Vasectomy reversal can be performed under local, regional, or general anesthesia; however, the authors prefer general anesthesia to limit motion artifact while working under the operating microscope. Patient preparation includes use of iodine-based or chlorhexidine antiseptic solutions on a shaved scrotum. If the patient has had prior inguinal surgery or a large vasectomy gap, both groins should be prepared for the possibility of performing an inguinal vasectomy reversal.
Correct patient positioning is essential to allow the microsurgeon to sit or stand to perform vasectomy reversal comfortably. The patient is positioned supine and as far toward the foot of the operating table as possible. It is important that the surgeon and assistant support the ulnar portion of the hands, wrists, and forearms to minimize tremor. The operating microscope should be positioned to maximize the comfort of the operating surgeon. If the microscope has foot pedals, they should be readily accessible to the operating surgeon, as should the bipolar pedal for operative cautery.
Several specific instruments are needed for microscopic vasectomy reversal: (1) straight microforceps with a tying platform, (2) curved nonlocking microneedle holder, (3) toothed tissue microforceps, (4) vas deferens clamp (Microspike, ASSI, New York, USA) or holding apparatus, (5) straight and curved tip jeweler microforceps, (6) micro-tip bipolar cautery forceps, (7) microscissor, and an (8) operative microscope. Additional instruments include glass microscope slides with coverslips and capillary tubes, microirrigator made from a 10-mL syringe and a 24-gauge angiocatheter, 15-degree microknife, microswabs, and a bench microscope. Bipolar electrocautery should be at a low setting to minimize tissue damage. Key sutures required in microsurgical vasectomy reversal include 9-0 nylon suture (VAS 100-4) (Ethicon, Somerville, NJ) and double-armed 10-0 nylon suture with 70 µm diameter taper-point needles (Sharpoint, Surgical Specialties Corp., Reading PA or Ethicon).
Incisions and Preparation of the VAS Deferens
Several options are available for the initial incisions. Primary vasectomy reversal, in which the vasectomy site is in the straight portion of the vas deferens and is readily palpable, can be performed through a small 1.5-cm median raphe incision after isolating the vasectomy site with a penetrating towel clamp or no-scalpel vasectomy clamp. In complex cases, such as a large defect or if a vasoepididymostomy is required, this incision can be extended to deliver the testis. Bilateral high scrotal incisions can similarly be utilized and extended toward the inguinal region if needed. In this instance, the testis is subsequently delivered with the tunica vaginalis intact
A healthy portion of the vas deferens is isolated about 1 cm away from the vasectomy site without stripping the adventitia and preserving blood supply to the anastomosis ( Fig. 111.1 ). A Penrose-covered metal ruler background or flat clamp is placed under the vas deferens, and a #10 or #11 scalpel blade or microknife is used to transect the vas with a 90-degree perpendicular cut angle. Alternatively, a slotted, nerve-holding clamp and ultrasharp blade may be used to transect the vas deferens. A temporary stay suture can be placed in the adventitia of the vas deferens to prevent migration.
Fluid is coaxed from the testicular portion of the vas deferens and examined for spermatozoa. The abdominal portion of the vas deferens may be cannulated with a 24-gauge microirrigator and saline injected to ensure patency ( Fig. 111.2 ). A free-flowing gentle injection of saline confirms patency. The abdominal and testicular portions of the vas deferens can now be approximated using a vas deferens clamp or a precisely placed suture in the perivasal tissue of the proximal and distal ends. Sufficient mobility should be attained to allow for a tension-free anastomosis. Copious irrigation is maintained throughout. The anastomosis is then performed based on surgeon preference and familiarity.
Modified One-Layer Closure
In the modified one-layer closure, six 9-0 nylon sutures are used for each layer of the anastomosis. Three initial sutures are placed through the full thickness (mucosa, muscularis, and adventitia) of the vas deferens on the anterior wall, incorporating the lumen, and then tied ( Fig. 111.3 ).
Additional 9-0 nylon sutures are interposed between each full-thickness suture, incorporating only the seromuscular portion of the wall ( Fig. 111.4 ).
The vas clamp is then rotated 180 degrees, and three additional full-thickness sutures are placed without tying ( Fig. 111.5 ). After all three are placed, they are tied, and three additional seromuscular sutures are interposed between these full-thickness sutures to complete the anastomosis.