Orchidopexy Laparoscopic Stage 2

Orchidopexy laparoscopic stage 2 surgery

The second and last procedure in the Fowler-Stephens two-stage procedure is laparoscopic Stage 2 orchidopexy, which is used in high undescended testicles that are incapable of being safely repositioned in one operation because the testicles have short testicular vessels.

Stage 1 (already completed in the previous step) will be the clipping or dividing of the testicular vessels so that they can promote collateral blood flow.

In the second stage, the testicle is pulled further into the scrotum. 

What Is Stage 2 Laparoscopic Orchidopexy? 

Stage 2 is performed 3 to 6 months after Stage 1. During this step, the surgeon applies laparoscopy to:

• Monitor Stage 1 collateral blood supply.
• Move the testis and cord structures.
• Drag the testis into the scrotum.
• Permanently attach it in a pouch (orchidopexy).
• In this way the chances of survival and proper positioning of the testicle are increased.

Benefits of Laparoscopic Stage 2 Orchidopexy 

• Safely mobilizing without stretching fragile ships.
• Minimal scarring
• Faster recovery
• Enables evaluation of blood flow in the operating room.
• Successful Bringing high abdominal testis into scrotum high.

Laparoscopic stage 2 orchidopexy procedure

3-6 months after Stage 1 laparoscopic Stage 2 orchidopexy is done to lower the high intra-abdominal testis into the scrotum when collateral blood supply has grown.

Anaesthesia

• General anaesthesia is used in performing surgery.
• Child is sorely asleep and pain free.

Positioning and Preparation of the patient

• Lying of the patient, supine (on the back).
• Abdomen and groin are cleaned off, sterilized.

Port Placement

• Typically three laparoscopic ports (5 mm or 3 mm):
• One at the umbilicus (at the camera)
• Two lower abdomen working ports.

Laparoscopic Inspection

The surgeon evaluates:

• The testis position
• Stage 1 Collateral circulation.
• Testicular and vas deferens motility.
• Adequate collateral blood supply needs to be ensured prior to descent.

Mobilization of Testis

• The structures of testis and its cord are carefully removed out of the surrounding tissue.
• Surgeon traces the vas deferens.
• The collateral vessels that are developed post Stage 1 are maintained.
• Any other attachments inhibiting movement downwards are discharged.
• Target: Maximum length and no tension.

Laying of Peritoneal Tunnel

The abdomen is opened down to the groin/scrotum:

• A course is followed along the middle of the inferior epigastric vessels.
• The result of this new track is that the testis can be able to descend without pressure and straining.

Dartos pouch Scrotum

• A minor cut is done on the scrotum.
• To hold the testis, a space is formed beneath the skin known as a dartos pouch.
• The testis of the abdomen is inserted into the pouch.

Introduction of the Testis in Scrotum

• The testis is manipulated via the peritoneal tunnel.

Caught into the scrotal pouch with:

• A grasper
• Or traction suture method.

Key principle:

• No straining of collateral blood flow.
• No twisting/ compression of vas deferens.

Orchidopexy (Fixation)

• The scrotum contains the testis well.
• It is sewed to the scrotal dartos tissue to avoid relocation or re-ascendancy.

Final Checks

Surgeon confirms:

• A testis is freely moved in the scrotum.
• No kinking of vas deferens
• Testis good colour and perfusion.

Closure

• Laparoscopic ports are taken out.
• Little abdominal and scrotal punctures using dissolvable sutures.
• No or few external visible stitches.

Duration

• Time of procedure 45-90 minutes, based on complexity.

Post-Procedure

• Observation for a few hours.
• Majority of children are sent home on the same day or the following morning.

Two-stage Fowler-Stephens orchidopexy

Two-stage Fowler-Stephens orchidopexy is a surgical procedure applied where the undescended testis is high in the abdomen and the testicular vessels are too short to deliver the testes safely in a single operation.

This technique enhances the survival of testicles because it permits the development of collateral blood supply before being ultimately placed in the scrotum.

Indications

Two-stage FSO is suggested where:

• Testis is high intra-abdominal (pathologically, close to the kidney or over internal ring)
• Primary testicular vessels are quite short or constricted.
• The possibility of tension or injury to the testicular artery during one-stage repair.
• Vas deferens is normal and well maintained.

Overview of the Two Stages

Stage 1 Laparoscopic Fowler-Stephens Vessel Ligation:

• Aim: Form new collateral blood supply of surrounding tissues prior to the removal of testis.

