Laparoscopic Orchiopexy: How Is an Intra-Abdominal Testicle Brought Down?

A non-palpable testicle on examination accounts for roughly one in five cases. Because ultrasound and MRI do not reliably show the location of these testicles, guidelines do not routinely recommend imaging; evaluation is carried out in the operating room.

• The first step is a repeat examination under anesthesia: some testicles that are non-palpable while the child is awake, due to muscle contraction, become palpable once the child is asleep, and the operation proceeds as a standard orchiopexy. If the testicle is still not palpable, diagnostic laparoscopy is performed, and treatment proceeds in the same session based on the findings. In our practice, these three steps — examination, laparoscopy, and the descent procedure — are all carried out in a single session by two pediatric urology specialists.

Once the camera is inside the abdomen, the internal ring area and the testicular vessels are examined. The findings fall into one of several patterns, each leading to a different next step.

• Testicle inside the abdomen, close to the internal ring: brought down with laparoscopic orchiopexy in the same session.
• Testicle right beside the internal ring, ‘peeping’ into the canal (peeping testis): usually brought down in a single stage, either laparoscopically or through the groin.
• High intra-abdominal testicle (vessels too short to reach the scrotum): a staged approach — Fowler–Stephens or the Shehata (traction) technique — comes under consideration.
• Vessels and vas deferens entering the canal through the internal ring: the groin is opened; if a viable testicle is found, it is brought down, and if a non-functional remnant (nubbin) is found, it is removed.
• Vessels ending blindly within the abdomen: the testicle was lost before birth (vanishing testis); there is no testicle to bring down.

If the testicle is within the abdomen and its vessels are of sufficient length, the operation continues with the laparoscopic technique.

• Anesthesia and ports: Under general anesthesia, a camera is placed through the navel, and two 3–5 mm working ports are placed in the lower abdomen.
• Assessment of the testicle: Its size, its relationship to the epididymis, and the course of the vessels and vas deferens are examined; distance to the internal ring is assessed.
• Mobilization: The gubernaculum (guiding ligament) attachments holding the testicle are divided; the testicular vessels are freed upward beneath the peritoneum, extending as far as below the kidney if needed. The peritoneum around the vas deferens is preserved as a wide triangle of tissue.
• Creating a new pathway: The testicle is usually routed through a short path medial to the inferior epigastric vessels, leading directly to the scrotum; this bypasses the winding route of the inguinal canal and gains additional length.
• Fixation in the scrotum: A subdartos pocket is created through a small scrotal incision; the testicle is placed into it without tension.
• Closure: The internal ring is narrowed if needed; the ports are closed with dissolvable stitches.

• Duration is usually 60–90 minutes for a unilateral procedure. Most children go home the same day or the following morning; whether admission is needed depends on the extent of surgery and the child’s age.

The deciding question is whether the vessels are long enough to bring the testicle to the scrotum without tension. In practice, criteria such as the testicle’s distance from the internal ring, the length of the vessels, and whether the testicle reaches the opposite internal ring after mobilization are used.

• If the testicle reaches comfortably, it is brought down in a single session. If it does not, rather than forcing it, a staged approach is used: Fowler–Stephens, in which the main vessel is divided, or the Shehata technique, in which the vessel is preserved and the testicle is anchored under tension to the abdominal wall. This decision is made during surgery, based on the joint assessment of the two specialists; the possibility is discussed with the family beforehand during the consent conversation.

In the first days, mild pain at the port sites and swelling and bruising in the scrotum are normal; shoulder pain resolves as the gas used in the abdomen is absorbed. Simple pain relievers are usually enough.

• Outcomes for an intra-abdominal testicle are viewed somewhat more cautiously than for a palpable one: even after being brought into the scrotum, the testicle may remain smaller than the other side, and the risk of atrophy is higher. For this reason, follow-up visits occur several times in the first year and then yearly; size and development are reassessed at adolescence.