A combined preperitoneal and inguinal approach for redo orchiopexy

Redo orchiopexy involves a hazardous dissection inside the inguinal canal (IC) where scar tissue encircles the testicular vessels (TesV), vas deferens (VD), and the testis.

The aim was to describe and evaluate a combined preperitoneal and inguinal approach (CPI) through a single cutaneous incision and accomplish this task as safely as possible, at the same time permitting additional maneuvers for cord lengthening.

We prospectively studied eight patients aged from 2.7 to 13 years (mean 7 years) reoperated for failed orchiopexy using the CPI approach. Reoperation took place 12 months to 11 years (mean 4.4 years) after the initial operation. Through a single transverse skin crease incision over the IC, at the level of the deep inguinal ring (DIR), we gained access to both the preperitoneal space (PPS) and the IC. We first entered the PPS, the peritoneum is retracted, and the VD and TesV are seen entering the DIR. They are gently dissected and two vascular lacets are passed around them. We introduce the backside of an anatomic forceps through the DIR, just under the anterior IC wall, until it is impeded by adhesions and then incise above the forceps, thus protecting the cord structures. Through that opening we transpose one of the lacets that encircle the VD and TesV and exercise traction upon them (figure, 1), revealing step by step the points where adhesiolysis must take place (figure, 2). The testis is dissected last of all and delivered back, through the DIR, into the PPS. There, the TesV and VD are freed from their retroperitoneal attachments (figure, 3). Finally, the testis is fixed into a Dartos pouch.

In all cases the testes were relocated to the scrotum without any mishaps. All testes were inside the scrotum at first month examination and with good consistency. At 6 months, one testis ascended at mid-scrotum. At 2 years they all retained their position and their good standing, according to clinical and ultrasonographic findings.

Several procedures of redo orchiopexies have been published so far, most of them rely on the surgeon's dexterity for good results. The CPI procedure offers a practical maneuver to protect the cord elements while dissecting and also exposes all the regions where dissection will offer lengthening of the cord.

Our results have demonstrated that the CPI can be considered as a safe and efficient procedure for redo orchiopexy.