Surgical Technique Patient Preparation

The patient should be advised of the risks and benefits to varix ligation and of the available approaches with discussion of the advantages and disadvantages to each (40). Special emphasis is paid to the risks peculiar to laparoscopy and to the possibility need to convert to open technique and possible laparotomy to repair injury to intestine or blood vessel. In our series to date, all varix ligations have been completed laparoscop-ically. Each patient should be aware that successful varix ligation results in improvement in semen parameters and/or reduction in pain in most but not all patients. In fact, there is a nominal risk of testicular atrophy due to compromise of testicular arterial blood flow. In a recent study laparoscopic varix ligation for painful varicocele resulted in complete resolution of pain in 84.5% at a median follow-up of six months (41).

Laparoscopy is typically performed under general anesthesia. Although this procedure has been done under both epidural and local anesthesia, we feel that laparoscopy with pneumoperitoneum is best tolerated under general anesthesia. There is a report of laparoscopic varix ligation using local anesthesia but no attempt to preserve the testicular artery was made (42). Preservation of the spermatic artery is delicate and time-consuming and hampered by patient movement. Proponents of the retroperitoneal approach to varix ligation debate the utility of sparing the spermatic artery. Several reports have found no difference in testis volume after laparoscopic clipping of the entire retroperitoneal spermatic vascular bundles without arterial sparing (43-45). Several authors report increased rates of varix recurrence and hydrocele formation when the spermatic artery is spared (43,46,47). Conversely, many surgeons have excellent success with arterial sparing techniques (29,48).

We do not currently require a bowel preparation prior to laparoscopic varix ligation. Routine antibiotic prophylaxis consists of a cephalosporin one hour before surgery. After induction of anesthesia, an oral gastric tube is placed and the stomach evacuated. The surgical field includes the external genitalia and the entire abdomen. Gentle retraction of the testes and spermatic cord can aid in identifying the spermatic vessels and collateral veins traversing the internal ring. We typically pass a straight catheter to drain the bladder before proceeding with insertion of the Veress needle.

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