Operative Therapy

Surgical treatment options are derivatives of either the inguinal approach of Ivanissevich (27) or the retroperitoneal approach of Palomo (28). Microsurgical techniques in the inguinal and subinguinal exposures require careful dissection in order to protect the spermatic artery and preserve lymphatic channels; maginification (e.g., loupes in the inguinal approach and microscope in the subinguinal approach) is mandatory (16,29). The inguinal approach identifies the spermatic vessels as they course through the inguinal canal where spermatic cord structures incorporate the cremasteric vein that may contribute to the varix pathophysiology. The spermatic and cremasteric veins are isolated and ligated while protecting the vas and spermatic artery. The inguinal approach is associated with increased postoperative pain and delay in return to full activity when compared with the subinquinal or laparoscopic techniques (30,31).

The subinguinal approach requires magnification and ligation of a greater number of venous tributaries that are intimately associated with the testicular artery (32). Furthermore, multiple spermatic arteries may course through the spermatic cord at the subinguinal level making dissection more demanding (33). Doppler ultrasound can facilitate detection of number and location of spermatic arteries.

The Palomo approach, e.g., ligation of the spermatic veins above the internal ring, can be performed by open or laparoscopic technique. The retroperitoneal approach permits ligation of spermatic veins without the attendant risk of injuring arterial collaterals, specifically the cremasteric and deferential arteries, which join the spermatic cord at or below the internal ring. One disadvantage of this approach is the lack of access to the cremasteric vein, which, according to Enquist and Stein, will contribute to a higher recurrence rate when compared with the subinguinal approach (32,34).

Advantages of laparoscopic varix ligation

■ Access to right and left varices with the same number of access ports (25,35);

■ Improved visualization of the vessels via a transperitoneal approach especially in the obese patient;

■ Decreased number of veins to ligate (and fewer arteries to spare in the cephalad spermatic vascular bundle if one so chooses);

■ Magnification of vascular structures and a panoramic view of the retroperitoneal structures, which permits identification and ablation of aberrant collateral veins arising from the kidney, iliac vein, or sigmoid colon;

■ Minimal postoperative pain and a very short convalescence with reduction in lost productivity and early return to work;

■ Avoidance of injury to the vas and collateral arterial flow as may occur with the inguinal or subinguinal approaches;

■ An option in the presence of a failed inguinal/subinguinal or percutaneous embolization approach or in patients who have had previous inguinal hernia repair (36).

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