Obtaining sufficient length on the vas deferens is a critical portion of the early stages of the operation. Vas deferens exposure is generally accomplished by making parallel paramedian incisions in the scrotum. Midline incisions have been used successfully for this technique but limit the surgeon’s ability to extend the incision cephalad for increased vas exposure. The testicle can be used as a backing to facilitate this incision. Alternatively, incision through the skin and blunt dissection through the Dartos muscle can mobilize the cord adequately to deliver the testicle. The vas deferens is isolated and transected near the level of the convoluted vas or at the site of the prior vasectomy, preserving as much length and perivasal tissue as possible. Blunt dissection with the tip of a finger, the use of a Penfield osteal elevator, or Peanut is often helpful to push away loose connective tissue [5]. Extending the incision to the level of the inguinal canal is occasionally necessary to achieve adequate vasal length. A useful tool for transection of the vas deferens and the epididymis is the slotted nerve clamp (Accurate Surgical and Scientific Instruments, ASSI NHF2-ASSI NHF6 for sizes ranging from 2.0 to 6.0 mm) [7]. An ultrasharp blade (Accurate Surgical and Scientific Instruments, ASSI-CBS-35) fits through the slot in this nerve holder and makes excellent 90° cuts. The blade dulls quickly after 2–3 cuts.

The vas deferens is mobilized sufficiently to achieve a tension-free length that will easily meet the epididymis. Preserving perivasal adventia and sheath is important to preserve blood supply and assist in subsequent closure [7]. After verifying abdominal vasal patency with a 2-0 nylon suture, saline vasogram, methylene blue vasogram, or contrast vasography, the abdominal vas deferens is sutured to the posterior edge of the epididymal tunic with 2–3 interrupted 9-0 nylon sutures. Some surgeons prefer using the Microspike approximator (ASSI, Westbury, New York) to align the vas deferens and epididymis at this step [7]. The vas deferens should be transected cleanly after control of the vasal vessels. One of the authors uses 6-0 prolene suture to control the vessels, other surgeons use 6-0 nylon or bipolar cautery.

The epididymis is inspected for signs of obstruction. The most distal portion of unobstructed appearing epididymis is transected leaving multiple tubules exposed (Fig. 5.1). Gentle irrigation of these tubules by the surgical assistant will expose the single tubule effluxing fluid. Only the tubules above the level of obstruction will efflux sperm. Examination of the fluid under 200–400× light microscopy will reveal motile or nonmotile sperm from this tubule. If no fluid is identified, repeat sectioning of the epididymis at a higher level will ultimately lead to identification of an unobstructed tubule. This process should be continued until many normal-appearing, motile sperm are identified in the epididymal fluid. The presence of only sperm parts suggests an additional obstruction above that level with an associated lower rate of patency [2]. Aspiration of sperm for cryopreservation is an option at this point.

Using the end–end EV technique, it is often necessary to mobilize the epididymis free from the testis by incising the tunical plane between the testis and epididymis distally. Care must be taken not to injure epididymal blood supply. This is usually less evident in the cauda epididymis. Occasionally, the medial and inferior epididymal arteries may need to be ligated, often at the corpus or cauda epididymis level. The superior epididymal vessels need to be preserved at the caput epididymis. Once the epididymis is transected at the correct level the cut tubule edges may be outlined by applying methylene blue to the cut end.

Anastomosis to a single cut tubule is recommended. If fluid effluxes from more than one site, reevaluation of the tubules under high magnification should be performed. Further transection to isolate a single tubule may be needed. The lumen of the epididymal tubule is anastomosed to the vasal mucosal lumen with equally spaced, inside-out, double-arm 10-0 Nylon sutures [5]. Facilitating the placement of all three stitches, the first stitch is placed at 6 o’clock and tied, but the other three stitches are placed prior to tying (Fig. 5.2). Care must be taken not to tangle these sutures. Wide bites for the mucosal sutures should be avoided. Wide bites have the risk of occluding an adjacent convoluted epididymal tubule. The seromuscular layer of the vas and visceral tunica vaginalis overlying the epididymal tubules are approximated with interrupted 9-0 Nylon sutures (Fig. 5.3). Meticulous hemostasis is essential to ensure the maximal chance for patency. The parietal tunica vaginalis is approximated with absorbable suture and the testicle is replaced within the scrotum.

Needles and suture choices are important to the success of this operation (Table 5.1). For the thick seromuscular layer of the vas deferens, the Ethicon 9-0 nylon (6 in. length) on a vas100-4 cutting needle (Ethicon, Johnson and Johnson) is sturdy and very effective. For mucosal vas surface to epididymal tubule, a more delicate needle is required. The Sharpoint 10-0 nylon (1 in.) double-arm suture with a 70 μm needle is very effective for the mucosal anastomosis (Surgical Specialties Corporation, Reading Pennsylvania, USA). The Ethicon 10-0 nylon (single arm, 6 in.) on a BV100-3 taper needle (Ethicon, Johnson and Johnson) can be a good choice; however, the shape of the needle is not as ideal as the Sharpoint 3/8 circle needle described above. Careful needle handling is necessary to minimize bending of the needle and dulling of the point for many of these needles.