What the Anesthesiologist Should Know before the Operative Procedure
Orchiopexy is the surgical fixation of an undescended testicle into the scrotum. Surgical approach, often determined by palpability of the testis, can vary from a two-stage laparoscopic intraabdominal autotransplantation (Fowler-Stephens procedure) to inguinal exploration and mobilization to scrotal incision with a tacking stitch. Cryptorchidism, the absence of at least one testicle in the scrotum, has a reported incidence of 2.5%-9% in full term male infants, which decreases to 1%-2% by the first year of life. Incident increases with prematurity, low birth weight, and intrauterine hormonal interference. Although it is associated with certain syndromes (i.e., Prader-Willis, Noonan’s), it is typically found in isolation.
Left untreated, cryptorchidism is associated with decreased fertility (if bilateral), testicular atrophy, and malignancies. Histological changes in undescended testicle can be seen as early as 9 months of age. The risk of developing cancer is approximately 5 times great than normal for an undescended testicle regardless of location. Risk of malignancy decreases to that of the general population if surgical correction is performed by 10 years of age. Ideally, orchiopexy should be performed between 6 and 12 months of age.
1. What is the urgency of the surgery?
What is the risk of delay in order to obtain additional preoperative information?
These procedures are performed electively.
2. Preoperative evaluation
There are no special considerations for otherwise healthy boys between 6-12 months of age undergoing orchiopexy. For Noonan’s syndrome, the presence and severity pulmonary stenosis should be determined. For Prader-Willi syndrome, hypotonia and developmental delay may be confounding factors
3. What are the implications of co-existing disease on perioperative care?
For otherwise healthy male patients between 6-12 months of life, a complete history and physical should be obtained.
b. Cardiovascular system
Pulmonary valvular stenosis (Noonan’s syndrome) is associated with pulmonary valvular stenosis and cryptorchidism.
Obstructive sleep apnea in older children with Prader-Willi syndrome.
Chronic disease: Developmental delay (Noonan’s and Prader-Willi syndromes)
Abnormal glucose tolerance test and insulin levels in older children with Prader-Willi syndrome
g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
Hypotonia (Prader-Willi syndrome)
4. What are the patient's medications and how should they be managed in the perioperative period?
h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
i. What should be recommended with regard to continuation of medications taken chronically?
j. How To modify care for patients with known allergies –
k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
l. Does the patient have any antibiotic allergies- [Tier 2- Common antibiotic allergies and alternative antibiotics]
m. Does the patient have a history of allergy to anesthesia?
Malignant hyperthermia (MH)
Documented: Avoid all trigger agents such as succinylcholine and inhalational agents:
Family history or risk factors for MH: Patients with an immediate family member with a positive MH history should not be exposed to triggering agents.
Local anesthetics/muscle relaxants: Patients with known allergies to local anesthetics should not receive regional or field blocks. Multiple analgesics are available to prevent/treat postoperative pain.
5. What laboratory tests should be obtained and has everything been reviewed?
ECG, echocardiogram for children with Noonan’s Syndrome
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
Surgical technique is determined by the preoperative evaluation. Patients with palpable testicles within the inguinal canal will be repaired by an approach similar to that of a herniorrhaphy while those with nonpalpable testicles will undergo a laparoscopic exploration to identify the testicle (if present) and then a single or two step procedure to mobilize and relocate the testicle to the scrotum.
a. Regional anesthesia –
Benefit: Neuraxial blocks offer the advantage of anesthesia and postoperative analgesia for patients undergoing scrotal, inguinal, and/or intraabdominal surgeries.
Drawbacks: Children 6-12 months of age will require general anesthesia or sedation to cooperate with block placement.
Issues: GA combined with a caudal block using local anesthetics of intermediate duration alone or in combination with preservative-free analgesics or adjuncts is a popular approach.
Peripheral nerve block
Benefit:Peripheral blocks offer the advantage of unilateral anesthesia and postoperative analgesia for patients undergoing unilateral inguinal repairs while avoiding the delivery of unneeded anesthesia/analgesia to the contralateral side or lower extremities.
Drawbacks: The patients will require general anesthesia or sedation to cooperate with block placement. Peripheral nerve blocks may be inadequate for complex repairs and laparoscopic approaches.
Issues: Ultrasound guided placement of these blocks has increased their use and safety.
b. General Anesthesia
Benefits: GA ensures cooperativity for block placement, if used, and surgery. GA may be necessary for complex repairs and techniques using laparoscopy.
Drawbacks: Complications and side effects associated general anesthesia can be observed in these patients including laryngospasm, postintubation croup, and postoperative nausea and vomiting.
Airway concerns: During simpler and brief procedures laryngeal mask airways can be used. For children undergoing longer explorations, endotracheal intubation is a common practice.
c. Monitored Anesthesia Care
6. What is the author's preferred method of anesthesia technique and why?
For otherwise healthy children undergoing orchiopexy, an inhalation induction with sevoflurane, insertion of a laryngeal mask airway (LMA) or an endotracheal tube, and placement of a caudal block with ropivacaine is our preferred technique. With an LMA in place, sevoflurane is the maintenance agent of choice; with an endotracheal tube, sevoflurane or desflurane can be used. The addition of opioids, ketamine, and clonidine has been shown to prolong and intensify caudal blocks but can also be associated with increased postoperative sedation. A one-time dose of rectal acetaminophen may be given to supplement the postoperative analgesia supplied by the caudal block. Because patients undergoing orchiopexy are at moderate to high risk for postoperative nausea and vomiting, ondansetron and dexamethasone are given intravenously
What prophylactic antibiotics should be administered?