Procedure Steps

• General anaesthesia
• Laparoscopy in order to locate the testis.
• Testicular artery and vein.
• Cut or cut off the testicular vessels.
• Incidences near the testis to save branches around it.
• Collateral vessels and vas deferens are left intact.
• No endeavor to lower-down testis.
• Closed abdomen; collateral circulation to increase.

Why Stage 1 is important?

Cutting the main testicular vessels provokes the formation of the alternative blood flow in case of:

• The vasal artery
• Cremasteric vessels
• There is the prevention of testicular atrophy in the cases where the testis is descended later.
• Time between Stages
• Collateral circulation to mature within 3-6 months.

Laparoscopic orchidopexy second stage:

• Indications: Introduction of newly formed collateral supply into the scrotum to bring testis in.

Procedure Steps

• General anaesthesia
• Testis laparoscopic mobilization.
• Free and collateral vessels, gently.
• Make peritoneal (retroperitoneal) tunnel.
• Incise scrotum→ dartos pouch.
• Drag testis down through tunnel to scrotum.
• Fix it securely (orchidopexy)
• Assure of good circulation; seal wounds.

Advantages of Stage 2

• No tension during descent
• Minimized danger of destruction of newly developed blood vessels.
• Reduced risks of atrophy by far as compared to single-stage procedure.

Stage 2 laparoscopic orchidopexy Recovery

Stage 2 refers to the operation during which the testis is eventually removed down into the scrotum. The recovery process is generally easy since it is a less invasive procedure.

First 24 Hours

• The discharge of child normally occurs within the same day or upon overnight observation.
• Groin or scrotal mild discomfort is frequently found.
• There may be small abdominal port-site bandages.
• After a few hours, one is allowed to eat, drink and take light walks.

Pain & Medication

• Pain is typically mild.
• Occasionally a course of antibiotic.
• The pain generally gets better in 2-3 days.

Wound Care

Abdominal Incisions

• Laparoscopic wounds (small) 5 mm / 3 mm.
• Keep clean and dry for 48 hours
• Take dressing off when recommended.

Scrotal Incision

• Mild swelling is normal
• Snug-fitting diaper or supportive panties are beneficial.

Bathing

• Sponge bath for 2 days
• Complete bathing permissible after 48-72 hours.

Activity Restrictions

• Encourage gentle walking

Do not eat the following 2-3 weeks:

• Running, cycling
• Jumping, rough play, sports
• Straddle toys (tricycle)
• Resumption of school may be made after 3-5 days on comfort basis.

What to Expect in Terms of Scrotal Changes

• Minor bruising
• Mild edema
• Testis may rise slightly at first but eventually settles.
• A solid feeling around the testis is nothing to worry about.
• These changes are diminished over 1–2 weeks.

Diet 

• Normal diet can be resumed the same day.
• Hydration is encouraged.

Appointments for Follow-Up

Typical schedule:

• 7–10 days after surgery – wound check
• 3 months – orbit of testis and size
• 6 months–1 year – long term follow-up

Regular follow-up is important to make sure that the testis grows in the right place.

Best hospital for laparoscopic stage 2 orchidopexy India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Laparoscopic stage 2 orchidopexy success rate

The success rate of Laparoscopic Stage 2 Orchidopexy (the second stage of the two-stage Fowler-Stephens orchidopexy) is excellent provided sufficient collateral blood supply is well established following Stage 1.

Success Rate of Laparoscopic Stage 2 Orchidopexy

• The overall success rates: 90-95%
• This means that after healing, the testis enters the scrotum with adequate position, size and blood flow.

Conclusion

Laparoscopic Stage 2 orchidopexy is the final, and most important, step of the two stage Fowler–Stephens procedure to safely bring down a high intra-abdominal undescended testis into the scrotum. This staged approach, which permits collateral vessels to develop after Stage 1, greatly minimizes the risk of testicular atrophy and achieves a high success rate of 90–95%. Laparoscopy, a minimally invasive technique, provides rapid recovery, decreased pain, and excellent cosmetic results. With appropriate postoperative management and follow-up, most patients attain not only adequate testicular position and size, but good long-term function.

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FAQ

1. Why are two stages necessary?

• Because the testicular vessels are too short or tight to safely bring the testis down in one operation. Stage 1 increases blood flow; Stage 2 moves the testis into the scrotum without tension.

2. Will fertility be impacted?

• Most boys retain a good chance of fertility, particularly if surgery is performed early in life and if both testes are normal.

3. Can the testis go back up?

• Exceptionally, but it can. Good scrotal fixation at surgery prevents this.