Fig. 3.1
A 2–3 cm incision is typically made in a subinguinal location, just lateral to the base of the penis, a few centimeters caudal to the external ring
Skin is incised sharply, and the deep dermal layer and subcutaneous adipose tissue are divided with electrocautery, taking care to stay superficial to avoid inadvertent injury to the spermatic cord. The authors prefer an insulated needle-tip for the monopolar electrocautery. Twenty watts works well for performing the initial skin incision, and power is reduced to 15 W when later working on gross structures in the spermatic cord. Bipolar cautery is mandatory to have as well, when later isolating individual structures in the vascular portion of the cord.
Retraction with Army-Navy retractors can then be used to bluntly dissect tissue down to Scarpa’s fascia (Fig. 3.2), which is then entered bluntly with the retractors or by spreading with the tips of a Metzenbaum scissors. Retraction parallel to the spermatic cord should then quickly identify the cord. Slight traction on the ipsilateral testis will show motion in the cord to aid identification if needed. The lateral and medial aspects of the cord are then exposed by spreading with a Metzenbaum scissors. Spreading is most effective and less traumatic to the cord if it is done parallel to the cord, rather than perpendicular. Once freed from attachments to tissues in the prepubic space, the cord can be atraumatically grasped with a Babcock or spermatic cord clamp and brought up into the incision. Some blunt finger dissection along the surface of the cord in the cranial and caudal direction is usually required to further release any attachments between the cord and prepubic adipose tissues, allowing the cord to be brought up above the level of the skin. Palming the Babcock in the dominant hand, hooking the dominant index finger underneath the cord, and then using a 4″ x 8″ sponge for blunt, gentle, sweeping will help isolate the cord circumferentially from the surrounding tissues (Fig. 3.3). The isolated cord is elevated with a Penrose or Army-Navy and the prepubic space is inspected for any external cremasteric veins, which are then ligated. Loupes may be of help in identifying these veins.
Fig. 3.2
Army-Navy retractors are used to bluntly dissect tissue down to Scarpa’s fascia, which is then entered bluntly with the retractors or by spreading with the tips of a Metzenbaum scissors
Fig. 3.3
A Babcock clamp is used to bring the spermatic cord up through the skin inclsion
After isolation of the cord, we find that suspension of the cord above the skin level is best performed by passing the Army-Navy under the cord (Fig. 3.4). Other surgeons may prefer an empty scalpel handle or Penrose to similarly keep the cord elevated. In cases of bilateral varicocelectomy, a Penrose drain tagged around the cord works well to maintain control of the cord while the contralateral incision is performed, prior to bringing in the operative microscope.
Fig. 3.4
After isolating the cord, it is suspended above the skin level by passing the Army-Navy under the cord
Under microscopic view, the external spermatic fascia, cremasteric muscle fibers, and internal spermatic fascia are then opened along the direction of the cord with electrocautery (Fig. 3.5). Often, these three layers essentially separate out as one. A bundle of spermatic fasciae and cremasteric muscle fibers is then isolated medially and laterally, and these are retracted perpendicularly from the cord in opposite directions with blue microvessel loops (Fig. 3.6). This maneuver helps expose the vas deferens and vascular elements of the cord.
Fig. 3.5
Under microscopic view, the external spermatic fascia, cremasteric muscle fibers, and internal spermatic fascia are then opened along the direction of the cord with electrocautery
Fig. 3.6
A bundle of spermatic fasciae and cremasteric muscle fibers is isolated medially and laterally, and retracted perpendicularly from the cord in opposite directions with blue microvessel loops
Before further dissection or manipulation of the cord, the 20 MHz microvascular Doppler (Vascular Technology—Nashua, NH) is used to survey the cord for arteries (Fig. 3.7). Significant manipulation of the cord can cause vasospasm of the artery(ies), so Doppler exam is performed first to identify the number and relative position of arteries before the fine dissection is begun. If vasospasm occurs or is suspected during the dissection, application of papaverine (30 mg/mL) diluted in a 1:5 ratio with saline to the operative field via a 5 cc syringe with 24 G angiocatheter will help dilate the arteries to aid in Doppler identification.
