Laparoscopy used for the diagnosis and treatment of nonpalpable intra-abdominal cryptorchidism has been universally accepted in clinical practice, while the inguinal palpable cryptorchidism is tended to the traditional typical open inguinal orchiopexy. However, there are some conspicuous defects in this surgical procedure; firstly, the conventional inguinal incision is not easy to be adequately exposed, and it is likely to damage the testicular blood supply when separating the retroperitoneal spermatic cord vessels, which increases the risk of postoperative testicular atrophy. Neheman et al reported 5 cases of testicular atrophy in 134 cases of inguinal cryptorchidism by trans-inguinal orchiopexy, the rate is about 3.7%. Ein et al indicated that testicular atrophy occurred in about 5% of low typical inguinal cryptorchidism, while the figure reach up to 9% in higher inguinal position when testicular fixation by inguinal open approach. So far, testicular atrophy has not been found in 773 patients in this group. Secondly, open surgery requires separate the inguinal canal, which not only destroys the anatomical structure of the inguinal canal, but also needs to cut the intra-abdominal oblique muscle and the transverse abdominis muscle at the inner ring for a higher position of the inguinal typical cryptorchidism, which would be prone to occur wound infection, bleeding, and even testicular retraction; according to the literature, the wound infection rate of open inguinal orchiopexy is 1.9%-2.5%[2, 10].At last, the most important is trans-inguinal orchiopexy unable to detect a contralateral occult hernia or patent processus vaginalis, cryptorchidism associate with a contralateral patent processus reach up to 33%-40%[7, 9], while preoperative color Doppler ultrasound examination only discovers about 20%. A prospective study in Japan indicated that the diameter of the contralateral processus vaginalis can be developed into symptomatic inguinal hernia with a diameter of >2 mm, with specificity and sensitivity of 81.8% and 71.3%, respectively.
In 1995, Docimo et al first introduced laparoscopic orchiopexy for treatment of cryptorchidism that can touch the testicles in the inguinal canal. Subsequently, Mario et al, He et al confirmed that the technology is feasible, safe and effective. Compared with traditional open surgery, laparoscopic technology has obvious advantages: above all, by the amplification of laparoscopy, it is easier to loosen and separate the retroperitoneal spermatic vessels under visualization, and even reach the proximal next to the inferior pole of the kidney when it is necessary. The testis is fixed in the scrotum without tension, which can effectively reduce the occurrence of testicular atrophy and retraction. Then the anatomical integrity of the inguinal canal is maintained. For the high inguinal typical cryptorchidism, the intra-abdominal oblique muscle and the transverse abdominis muscle can be avoided cutting at the inner ring. Compared with the traditional open surgical methods, the postoperative pain is smaller, and the recovery is faster. No obvious surgical scars, parents have higher satisfaction. Finally, laparoscopic surgery can simultaneously detect a contralateral occult hernia. Studies have shown that more than 10% of asymptomatic hernia accidentally found by laparoscopic will develop into symptomatic metachronous inguinal hernia[13, 14], which require surgery again under anesthesia. A 17-year follow-up study of Taiwan also pointed out that up to 12% of contralateral occult hernia can develop into clinically inguinal hernia, about 63% of the symptoms appear within 2 years after the affected side operated, and the ratio will be as high as 91% in 5 years. Laparoscopic orchiopexy can simultaneously treat contralateral occult hernia, avoid suffering a second pain and fear caused by reoperation and anesthesia. The study reveals that 34% of palpable cryptorchidism associate with a contralateral patent processus vaginalis, consistent with the reported literature.
There are two remarkable limitations of our research. First, our follow-up period is too short to making an authoritative assessment of outcome after surgery for undescended testis. The second shortage of our research is that we are indeterminable that a contralateral patent processus vaginalis truly indicates that these children will develop into clinically inguinal hernia in the future. But what I can definitely believe is that it will significantly reduce the chance of suffering reoperation and anesthesia.