Patient Position and Port Placement

We place the patient in supine position with arms adducted. Skin preparation includes the abdomen and genitalia. After infiltrating with 0.25% marcaine, a 5 mm skin incision is made just above the umbilicus. The Veress needle is passed through this incision and into the peritoneal cavity. Proper positioning of the Veress needle is confirmed using appropriate tests and insufflation proceeds to reach intraperitoneal pressure of 20 mmHg. Once proper pneumoperitoneum is achieved, a 5 mm trocar is advanced into the peritoneal cavity and a 45° camera is inserted. We inspect the peritoneal contents, giving special attention to viscera deep to the site of the Veress needle and first trocar insertion. Next, we place two 5 mm ports. In the case of a left varicocele, one port is placed lateral to the rectus muscle just below the umbilicus and the other is placed in the midline midway between the umbilicus and pubis. For bilateral varicoceles, both ports are placed lateral to the left and right rectus muscle just below the level of the umbilicus. Once the ports are in place the patient is placed in the Trendelenburg position.

Dissection and Ligation

If the sigmoid colon is fixed over the spermatic veins cephalad to the left internal ring (the proposed site of surgery), the colon is mobilized to expose the spermatic vascular bundle incising along the lateral peritoneal reflection. Once the internal ring is exposed, the spermatic vessels are identified deep to the peritoneal membrane passing cephalad over the psoas muscle. The vas is seen curving medially over the external iliac vein and artery.

Using curved scissors, a 3- to 5-cm incision through the peritoneum is made parallel and lateral to the spermatic vessels with the caudal limit 3 cm above the internal ring. This minimizes injury to the vas deferens and scrotal insufflation. The medial flap of the peritoneum is grasped and the underlying spermatic vessels are gently and bluntly swept from the underside of this flap. From the midpoint of the first incision a perpendicular incision is made through the medial peritoneal flap to the lateral aspect of the iliac artery. This resulting T incision provides ample exposure. External traction on the testis/spermatic cord helps to identify all veins that may contribute to the varicocele.

The entire spermatic vascular bundle is mobilized from the underlying psoas muscle using both blunt and sharp dissection. Deep dissection is avoided to spare the underlying genitofemoral nerve crossing anterior to the psoas muscle. Loose adventi-tial tissue is stripped from the spermatic vessels. The vascular bundle is separated into medial and lateral bundles. Typically there are three to eight spermatic veins and a single spermatic artery located posterior and medial to the veins. The spermatic artery is not specifically identified and intracorporeal knotting techniques are used to ligate and divide each vascular bundle, which are then divided between ligatures. The procedure may be performed on the contralateral side as needed.

Completion of the Operation

An orderly and systematic departure from the abdomen is recommended to ensure hemostasis and rule out inadvertent injury. The operative site(s) is inspected with intraperitoneal pressure reduced to <8 mmHg and active bleeding sites are identified and cauterized. Each trocar site is inspected at the time of removal to ensure no active bleeding from the anterior abdominal wall. Scrotal emphysema from extravasation of CO2 through the internal ring can be massive and this can expressed back into the peritoneal cavity and vented through an open trocar site. The patient is returned to the horizontal position; we aspirate any blood or irrigant that may have collected in the pelvis. The subcutaneous tissues are reapproximated and the skin is closed with a sub-cuticular 3-0 Vicryl Rapide®b or Dermabond®c. Virtually all procedures are performed in the outpatient setting. The patient is advised to return to full activity as tolerated. Semen analyses are performed every three months for one year or until pregnancy is achieved (16).

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