Inguinal Hernia After Laparoscopic Orchiopexy

During the last decade laparoscopic orchiopexy has become the procedure of choice for the diagnosis and treatment of nonpalpable testis. The laparoscopic approach to the intraabdominal testis allows optimal high dissection of the spermatic vessels and facilitates tension-free positioning of the testis into the scrotum without the need for an inguinal incision. The reported success rates for laparoscopic orchiopexy have been as high as 96%.1, 2 Complications specific to laparoscopic orchiopexy are rare and include testicular atrophy, ileus, gonadal vessel avulsion, hydrocele, bladder perforation, laceration of the vas and bowel injury.1, 2 A potential disadvantage of laparoscopic orchiopexy compared to the traditional open approach is subsequent development of an inguinal hernia, since formal ligation of the associated hernial sac and/or closure of the internal ring is usually not undertaken. To our knowledge we report the first case of indirect inguinal hernia formation following routine laparoscopic orchiopexy. CASE REPORT A full-term male neonate was evaluated for bilateral severe hydronephrosis discovered prenatally and bilateral nonpalpable testis. Radiographic studies were consistent with bilateral ureteropelvic junction obstruction, and bilateral pyeloplasty was undertaken in a staged fashion by age 6 months. At age 10 months the patient underwent bilateral laparoscopic orchiopexy. Intraoperatively the testes were observed above the level of the internal ring. Both testes were associated with hernial sacs that entered the ring. The hernial sacs were pulled into the abdomen and dissected free from their attachments within the inguinal canal. Following successful mobilization of the spermatic vessels and relocation of the testis into the scrotum, no attempt was made to close the internal ring although its edges were cauterized to promote scarring and spontaneous closure of the ring. The child did well with good viability and position of the testes noted postoperatively. Approximately 8 months later the patient presented with acute swelling and discomfort in the right inguinal region. Examination was consistent with a reducible inguinal hernia. Surgical exploration revealed an indirect hernia with a well defined sac entering the canal through the internal ring. Given these findings, we elected not to undertake formal exploration of the anterior rectus fascial defect around the vessels and medial to the canal where the testis was brought through at the time of laparoscopic orchiopexy. The hernial sac was ligated with suture closure of the ring. No recurrence was noted on either side during 14 additional months of followup. DISCUSSION Laparoscopy allows the surgeon to perform dissection of the spermatic cord structures into the retroperitoneum up to the level of the origin of the spermatic vessels. This dissection enables the surgeon to fix the testis in the scrotum without tension on the cord. Although the original descriptions of laparoscopic orchiopexy included closure of the internal ring, recently the consensus in the literature from large series has been to leave the ring open since no subsequent hernias have been reported to date when the internal ring is not formally closed.2, 3 To our knowledge we report the first indirect inguinal hernia after laparoscopic orchiopexy. This case clearly illustrates that a hernia can occur following laparoscopic orchiopexy even when attempts are made to remove the hernial sac from the canal. With this approach one would expect spontaneous closure of the ring due to scarring from the dissection at this level. In the last 2 years we have performed 25 laparoscopic orchiopexies with 1 postoperative inguinal hernia for an incidence of 4%. However, Baker et al reported 310 laparoscopic orchiopexies in 252 patients without any instance of postoperative inguinal hernia formation.1 With these numbers in mind it is likely that the overall risk of hernia formation is less than 1%. While this case has not changed our current practice in that the internal ring is still not routinely closed in laparoscopic orchiopexy, it is important for the surgeon to be aware that hernia formation is a potential complication of this approach. This possibility should be included in preoperative discussion of the potential complications of this procedure, and consideration of closure of the ring may be appropriate in select cases of a large internal ring defect.