Long Loop Vas – A Rare Entity

Case Report and Review of Literature

Abstract

Long loop vas, encountered during orchidopexy for undescended testis, is a rare entity and deserves a note. We report the case of an 8-year-old child who presented with pain in the left groin and was clinically diagnosed to have undescended testis and palpable in the left groin. Ultrasonography confirmed the presence of testis in the left inguinal region. The incidental finding of long loop vas intraoperatively mandates careful dissection during surgery to preserve the viability of the testis. Examination for a looping vas by inspecting structures caudal to the testis should be done during orchidopexy to avoid inadvertent transection. In view of paucity of literature of long loop vas, our aim is to enhance the already existing scanty literature and suggest the effective single-stage management of this rare condition.

INTRODUCTION

Long loop vas is a rare entity. After extensive search of literature on PubMed, Index Medicus, and Google Scholar, we found only four articles reported in the English literature till date.[¹²³⁴] Further, it is still difficult to identify during surgery as such entity is rare and hence not known to many surgeons. The long loop vas should be dissected very carefully to preserve the blood supply to testis, as collaterals run by the side of the vas deference and also accidental damage to vas should be prevented.[²³] Here, we report the case of an 8-year-old child who presented with undescended testis, and during orchidopexy, we found long loop vas which was carefully dissected and preserved. This case highlights the possibility of anatomical variations and the importance of keeping them in mind to prevent complications at time of surgery.

CASE REPORT

An 8-year-old child presented with pain in the left groin region and empty left scrotum since birth. There was no other significant history. On examination, per abdomen was soft and there was evidence of lump palpable at the superficial inguinal ring in the left inguinal region. Scrotal examination revealed right testis descended retractile, and the left side of the scrotum was empty. Penis was normal and prepuce was retractile.

Ultrasonography examination of the abdomen and pelvis with scrotum was suggestive of left undescended testis in the inguinal region. Right testis was descended in the scrotum.

The patient was planned for left-sided open orchidopexy. A small skin incision was taken along the left inguinal crease and the incision was deepened. Gubernaculum was separated under vision; long loop vas was safeguarded. Sac opened testis was everted, and sac was separated from cord structures. Sac was cut, transfixation with high ligation was done, and adequate length was achieved. Testis was brought out through separate scrotal incision, and three-point fixation was done in subdartos pouch. Scrotal incision was closed with vicryl 3-0 and groin incision closed in layers with skin subcuticularly.

The patient was given single-dose injectable antibiotic at the time of surgery. Postsurgery, normal diet was resumed after 4 h. The patient was discharged the next day.

Figure 1: Long loop vas -, Testis-, testicular vessels-

On follow-up, after 8 days postoperation, left groin sutures were removed. On follow-up, after 15 days postoperation, the child is healthy and operative area healed with testis in the left scrotum.

DISCUSSION

Cryptorchidism occurs because of both failure of migration congenitally and failure of elongation of the spermatic cord postnatally. The configurations of epididymides and vas deferens in the undescended testes are also affected due to these problems.[²]

There are six reported anatomical variations (Turek et al.) of epididymis and the most common one is type 1. Their data revealed that the incidence of epididymal abnormalities in undescended testis was 41%.[³]

Elongated epididymis is an abnormality encountered most frequently in patients who have an undescended testis. To clarify the implication of this anomaly in the testicular descent, the anatomic configuration of paratesticular structures, especially the site of cranial attachment of the gubernaculum in relation to the configuration of the vas deferens, was evaluated by Abe et al. in 54 undescended testes of 44 patients. Undescended testis was associated with an elongated epididymis in 42.5% of these cases. Of these, the cranial gubernaculum was attached solely to the vas deferens in 73.9%. In this group, the cranial gubernaculum was attached to the most descended part of the loop of the vas deferens.[³]

Ductal abnormalities are reported in the literature and have an incidence of 10%–27% in infertile patients compared to 0.5%–1% in the normal population. Bilateral absence of the vas deferens is the most common abnormality and occurs in 1%–2% of men presenting with infertility. Males with the absence of the vas deferens commonly have other urogenital anomalies.[¹²] Variations in the testicular anatomy have also been reported including cryptorchidism, polyorchidism, monorchidism, and testicular agenesis. Anatomical abnormalities of the vas deferens and epididymis are reported in many studies of cryptorchidism.[³]

