We have used both the Veress needle and the open Hasson technique to gain initial pneumo-peritoneum. Currently, we use the Veress needle and feel this is safe when appropriate precautions are taken. The principle instruments we use are curved scissors, a curved dissector, and a right-angle dissector. For intracorporeal ties we add two laparoscopic needle drivers. Five millimeter clip appliers can be used to clip-ligate smaller vessels. A 5-mm 45° laparoscopic lens is used. We no longer routinely use a 5 mm laparoscopic Doppler probe to assist in the identification of the spermatic artery or arteries because several investigators have shown no benefit from sparing the internal spermatic artery (43-45). We use 5-mm ports, which decrease morbidity when compared with 10mm ports. Small veins can be ligated with use of the 5-mm clip applier. Larger veins or bundles of veins that exceed the capacity of the 5-mm clip can be ligated with 2-0 silk ligature using intracorporeal tying techniques thus avoiding the need to separate the venous branches into several small bundles. An instrument tie can be accomplished using two needle drivers or two curved dissectors. Alternatively, one may ligate by performing extracorporeal ties using a 5-mm knot pusher. If choosing not to preserve the testicular artery, mass ligation of the entire vascular bundle can be accomplished with extracorporeal ligation or a two-port technique using the harmonic scalpel.

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