What do I need to know about the surgical technique to optimize my anesthetic care?
In patients with nonpalpable testicles, laparoscopic exploration and surgery can be very brief or extend in duration. Endotracheal intubation is best performed at the beginning of the case regardless of planned duration.
What can I do intraoperatively to assist the surgeon and optimize patient care?
Even with GA and a working caudal block, laryngospasm can occur during spermatic cord manipulation. The level of general anesthesia should be deepened during this step of the procedure.
b. If the patient is intubated, are there any special criteria for extubation?
If possible, extubation should be timed to minimize the amount and degree of “bucking” so as not to compromise the surgical repair.
c. Postoperative management
What analgesic modalities can I implement?
If intraoperative blocks appear not to be sufficient, use of intravenous ketorolac can be effective while avoiding the side effects of opioids.
What level bed acuity is appropriate?
Orchiopexy is most often an ambulatory procedure.
What are common postoperative complications, and ways to prevent and treat them?
Common postoperative complications include (1) emergence delirium which can be treated with propofol, fentanyl, midazolam, and/or dexmedetomidine and (2) postoperative nausea and vomiting, which can be treated with ondansetron and dexamethasone, (if not already given intraoperatively), promethazine, granisetron, hydroxyzine, and/or dimenhydrinate.
What's the Evidence?
Ansermino, M, Basu, R, Vandebeek, C, Montgomery, C. “Nonopioid additives to local anaesthetics for caudal blockade in children: a systematic review”. Paediatr Anaesth. vol. 3. 2003. pp. 561-73. (A system review paper that compares caudal duration of analgesia with and without additives to local anesthetics.)
Breschan, C, Jost, R, Krumpholz, R, Schaumberger, F, Stettner, H, Marhofer, P, Likar, R. “A prospective study comparing the analgesic efficacy of levobupivacaine, ropivacaine and bupivacaine in pediatric patients undergoing caudal blockade”. Paediatr Anaesth. vol. 15. 2005. pp. 301-6. (A prospective comparative study evaluating levobupivacaine, rupivacaine and bupivacaine for caudal block in children.)
Elyas, R, Guerra, LA, Pike, J, DeCarli, C, Betolli, M, Bass, J, Chou, S, Sweeney, B, Rubin, S, Barrowman, N, Moher, D, Leonard, M. “Is staging beneficial for Fowler-Stephens orchiopexy? A systematic review”. J Urol. vol. 183. 2010 May. pp. 2012(An elecronic literature database search comparing 1- and 2-staged Fowler-Stephens orchiopexy. Although both stages have high success rates, the 2-stage procedure had a slightly better odds ratio.)
Khalil, SN, Matuszczak, ME, Maposa, D, Bolos, ME, Lingadevaru, HS, Chuang, AZ. “Presurgical fentanyl vs caudal block and the incidence of adverse respiratory events in children after orchidopexy”. Paediatr Anaesth. vol. 19. 2009. pp. 1220-5. (A comparison of caudal block to intravenous fentanyl in children undergoing elective orchiopexy. Patients with a caudal had less post-extubation adverse upper airway events.)
Ozdamar, D, Güvenç, BH, Toker, K, Solak, M, Ekingen, G. “Comparison of the effect of LMA and ETT on ventilation and intragastric pressure in pediatric laparoscopic procedures”. Minerva Anestesiol. vol. 76. 2010. pp. 592-9. (A small sample size study suggesting that LMA classic is suitable for laparoscopic surgery in children.)
Ritzén, EM. “Undescended testes: a consensus on management”. Eur J Endocrinol. vol. 159. 2008. pp. S87-90. (A set of recommendations for the management of undescended testes.)
Weintraud, M, Lundblad, M, Kettner, SC, Willschke, H, Kapral, S, Lönnqvist, PA, Koppatz, K, Turnheim, K, Bsenberg, A, Marhofer, P. “Ultrasound versus landmark-based technique for ilioinguinal-iliohypogastric nerve blockade in children: the implications on plasma levels of ropivacaine”. Anesth Analg. vol. 108. 2009. pp. 1488-92. (The use of ultrasound for ilioinguinal iliohypogastric nerve blocks results in faster absorption and higher plasma concentrations when compared to a landmark injection technique.)
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- What the Anesthesiologist Should Know before the Operative Procedure
- 1. What is the urgency of the surgery?
- What is the risk of delay in order to obtain additional preoperative information?
- 2. Preoperative evaluation
- 3. What are the implications of co-existing disease on perioperative care?
- b. Cardiovascular system
- c. Pulmonary
- d. Renal-GI:
- e. Neurologic:
- f. Endocrine:
- g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
- 4. What are the patient's medications and how should they be managed in the perioperative period?
- h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
- i. What should be recommended with regard to continuation of medications taken chronically?
- j. How To modify care for patients with known allergies -
- k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
- l. Does the patient have any antibiotic allergies- [Tier 2- Common antibiotic allergies and alternative antibiotics]
- m. Does the patient have a history of allergy to anesthesia?
- 5. What laboratory tests should be obtained and has everything been reviewed?
- Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
- 6. What is the author's preferred method of anesthesia technique and why?
- a. Neurologic:
- b. If the patient is intubated, are there any special criteria for extubation?
- c. Postoperative management