Fig. 3.7
A 20 MHz microvascular Doppler (Vascular Technology—Nashua, NH) is used to survey the cord for arteries
Technical Pearls
The goals of cord dissection are to: (1) identify and preserve the vas deferens and vasal vessels, (2) identify and preserve any internal spermatic arteries, (3) preserve adequate lymphatic channels, and (4) ligate and divide any veins of the pampiniform plexus and preferably cremasteric layer as well.
A fine Jacobson mosquito is the authors’ preferred dissection instrument. Some surgeons find a fine Detrich right angle useful for blunt dissection as well. Microsurgical forceps are a necessity; we prefer the 8″ Pierse microsurgical forceps. We prefer to isolate the vas and vasal vessels first (Fig. 3.8), as to avoid inadvertent later injury to these vital structures. Microdissection is then performed to isolate the internal spermatic arteries, during which obvious veins are double ligated with 4-0 silk ties or vascular titanium clips (Horizon™) and sharply divided using Westcott scissors. Liberal utilization of the Doppler probe is advised to verify that any vessel or tissue about to be ligated is not arterial, and also to periodically identify the patency of the arterial supply elsewhere in the cord. Any packets of vascular elements that have a Doppler-identified arterial wave pulse are looped with a red vessel loop, and retracted for later meticulous dissection. The internal spermatic artery(ies) invariably lie within the venous plexus, and very commonly have closely associated veins or lymphatic structures. Once artery-containing vascular bundles are isolated and the whole spermatic cord is superficially/grossly dissected, fine dissection of individual packets is then performed.
Fig. 3.8
The vas and vasal vessels are isolated to avoid inadvertent later injury to these vital structures
To separate other structures off the artery of interest, a few technical aspects have been found to be very useful. A very fine-tipped instrument such as a curved micro-forceps can tease an adherent vein off the artery (Fig. 3.9). This should only be done under situations of fine dissection where all structures are well seen, because the sharp-tipped instrument may easily disrupt the arterial wall. Fine veins separated off the artery are then ligated with bipolar electrocautery. Care must be taken to NEVER to use monopolar cautery in this setting, as the current will conduct down the artery when such fine structures have been isolated. A fine-tipped bipolar cautery forceps can be used for fine dissection of structures off the artery as well, which then allows bipolar cauterization of the structure without the need to change instruments. Any small-caliber lymphatics separated from the artery are spared.
Fig. 3.9
A micro-forceps can tease an adherent vein off the artery
Constant watch for lymphatic channels is performed while dividing veins of the pampiniform plexus and isolating and preserving any arteries. Lymphatics are frequently identified superficially just below the internal spermatic fascia or often are found near the internal spermatic arteries. A minimum of 1–2 lymphatics are all that is probably necessary to prevent a postoperative hydrocele, but the authors prefer to isolate at least 4–5, after which any additional obvious lymphatics are spared, but extremely fine dissection looking for further lymphatics is not typically pursued because of the low rate of hydrocele formation once multiple lymphatics have been identified and preserved. Occasionally it will be difficult to tell a very small lymphatic vessel from a vein, in which case moving on to another portion of the dissection and then later reexamination of the vessel may be elucidative; otherwise it should be ligated as long as significant lymphatics have otherwise been spared.
After dissection of the vascular structures of the cord beneath the internal spermatic fascia, with preservation of the vas deferens and vasal vessels, lymphatic vessels, and internal spermatic arteries, the layers of spermatic fasciae and the cremasteric muscle fibers are then addressed. These bundles had previously been retracted laterally and medially with blue vessel loops. The Doppler device can be used to identify any significant arterial wave pulses, but these are often not able to be identified. An occasional sizeable cremasteric artery can be identified and preserved. Provided that sufficient internal spermatic arteries are identified and preserved, the cremasteric fibers can then be ligated and divided. These are typically doubly suture-ligated with silk ties and sharply divided (Fig. 3.10). The authors will commonly leave 1/3–½ of the cremasteric fibers doubly ligated but not divided. The theory is this will maintain a bit of cremasteric reflex for the ipsilateral testicle, and will provide some support so the arterial structures are theoretically less at risk for traction injury. Significant venous collaterals can be found in the cremasteric layer, so ligation of this layer should reduce the incidence of recurrence of the varicocele. Some surgeons routinely deliver the testicle to ensure that any gubernacular collaterals are also disrupted, but this may not be necessary given the low baseline recurrence rates with modern microscopic techniques. Data exist to support equivalent outcomes with and without delivery of the testis [22, 23].
