LAPAROSCOPIC TREATMENT OF VARICOCELE IN CHILDREN
1945
DISCUSSION
TABLE 2. Indications for surgery
Indication
Third degree varicocele
No. Pts.
57
Several operative procedures may be used to treat pediat-
ric varicoceles. Some prefer to perform percutaneous embo-
lization or sclerosis, while others prefer open surgery with or
without a loupe or microscope magnification. A few perform a
microsurgical venous bypass. However, a review of the med-
ical literature of the last 5 years reveals that varicocele is
often treated via the laparoscopic approach in adulthood and
childhood.8, 9 For this reason and to analyze objectively the
results and pitfalls of laparoscopic treatment of varicocele in
children we evaluated data from a large (161) case series of
the Italian Society of Video Surgery in Infancy multicenter
study treated during a 3-year period.
The most striking evidence is the common trend of several
to adopt the laparoscopic technique for treating varicocele. In
fact, more than 82% of the patients in our current series
underwent the Palomo technique. This general tendency
seems to be associated with its lower recurrence rate, which
was 2.2% in our series, versus that of other procedures.8, 10, 11
Postoperatively venography indicated that recurrence in
our series may have been due to reflux through the deferen-
tial veins associated with obstruction of the left common iliac
vein. We think that this extremely rare event, which devel-
ops in about 5% to 10% of children with varicocele, may be
prevented by systematic venography in the preoperative pe-
riod or by also sectioning the deferential veins when laparo-
scopic examination shows that they are varicose compared
with the contralateral side. In our opinion the latter solution
is much better. To confirm this hypothesis we examined the
videos of 2 of the 4 recurrences in our series that were filmed
and noted dilated deferential veins associated with inner
spermatic vessel dilatation.12–15 Another interesting finding
is that during the operation 6.2% of the patients in our study
required another surgical procedure simultaneously with
varicocelectomy. A great advantage in children is that lapa-
roscopic view magnification enables the identification and
treatment of any other associated pathological condition,
such as a permeable peritoneal vaginal duct, or adhesions
due to previous appendectomy or another abdominal inter-
vention.
When criticizing the laparoscopic treatment of varicocele,
some mention high cost. We think that this problem is almost
eliminated when reusable trocars and instruments are ap-
plied. The only nondisposable instrument in our series was
the clips applier, which was sometimes replaced with tradi-
tional ligatures.16 On the other hand, in our series we ob-
served a high 5.6% rate of hydrocele associated with ligation
of the lymphatic vessels. This etiology was confirmed by the
analysis of hydrocele fluid in our patients, which revealed a
high protein content.
The Ivanissevich procedure seems to decrease the rate of
hydrocele by sparing the lymphatic vessels adherent to the
spermatic artery, although unfortunately it has a higher rate
of recurrence than the Palomo technique.17 In our experi-
ence, which confirms most reports in the literature, there
were no cases of testicular hypotrophy or atrophy using the
Palomo technique because the collateral blood supply to
the testis originated from the gubernaculum, anterior and
posterior scrotal vessels, intrascrotal anastomosis and defer-
ential vessels.10, 18, 19 On the other hand, we noted no im-
provement in spermatogenesis in our series because less
than 5% of our patients underwent semen analysis, mostly
due to young age at the time of intervention.
Pain or scrotal discomfort (varicocele degree):
First
Second
18
49
Testicular hypotrophy (varicocele degree):
First
Second
3
32
2
Varicocele recurrence after traditional open surgery
Total No.
161
lation, while in 20 (12.4%) only 2 trocars were needed. Liga-
tion of the veins only was done in 28 boys (17.3%) using the
Ivanissevich procedure, while ligation of the veins and artery
was performed in 133 (82.7%) by the Palomo technique.
In 22 patients (13.7%) the spermatic vessels were sectioned
and the posterior peritoneum was closed using separate
stitches and resorbable suture. In the other 139 cases the
posterior peritoneum remained open. In 10 children (6.2%)
an additional procedure was performed simultaneously, in-
cluding closure of a patent peritoneal vaginal duct on the
right side in 7 patients and sectioning of epiploic adhesions
between the intestinal loops and anterior abdominal wall due
to previous appendectomy in 3. The latter 3 boys had a
history of chronic abdominal pain after appendectomy, which
would have required laparoscopic exploration. Pneumoperi-
toneum pressure ranged from 8 to 14 mm. Hg (median 11).
RESULTS
All operations were completed via laparoscopy and no con-
version to open surgery was needed. Median operative time was
30 minutes (range 20 to 60) and median hospital stay was 24
hours (range 1 to 4 days). There were only 5 perioperative
complications (3.1%), including slight bleeding from the inner
spermatic vessels in 3 cases that resolved using clips and a
technical problem associated with blockage of a clips applier in
1. In addition, the light source broke during surgery in the
latter case.
Followup was 1 to 4 years (median 30 months), and in most
cases involved clinical examination, while only 14 (8.7%)
underwent ultrasonography or echo color Doppler ultra-
sound. We noted 13 (8%) major complications in our series,
including left hydrocele in 9 children (5.6%) who underwent
the Palomo technique, minor scrotal emphysema in 2 and
umbilical granuloma in 2. Granuloma was treated with ni-
trogen dioxide and scrotal emphysema resolved at the end of
the operation.
Of the 9 patients with hydrocele 3 underwent surgery via
the scrotal approach. In 2 boys the condition regressed nat-
urally and 1 with persistent recurrence after open surgery
was treated with scrotal punctures. In this case the hydrocele
resolved after 5 punctures during a 1-year period. The other
6 patients were treated with scrotal puncture. In 4 boys who
underwent therapy every 2 to 3 months hydrocele disap-
peared within a median of 12 months. In the remaining 2
cases hydrocele persisted after 2 punctures but was de-
creased in size.
We observed 4 recurrent varicoceles (2.4%) in our series,
including 1 after the Ivanissevich procedure (1 of 28 cases or
3.5%) and 3 after the Palomo technique (3 of 133 or 2.2%).
These 4 children underwent venography postoperatively
to identify the possible cause of recurrence. After the
Ivanisevich procedure venography showed varicocele
through a residual internal spermatic vein that was probably
not sectioned at surgery. After the Palomo technique the
study revealed recurrence through the deferential veins. Re-
peat laparoscopic surgery resolved the problem in these 4
CONCLUSIONS
Our preliminary experience shows that the recurrence and
children. To verify improvement in the affected testis fol- complication rates of the laparoscopic approach are compa-
lowup should continue even during puberty and include sper- rable to if not better than those of the open or radiological
miography as well.
approach.5, 8, 20 However, laparoscopy seems to have a great
Weith
