Identification and protection of testicular artery is of upmost importance. Pulsations of the artery should be inspected but it is not always possible to observe. To aid identification of artery and separation of it from the adjacent veins, micro-Doppler should be introduced before fine dissection of the spermatic cord (Fig. 16.3). Internal spermatic artery may be small in diameter or it may get smaller in diameter due to manipulations of the spermatic cord. In this case irrigation of the field with lidocaine 1 % solution or papaverine (30 mg/mL) diluted in a 1:5 ratio with saline helps to dilate the artery. Systemic hypotension due to anesthesia may also complicate identification of the artery. In this case the anesthesiologist should be requested to increase the systolic blood pressure over 100 mmHg. After identification of the artery, care the surgeon should take care of it throughout the surgery to protect and should be identified several times while performing fine dissection of the other structures.

After identification of the artery, internal spermatic veins should be ligated and divided. For ligation 3–0 or 4–0 silk is generally used. However we use titanium surgical clips for venous occlusion. While dividing the veins, special care for preservation of lymphatic vessels should be given. Optical magnification aids in identification of the lymphatics and it is responsible for decreased rates of hydrocele following sub inguinal varicocelectomy. After ligation of all veins, dissection of the cremasteric fibers should be performed and any cremasteric arteries identified should also be preserved.