Long loop vas is a rare entity. After extensive search of literature on PubMed, Index Medicus, and Google Scholar, we found only four articles reported in the English literature till date.[¹²³⁴]

Long loop vas could be encountered both in palpable and nonpalpable undescended testis. During open surgery, careful identification and dissection of long loop vas are mandatory. Identification of the vas among cord structures may provide false reassurance of normal ductal anatomy. Examination for a looping vas by inspecting structures caudal to the testis should occur at an early opportunity during orchidopexy to avoid inadvertent transection.[⁴] The long loop vas should be dissected very carefully to preserve the blood supply to testis, as collaterals run by the side of the vas deference and also accidental damage to vas should be prevented.[¹] Anatomical studies have demonstrated that testicular blood supply in the undescended testes is primarily through three sources – the internal spermatic artery, the deferential artery, and the cremasteric artery.[⁵⁶⁷] Fowler and Stephens concluded that the testicular artery was an end artery after entering the testis but received constant collaterals communication from the deferential and cremasteric artery close to its entry point into the testicular parenchyma.[⁵] Sampaio et al. showed that all human fetal testes are at least supplied by the testicular and deferential arteries.[⁶] The cremasteric artery, which enters the testis at its lower pole close to the gubernacular attachment, was an additional source in up to 72% of testes, as per one study.[²] The cremasteric component of the blood supply was least developed in true intra-abdominal testes and more prominent in the descended testes. The degree of vasoepididymal separation and the location of the testis also impact the presence of these collateral channels between the testicular and deferential arteries.[⁷⁸]

Fowlers–Stephens orchidopexy with high testicular vessel ligation is ideally suited for testis associated with long loop vas.[⁵] While dealing with long loop vas during open orchidopexy,[¹] Koff and Sethi modified the procedure especially to allow unfolding of long loop vas while preserving the collateral flow from deferential artery.[⁸]

Several studies have confirmed the higher testicular atrophy rate when testicular vessels are transected during orchidopexy compared to procedures where the testicular vessels are preserved.[⁹¹⁰] However, when the testis can be easily brought down as in our case after proper mobilization and meticulous preservation of long loop vas, Fowlers–Stephens ligation of the testicular vessels is not required, and entire procedure can be accomplished in single stage without compromising the vascularity.

Surgical options for intra-abdominal testes include laparoscopic orchidopexy, Fowler–Stephens orchidopexy (performed laparoscopically or open and in a staged manner or as a single stage), testicular auto-transplantation, and an open-staged procedure without vessel transection. The important principles of the Fowler and Stephens operation include early assessment and commitment during testicular mobilization to proceed with Fowler and Stephens operation to preserve a wide strip of peritoneum between vas and testicular vessels as well as the cremasteric and gubernacular vessels.[²⁵] For nonpalpable intra-abdominal testis, the presence of long loop vas was associated with a higher atrophy rate following laparoscopic second-stage Fowler–Stephens orchidopexy. Laparoscopic management of the long loop vas may be more challenging, and therefore, in such cases, open Fowlers–Stephens orchidopexy may result in better success rate by preserving the integrity of the collateral vessels.[²]

CONCLUSIONS

Long loop vas is a rare entity. The presence of long loop vas was associated with a high rate of complication of testicular atrophy if not dissected properly from collateral vessels supplying testis and also in preventing injury to the vas. This case reminds us the possibility of anatomical variations and the importance of keeping them in mind to prevent complications at time of surgery. Almost all the studies mention staged procedures for long loop vas; however, single-staged orchidopexy can be accomplished without any difficulty with proper dissection and safeguarding the vas as in our case. Examination for a looping vas by inspecting structures caudal to the testis should be done during orchidopexy to avoid inadvertent transection. However, two-staged orchidopexy is recommended according to the literature for both open and laparoscopic techniques for palpable and nonpalpable testis with long loop vas, respectively. In view of a paucity of literature of long loop vas, our aim is to enhance the already existing scanty literature and suggest the effective single-stage management of this rare condition.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.