Collateral Circulation after Spermatic Vessel Ligation for Abdominal Testis And Its Impact on Staged Laparoscopically Assisted Orchiopexy

Abstract

Staged laparoscopically assisted orchiopexy for abdominal testis entails initial spermatic vessels ligation followed by mobilization of the testis, preserving the vas and its vessels as a sole source of testicular blood supply. This mobilization includes all peritoneal attachments of the testis, including the gubernaculum, which may carry collateral circulation to the testis. This study considers the anatomy of the gubernaculum and the collateral circulation after spermatic vessels ligation and its possible effects on the viability of the testis. The anatomy of the gubernaculum and the effect of spermatic vessels ligation on the collateral circulation were studied in 90 boys with 100 abdominal testes with a short pedicle. Patients with vanishing testis or those not needing ligation of the spermatic vessels were excluded from the study. The anatomy and the vascularity of the testis, gubernaculum, and vas were studied at initial laparoscopy and 6 weeks later after spermatic vessel ligation. Based on these findings, the technique for laparoscopically assisted orchiopexy were modified, preserving the gubernaculum whenever possible in cases having prominent collaterals. Based on the attachment and blood vessel configuration of the gubernaculum, the patients were divided into two groups: in group 1 (open internal ring), there were 46 testes in which the gubernaculum passed through an open internal ring having an inguinal attachment. In group 2 (closed internal ring), there were 54 testes with a soft gubernaculum attached to a closed internal ring without inguinal attachment. In group 1 the gubernaculum was short and tough in 32 of 46 testes, with no visible blood vessels in all cases. In group 2 the gubernaculum was long and soft in 43 of 54 testes and showing evident blood supply before clipping of the spermatic vessels in 30 testes. Subsequent laparoscopy done after 6 weeks showed prominent collateral circulation around the gubernaculum in 26 testes and around the vas in 20 testes in the group 1 patients, and around the vas in 20 and the gubernaculum in 34 testes in group 2. Preservation of the gubernaculum was possible in 43/54 (80%) of group 2 patients and in 14/46 (30%) of group 1 patients. Routine cutting of the gubernaculum is not necessary for proper mobilization of the abdominal testis: collateral circulation varies from patient to patient, and once the gubernaculum shows prominent blood supply, its preservation is mandatory. The decision to cut the gubernaculum should be taken while the performing initial spermatic vessel ligation and not during the second stage to avoid compromise of the settled collateral circulation.