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K.F. LEE, Y.C. TANG and H.T. LEONG
Department of Surgery, Alice Ho Miu Ling Nethersole Hospital, Hong Kong SAR, P.R. China
Torsion of an intra-abdominal testis is a rare cause of acute abdominal pain. With a history of undescended testis, it is difficult to establish the diagnosis and to exclude other emergency abdominal conditions without a laparotomy. The following case report illustrates the usefulness of laparoscopy as a diagnostic as well as a therapeutic tool in such a condition.
Keywords: Intra-abdominal testis, laparoscopic orchidectomy, torsion
J.R.Coll.Surg.Edinb., 46, April 2001, 110-112
Elective laparoscopic procedures, both diagnostic and therapeutic, are well described in the management of cryptorchidism. However, use of laparoscopy in the management of acute problems complicating intra-abdominal testis has not been reported, to the best of our knowledge, in the English literature. Here we report a case of torsion of an intra-abdominal testis, which was success-fully managed with a laparoscopic technique.
A 28 year-old-man, who had an impalpable left testis since birth, presented with a sudden onset of severe left lower quadrant abdominal pain, of one days duration. The pain was not associated with any bowel or urinary symptoms. Examination revealed tenderness and guarding over the left lower quadrant of the abdomen. The rest of the abdomen was soft and non-tender. The right testis was normal in size and in position. The left testis could not be detected in the scrotum or left groin.
Urgent ultrasound examination was performed. It revealed a small-sized left intra-abdominal testis. The testis was diffusely hypoechoic and there was no demonstrable intra-testicular blood flow. The provisional diagnosis of torsion of the left intra-abdominal testis was made.
Emergency operation was arranged. A laparoscope was inserted through a subumbilical incision. A 1.5 cm ectopic testis was seen proximal to the left internal inguinal ring (Figure1). There was no obvious gangrene of the testis. No other abnormality was noted in the peritoneal cavity. Laparoscopic orchidectomy was carried out with two additional 5 mm ports. Testicular vessels (Figure 2) were isolated, clipped and divided. The vas deferens (Figure 3) was identified, clipped and divided. The testis was then completely mobilised and removed through the subumbilical port. The procedure took 50 minutes. Postoperatively, the patient made a satisfactory recovery and was discharged on day 2. Pathological examination of the removed testis confirmed an atrophic testis with no evidence of malignancy. No infarct or haemorrhage of the testis was noted.
Figure 1: Laparoscopic view of the intra-abdominal testis
Figure 2: The testicular vessels (arrow) were divided between clips
Figure 3: The vas deferens (arrow) was divided between clips
In male patients with an impalpable testis, the gonad may be intra-abdominal, canalicular, atrophic or absent. Different radiological techniques such as ultrasound, computerised tomography scan, magnetic resonance imaging, selective testicular arteriography, selective testicular venography, have all been utilized to locate the testis. However, successful and accurate localization still remains a problem. With rapid development of laparoscopic techniques, laparoscopy has been widely applied as a diagnostic tool for localization of the impalpable testis.1,2 Furthermore, therapeutic procedures can be carried out based on the laparoscopic findings.3,4 If the vas and vessels are blind-ended, no further treatment is necessary. If the vas and vessels are seen entering the deep ring, groin exploration usually reveals a small testicular remnant, as a result of perinatal torsion. If an intra-abdominal testis is seen, laparoscopic orchidectomy can be performed for adults and orchidopexy for children. If orchidopexy is needed, the position of the testis and the length of spermatic vessels, as revealed by laparoscopy, can determine whether a one-stage or two-stage Fowler-Stephens orchidopexy can be performed. Both the single stage and the first stage of the two-staged procedure can be done readily by laparoscopic means.5,6
Despite its widespread application in the elective setting, use of laparoscopy in the management of acute complications such as torsion of intra-abdominal testis, has not been documented in the English literature. Traditional groin exploration for torsion of an undescended testis only allows removal of the intra-abdominal testis lying near the internal inguinal ring; a high lying intra-abdominal testis will require an abdominal incision. Furthermore, if an apparently normal looking testis is found on groin exploration, it will result in a dilemma as to whether laparotomy is needed to exclude other causes of the acute abdomen. In the present case, the intra-abdominal testis may have untwisted spontaneously and so no infarction occurred. Laparoscopy was sufficiently to exclude other causes of acute abdominal pain. Laparoscopy allows the safe dissection and removal of an intra-abdominal testis. No additional difficulty was noted even with torsion of the testis. Thus, laparoscopy should be the modality of choice for management of suspected torsion of an intra-abdominal testis.
Copyright date: 19th September 2000
Correspondence: Mr K.F. Lee, Department of Surgery, Alice Ho Miu Ling Nethersole, Hospital, 11, Chuen On Road, Tai Po, N.T., Hong Kong SAR, China
E-mail: kflee148@i-cable.com
©2001 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb.