Indications and Contraindications

Varicocelectomy is indicated in patients with significant (20% or more) size discrepancy with left testicular hypotrophy, bilateral testicular hypotrophy, pain attributable to the varicocele, and abnormal semen parameters, which usually manifest as low sperm counts, poor motility, or both. Laparoscopic varicocelectomy may be of particular benefit in those with prior groin surgery, such as hernia repair, wherein adhesions and scar tissue may complicate traditional open or subinguinal microscopic approaches. With appropriate presurgical planning to avoid additional incisions, the laparoscopic approach can also be of benefit in treating bilateral varicoceles. There is some evidence to suggest that prophylactic ligation of varicoceles in prepubertal boys may allow for improved potential fertility and testicular catch-up growth, although this remains debatable.

There are few contraindications to performing laparoscopic varicocele ligation. Instances in which an alternate approach may be prudent include patients with extensive prior abdominal or retroperitoneal surgery, infections such as those of the abdominal wall or peritonitis predisposing to dense adhesions, large abdominal wall hernias, respiratory or cardiac compromise precluding sufficient pneumoperitoneum, and uncorrected coagulopathy. Prior surgery in the area of concern, specifically prior suprainguinal varix ligation by any approach or inguinal hernia repair with mesh, can lead to dense adhesions, making identification and mobilization of structures considerably more challenging, and complications more likely. If the artery is not to be spared, prior surgery that may have potentially compromised collateral blood supply to the testes also becomes a contraindication. Finally, although not a contraindication per se, obesity can increase the technical difficulty of the procedure and increase the possibility for complications.

Patient Preoperative Evaluation and Preparation

The preoperative evaluation of the adolescent with a clinically significant varicocele is the same whether an open, microscopic, or laparoscopic approach is planned. A thorough history should elucidate details regarding discomfort (pain, heaviness, visible and palpable varices) along with exacerbating and alleviating factors, such as varicocele reduction during recumbency. Physical examination should focus on a complete genital examination with palpation of the cord in both the upright and supine positions, and with the patient performing the Valsalva maneuver. Size discrepancy between the testes is of particular importance and should be documented clearly. Abdominal examination is performed to exclude abdominal masses.

Routine laboratory studies can be performed before laparoscopic surgery. In the adult patient, baseline semen parameters can be obtained; however, this is generally considered unnecessary in the adolescent patient. Imaging of the abdomen or scrotum is not routinely necessary. An exception is the isolated right-sided varicocele, which merits evaluation of the retroperitoneum, abdomen, and pelvis with cross-sectional imaging to rule out an underlying malignant process. On occasion, ultrasonography of the scrotum and spermatic cord for other indications may detect subclinical varicosities, for which treatment is customarily not recommended.

In obtaining informed consent, the patient should always be counseled on the possibility of conversion to open surgery if it becomes unsafe to proceed laparoscopically. No bowel preparation is required for laparoscopic varicocele ligation, nor is there a need to make blood available. However, some surgeons may choose to type and screen blood because there is a small risk of bleeding. A single perioperative dose of a broad-spectrum antibiotic, such as cefazolin, should be administered before the start of the procedure.

Operating Room Configuration and Patient Positioning

The operating room configuration consists of a single monitor positioned at the foot of the bed, and an optional second monitor positioned for use by and across the operating table from the assistant and/or scrub nurse. The surgeon and assistant are positioned opposite one another, with the surgeon on the right side of the patient, facing the foot of the bed. The scrub nurse and any additional assistants are positioned behind the surgeon ( Fig. 44-1 ).

Operating room configuration. The surgeon stands on the right side and faces the monitor at the foot of the bed.

The patient should void before entering the operating room to avoid the need for urinary bladder catheterization at the time of operation. Place the patient in the supine position and take care to pad all potential pressure points. The patient’s arms can either be abducted on arm boards, making sure to leave enough room for the surgeon to work comfortably, or adducted and tucked. Securing the patient with wide tape over the legs, hips, and shoulders is not routinely done but does allow for safe rotation of the bed and steep Trendelenburg positioning should this become necessary during the procedure. After establishment of the pneumoperitoneum, the patient is situated in a slight Trendelenburg position and usually remains there throughout the duration of the procedure. Surgically prepare the skin from the level of the xiphoid down to the upper thighs, and laterally to the anterior superior iliac spines. The penis and scrotum should be included in the surgical field, which will allow for traction on the testicle to aid in identification of the ipsilateral spermatic vessels.

Operating Room Configuration and Patient Positioning

The operating room configuration consists of a single monitor positioned at the foot of the bed, and an optional second monitor positioned for use by and across the operating table from the assistant and/or scrub nurse. The surgeon and assistant are positioned opposite one another, with the surgeon on the right side of the patient, facing the foot of the bed. The scrub nurse and any additional assistants are positioned behind the surgeon ( Fig. 44-1 ).

Operating room configuration. The surgeon stands on the right side and faces the monitor at the foot of the bed.

The patient should void before entering the operating room to avoid the need for urinary bladder catheterization at the time of operation. Place the patient in the supine position and take care to pad all potential pressure points. The patient’s arms can either be abducted on arm boards, making sure to leave enough room for the surgeon to work comfortably, or adducted and tucked. Securing the patient with wide tape over the legs, hips, and shoulders is not routinely done but does allow for safe rotation of the bed and steep Trendelenburg positioning should this become necessary during the procedure. After establishment of the pneumoperitoneum, the patient is situated in a slight Trendelenburg position and usually remains there throughout the duration of the procedure. Surgically prepare the skin from the level of the xiphoid down to the upper thighs, and laterally to the anterior superior iliac spines. The penis and scrotum should be included in the surgical field, which will allow for traction on the testicle to aid in identification of the ipsilateral spermatic vessels.