Preoperative Planning
Palpate the spermatic cord while the patient is erect. Proceed with varicocele ligation in the setting of a palpable varicocele ( Table 108.1 ) in a patient who is infertile, has testicular hypotrophy, or has pain without other cause. Emerging, relative indications for varicocele ligation include azoospermia (30%–40% chance of developing ejaculated sperm after ligation) and low testosterone (50–100 ng/dL improvement in testosterone after ligation).
| Grade | Description |
|---|---|
| I | Varicocele only palpable during or after Valsalva maneuver on physical examination |
| II | Varicocele palpable on routine physical examination without the need for the Valsalva maneuver |
| III | Varicocele visible to the eye and palpable on physical examination |
The veins draining the testis, epididymis, and vas deferens connect with deep and superficial venous networks. The concept of varicocele ligation is to prevent the retrograde or reflux flow of warmer, corporeal blood traveling from the body to the testis and thereby improve testicular function. It is believed that the gonadal veins, characterized by their course from the scrotal to the retroperitoneum, are most susceptible to reflux and therefore are the main targets of ligation. The vasal veins that travel with the vas deferens in the spermatic cord are not ligated during varicocelectomy because they are not predisposed to reflux and become the main venous outflow channels after varicocele ligation.
Four surgical approaches are used for varicocele ligation: (1) subinguinal approach; (2) inguinal approach, in which the gonadal artery is spared; (3) retroperitoneal approach, in which the artery may be included in the ligation; and (4) laparoscopic approach, which offers varix ligation at the same level as the retroperitoneal approach ( Fig. 108.1 ). When performed for infertility, a recent meta-analysis concluded that techniques that use the operating microscope (inguinal or subinguinal) have the best clinical responses with the fewest complications.
Subinguinal Approach
Microscopic subinguinal varicocelectomy avoids a muscle-cutting incision. However, it is also associated with a higher density of ligatable pampiniform plexus veins. Microscopic visualization of lymphatic channels minimizes postoperative hydrocele, and identification and sparing of the gonadal artery is important for success.
Instruments: Operating microscope (10–12× magnification); fine vascular forceps; Jacobsen clamps; Kittner dissector; and a 1.5- to 3-mm, high-frequency Doppler ultrasound probe.
Position and incision: Position the patient supine and in slight reverse Trendelenburg position to distend pampiniform veins. Under intravenous sedation or general anesthesia, identify the external inguinal ring digitally by invaginating the scrotum. If intravenous sedation is used, infiltrate the skin overlying the ring with 1% lidocaine mixed with 0.25% bupivacaine. Make a 2- to 3-cm transverse incision directly over the external ring along the lines of Langerhans and continue through the subcutaneous layer until the Scarpa fascia is reached. Using the index finger, bluntly dissect through the Scarpa fascia and visualize the subinguinal spermatic cord within the wound.
Lightly grasp the cord with a Babcock clamp, draw it up slowly, and separate the cremasteric attachments with a Kittner dissector. Encircle the cord with a 1-inch Penrose drain. Clip or tie any perforating posterior cremasteric or external spermatic veins.
Insert a tongue depressor into the Penrose drain to provide a surgical platform, and with the aid of optical loupes or an operating microscope at 6× to 10× magnification, incise the external spermatic fascia ( Fig. 108.2 ). Grasp the edges of the external spermatic fascia with mosquito clamps and separate the edges to expose the contents of the cord.
Inspect the cord contents, looking for pulsations of the gonadal artery, and confirm the location of the “packet” of vas deferens and its associated vasal veins to avoid dissection of these structures. Dilated veins usually invest the artery, and these will require ligation ( Fig. 108.3 ).
Identify the internal spermatic veins within the pampiniform plexus and dissect them free with fine forceps or Jacobsen clamps. Ligate them with 4-0 or 2-0 silk ties or clips, beginning with the largest veins. Following ligation, division of the veins is optional.
Dissect around the gonadal artery and ligate veins that accompany it. Preserve the lymphatics, which appear as vein-sized, clear vessels within the cord. A 1.5-mm high-frequency (20-mHz) Doppler probe is an excellent aid to help identify and avoid the artery ( Fig. 108.4 ). Remember that in at least 25% of cases, more than one artery may be present. If the patient is awake, ask him to perform Valsalva maneuver to fill any missed veins. It is helpful to ligate internal spermatic veins in a line perpendicular to the cord to avoid redundant vein ligation ( Fig. 108.5 ). After all internal spermatic veins are tied, infiltrate the proximal spermatic cord with 0.25% bupivacaine using a 25-gauge needle inserted just beneath the external spermatic fascia parallel to the cord. Close the Scarpa fascia with two to three sutures of choice and the skin with a 4-0 running subcuticular suture.
An alternative technique described involves ligation of perforating scrotal veins. After the spermatic cord is identified and encircled with a Penrose drain, the testis is then delivered extravaginally into the wound without disrupting the gubernaculum. Dilated external spermatic and gubernacular veins are identified and ligated. Return the testis to the scrotum and proceed with dissection of the internal spermatic veins within the cord using the operative microscope as described for the subinguinal approach. This additional veins treated with this approach may help avoid recurrences after prior varicocelectomy, although this has been debated.
Inguinal Approach
This approach manages the internal spermatic veins at the level of the internal inguinal ring. It involves an incision into the external oblique fascia. However, it is an easier, more superficial dissection than the retroperitoneal approach. In obese patients, less assistance is required and can be done under local anesthesia.
Instruments: Same as above. A self-retaining skin retractor may also be helpful.
Position and incision: Position the patient supine. Make a 3-cm incision two fingerbreadths above the symphysis pubis in line with the lateral aspect of the scrotum (above the palpable external ring) and extending obliquely along the course of the inguinal canal.
Incise the Scarpa fascia and gently clear the connective tissue overlying the external oblique aponeurosis and external ring ( Fig. 108.6 ). Insert a self-retaining retractor and incise the aponeurosis along its fibers, beginning at the external ring and extending toward the internal ring. Avoid the ilioinguinal nerve beneath. Control the edges of the external oblique fascia with mosquito clamps, elevate the spermatic cord between the thumb and forefinger, and palpate the vas deferens and artery.
