Vasectomy is a reliable procedure to attain permanent male sterilization. Interested men should be counseled on the nature of the procedure; the risks; what to expect before, during, and after the procedure; failure rates; the permanent intent of the procedure; and the need for continued contraception after vasectomy until azoospermia is confirmed. In many practices, vasectomies are performed as an office procedure, and men are offered benzodiazepine 30 minutes to 1 hour before the procedure. Typically, vasectomies are most easily performed in a warm room to allow the scrotum to relax and the vas deferens to be easily identified. The procedure is started with a standard surgical prep. Informing the patient of what to expect along the course of performing the vasectomy, so there are no “surprises,” is key. This minimizes patient anxiety and will help attain an overall positive experience for the patient.
The vas deferens is first isolated from the adjacent cord structures and manipulated to the scrotal midline approximately one third the distance from the penoscrotal junction to the bottom of the scrotum. For a right-handed surgeon standing on the patient’s right side, the vas deferens is grasped between the thumb and middle finger of the surgeon’s left hand with the middle finger on the posterior surface of the scrotum. The index finger is then placed cephalad to the surgeon’s thumb on the anterior scrotum, pulling the scrotal skin tight between the thumb and index finger ( Fig. 110.1 ). After the vas deferens is isolated and secured using a three-finger technique, the scrotal skin, between the thumb and index finger, is anesthetized with 2% lidocaine without epinephrine. Initially, a small subcutaneous wheal of lidocaine is injected. Through this wheal, a vasal block is performed by advancing the needle alongside the course of the vas deferens for approximately 1 to 1.5 cm toward the inguinal canal. Lidocaine is then injected as the needle is withdrawn. The perivasal tissues are anesthetized on both sides of the vas deferens using this technique. With formation of the initial skin wheal, the patient typically experiences a “stick and burn” or “a bee sting,” and with anesthetizing the perivasal tissue, typically a mild ache or pressure is sensed ( Fig. 110.2 ). A jet injector may also be used to anesthetize the skin minimizing discomfort with anesthetizing the skin.
The vas deferens is approached through the anesthetized area by first puncturing the skin using a single arm of the no scalpel dissecting hemostat. Both arms are then inserted into the puncture wound and spread, separating the skin ( Fig. 110.3 ). The vas deferens is then grasped through the incision using the ringed hemostat, and the dissection is continued through the dartos tunic and vasal sheath to expose the vas deferens. The exposed vas deferens is then delivered into the wound. Alternatively, the vas deferens may be isolated through the scrotal skin with the ringed hemostat and then the incision is made just cephalad to the ringed hemostat. After the vas deferens is delivered into the wound, it is cleared of its mesentery and the vasal vessels for a segment of 1.5 to 2 cm ( Fig. 110.4 ). A 1.5- to 2-cm segment of cleared vas deferens is excised, and the vasal ends are occluded. Occlusion of the vasal ends may be achieved by several different techniques. The lumen may be ablated using cautery or the vas deferens compressed using suture or hemoclips, or a combination of the two techniques may be used. The vasal sheath can be closed over the testicular or abdominal vasal remnant using a 4-0 absorbable suture to isolate the individual ends of the vas deferens from each other. Fascial interposition in this manner will further decrease the risk of recanalization.