By Hossein Aliabadi, M.D., F.A.A.P.,
Pediatric Laparoscopy Indications
Laparoscopy for Cryptorchidism
Laparoscopic appearance of a normal inguinal region.
orchiopexy - First Stage. Clipping
of the testicular vessels above the Stephen
Laparoscopic appearance of a moderate-sized inguinal hernia.
Laparoscopic varix ligation in progress. The metallic clips have divided the veins.
The application of
laparoscopic principles in the diagnosis and treatment of many pediatric
urologic conditions has gained
tremendous popularity in recent years. This interest has been fueled by the success and acceptance
of laparoscopic techniques in the adult population. While minimal access surgery offers a number of advantages for the adult
patient, the distinction is less
clear in the pediatric population, especially in infants and young children.
Many series and
anecdotal reports have been published, describing of success for this
technique, including laparoscopic nephrectomy, partial nephrectomy, ureteral reimplantation,
laparoscopic autoaugmentation of the bladder, and mitrofanoff appendico-vesicostomy.1'2
While these techniques are being
developed, it is difficult for us to justify their application in children
where well-established, successful,
and more cost-effective, open-surgical procedures exist without any compromise of the advantages currently attributed to
However, despite its limitations, laparoscopic procedures in infants, children and the
adolescent age group do offer
advantages in selected cases (Table 1). Laparoscopic techniques are particularly well-suited in such
conditions, with benefits that clearly outweigh the associated risks. We employ pediatric
extensively in the management of nonpalpable
testes, which occurs in about 20% of cases of cryptorchidism. Localization
of the testicle in the intra-abdominal
position by this technique helps us plan the appropriate intervention. If the vas
deferens and the vessels are seen to course through the internal inguinal ring (Figure 1), it
directs us to perform an inguinal incision and further helps in the choice
of surgical technique
(Table 2). If the vas deferens and spermatic vessels remain in an intra-abdominal
position, arrangements can be made for a single- or multiple-stage
orchiopexy for intra-abdominal testes or a microvascular testicular
auto-transplant, which is utilized very infrequently. Our preference with high, intra-abdominal testes is to
perform a two-stage Stephen Fowler's orchiopexy by clipping the testicular
vasculature approximal to the Stephen Fowler's membrane, allow collateral
circulation to develop, and then bring the testis down into the scrotal position in the second stage (Figure 2).
Laparoscopy is, therefore, quite helpful
in providing information regarding the presence or absence of the testis, its location, and in planning for the appropriate surgical management. Additionally, the
contralateral inquinal region can be inspected and if an asymptomatic
indirect hernia is diagnosed it may be corrected at the
same setting (Figure 3). Diagnostic laparoscopy also
helps us define the pelvic anatomy in some cases of intersex disorders,
associated with the presence of a dysgenetic gonadal issue,
which may be removed successfully at the same time.
Diagnostic accuracy for localization of
the nonpalpable testis by laparoscopic techniques has been extremely high in our experience and, therefore, employed routinely. In cases where the vas deferens and vessels
traverse the inguinal ring and the testis is not palpable in the groin
area, we routinely explore through the groin incision to locate the remnant
vas deferens and vessels and to remove the vanished testis as evidence for histologic viable testicular tissue which may
degenerate further, as seen in about 15% of all cases.
We have also employed laparoscopy in
the diagnostic evaluation and staging
of pelvic malignancies such as
rhabdomyosarcoma to help define
the extent of the disease and lymphatic involvement. Biopsies can also be obtained at that time to assist in
management. Use of laparoscopy in the evaluation of non-specific pelvic and
abdominal pain is well-recognized in instances where other modalities of
examination and imaging have been unrewarding, and to our knowledge, no
specific pathologic conditions have been missed. In adolescent males who
require ligation of varicocele, laparoscopic approaches are offered (Figure 4) in addition to
traditional open-surgical repair. The morbidity rate appears to be equal or
less than that for conventional open-surgical procedures, with a shorter recovery time.
Complications are rare and we have not seen an increase in recurrence
following laparoscopic varicocele
are rare following laparoscopic procedures
limited to these indications. We attribute this to careful patient selection
and preparation, along with
adherence to the basic principles of laparoscopic surgery and proper training. We have utilized
laparoscopy in children ranging in age from 2 months to early adulthood
with very favorable outcomes. Clearly, with further refinements in
instrumentation and further experience, indications for laparoscopic procedures in pediatric urology will evolve to include new
1. Koyle MA, et al. Laparoscopic nephrectomy in the
first year of life. J Fed Surgl993;28(5):693-5.
2. Peters CA. Laparoscopy in pediatric urology. Urol 1993;41:33-7.
3. Bloom DA. Two-step orchidopexy with pelviscopy clip ligation of the spermatic vessels. J Urol 1990;144:1030.
4. Aliabadi HA, Wolpert JJ, Reinberg Y. Short-stay nephrectomy in
infancy. Abstract 87:34, Eighth Annual Meeting of the European Society for
Pediatric Urology', Rome, Italy,
5. Diamond DA, Caldamone AA. The value of laparoscopy for 106
impalpable testes relative to clinical
preservation. J Urol 1992;148:632-4.
to: Drs. Aliabadi, Wolpert and Reinberg, Pediatric Surgical Associates,
Section of Urology, 2545 Chicago
Avenue South, Suite 104, Minneapolis,
telephone 612/813-8000 or 800/992-6983. Or Childrens Center for Pediatric Urology,
612/813-6262 or 800/CPU-6262.