 Failure of the first phase of descent is rare and results in intra-abdominal testes.13 One study cites the percentage of intra-abdominal testes as 45% among the impalpable variety.14 Orchiopexy is offered in boys aged between 6 and 12 months with palpable testes to facilitate normal spermatogenesis. In adults, orchidectomy is always preferred due to the fear of developing malignancy (about 5% risk),15 and since the testis is prone to torsion and trauma. Among undescended testes, an intra-abdominal testis has six times more potential to be malignant than an intracanalicular one.16 17 Also, such maldescended testis does not support normal spermatogenesis.17 The most common type of carcinoma is reported as seminoma and embryonal carcinoma.18 19 Ultrasonography is the initial investigation tool, although the sensitivity in an intra-abdominal testis is only 20% and laparoscopy is the gold-standard investigative modality in an impalpable variety,12 ever since its first use in undescended testes way back in 1976.20 Review of literature using PubMed, Google Scholar and ClinicalKey using keywords cryptorchidism, adult, inguinal hernia and eTEP revealed only two case reports which made use of TEP in treating undescended testes along with hernia repair, but in both case reports, the testes were intracanalicular.2 21 Other case reports made use of diagnostic laparoscopy along with TAPP in the treatment of intra-abdominal testes. Our case may be the first reported one in which a patient with high intra-abdominal testis along with hernia is offered orchidectomy along with hernia repair in the same sitting, using e-TEP, making use of routinely available equipment in the operating theatre and thus not markedly increasing the procedure cost.
A diagram illustrating the anatomy of the testis in relation to its correct anatomical descent illustrated by the corresponding author (Dr Athira Gopinathan) is shown in figure 5.
Diagram illustrating the anatomy of the testis in relation to its correct anatomical descent.
Learning points
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In our case, we found that the extended totally extraperitoneal (e-TEP) approach was safe, and we think that in expert hands, e-TEP may have an advantage over the transabdominal preperitoneal (TAPP) approach in treating adult patients with undescended testis along with hernia, and ours may be the first case reported.
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In this case, we found that e-TEP can be of immense help in delivering even a high lying testis. The safety and effectiveness of e-TEP as compared with the traditional TAPP need to be studied further in the management of undescended testes.
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e-TEP has facilitated better exploration of the extraperitoneal space without the space constraints of TEP procedure, and also mitigated the disadvantages of a peritoneal entry in TAPP such as visceral injury, paralytic ileus, bowel adhesion and peritoneal contamination.
Ethics statements
Patient consent for publication
Footnotes
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Contributors AG contributed to the conceptualisation, drafting and editing of the article. BR contributed to the editing, critical revision and final proofreading of the article. SR contributed to drafting the literature review and editing the article. PK contributed to the procurement and editing of images as well as drafting the article. All authors have agreed to take responsibility for and approved the final version submitted for publishing.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.
References
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