Varicocelectomy

1) Definition of Procedure

Indication Contraindication

2) Anesthesia Used

3) Position of Patient

4) Instrumentation and
Equipments

5) Nursing Responsibilities

Preoperative:
Intraoperative:

Postopertive:

6) Reaction

7) Source
Varicocelectomy, the surgical correction of a varicocele, is performed on an
outpatient basis. The three most common approaches are
inguinal (groin), retroperitoneal (abdominal), and infrainguinal/subinguinal (below the
groin). –Wikipedia

Retroperitoneal approach
The retroperitoneal approach involves incision at the level of the internal inguinal ring,
splitting of the external and internal oblique muscles, and exposure of the internal spermatic
artery and vein retroperitoneally near the ureter. The approach has the advantage of isolating
the internal spermatic vein proximally, at a level where only one or two large veins are present.
In addition, the testicular artery has not yet branched at this level, and is distinctly separate from
the internal spermatic veins. The major disadvantage of the retroperitoneal approach is the high
incidence of varicocele recurrence secondary to the presence of parallel inguinal and
retroperitoneal collateral vessels that may bypass area of ligation and rejoin the internal
spermatic vein proximal to the site of ligation. It may be difficult to identified and, therefore,
preserve the testicular artery and lymphatics because the they cannot be delivered into the
wound at this level.

Inguinal approach

Inguinal approach is the modification of the technique described by Ivanissevich and

Gregorini in 1918. The inguinal approach involves a 5 to 10 cm incision over the inguinal canal,
opening of the external oblique aponeurosis, delivery of the spermatic cord and ligation of all
dilated internal spermatic veins. The vas deferens and vasal vessels are preserved. An attempt is
made to preserve the testicular artery and, as many lymphatic channels as possible. In addition,
the cord is elevated and any external spermatic veins that are running parallel to the spermatic
cord or perforating the floor of the inguinal canal are identified and ligated. Inguinal approach
lowers the incidence of varicocele recurrence but do not alter the incidence of hydrocele
formation (4 - 15% with an average incidence of 7%). or testicular artery injury. The incidence of
testicular artery injury after inguinal varicocelectomy is unknown but may be more than is
generally realized .

Subinguinal approach

It popularized by Dr.MarcGoldstein is most commonly used presently by male infertility

specialists. The major advantage of this approach is more direct approach to the spermatic cord,
external spermatic veins. The small incision (corresponding to the length of the testis) is more
comfortable for the patient with less postoperative pain since there is no incision of aponeurosis.
The delivery of the testis is recommended to isolate and divide gubernacular veins and external
spermatic perforators. Gubernacular veins have been demonstrated radiographically to be the
cause of up to 10% of varicocele recurrences. After testis is returned to the scrotum, spermatic
cord is elevated on the Penrose drain and ligation and division of dilated internal spermatic veins
is performed under the operating microscope with 8-15 power magnification.

Surgery for the relief of a varicocele by ligature and excision and by ligation of the dilated veins.
-The American Heritage® Medical Dictionary
 • Patients who have ipsilateral testicular hypotrophy which is defined as a greater than 20%
size discrepancy when compared with the contralateral testicle using a Prader
orchidometer or ultrasound measurement

• Patients who have symptoms related to the varicocele, such as pain.

• Older teenager (who is willing to give a semen analysis) that shows abnormal semen
parameters.

• Bilateral varicoceles
• Symptomatic painful varicocele
• Abnormal findings on semen analysis

Varicocele ligation in a healthy patient has no specific contraindications, but various surgical approaches offer
different advantages, and certain procedures should be avoided in specific settings. For example, a history of
previous surgery may influence venous disruption within the site. With previous abdominal or retroperitoneal
surgery, laparoscopic surgery is less desirable.

A history of inguinal surgery makes a second inguinal approach more difficult and potentially hazardous to the
spermatic cord structures. Previous inguinal surgery may have also compromised the arterial supply of the testis.
For this reason, when an adolescent with prior inguinal hernia surgery develops a varicocele, the best technique
involves an inguinal approach with microscopic magnification to optimally identify and preserve the testicular artery.
A retroperitoneal approach with testicular artery ligation is contraindicated because the initial hernia surgery could
have inadvertently injured the vasal artery, and high ligation of the internal spermatic artery may cause testis
atrophy due to arterial insufficiency.

1. The large varicocele can be seen through the scrotal skin. B: Illustration of a
patient with a large left-side varicocele.

2. Retroperitoneal, inguinal, and subinguinal incisions for varicocele repairs. A

dot is made to mark the external inguinal ring (X).
3. Skin incision of varicocelectomy. The size of the testis governs the size of the
skin incision. A small testicle can be delivered comfortably through a 2.0 to
2.5 cm incision, while large testicle can comfortably delivered through a 3.0
to 3.5 cm incisions.

4. Maneuver used to expose the spermatic cord in a subinguinal

varicocelectomy. An index finger is hooked under the external inguinal ring
while a small Richardon retractor is slid along the dorsum of the index finger
and pulled in the opposite direction. With gentle traction the cord is exposed
and encircled with a Babcock clamp.
 5. The gubernacular vein and external spermatic perforators. Delivery of the
testicle enables the surgeon to identify and ligate these vessels, which are
responsible for some varicocele recurrences. Once all external spermatic
perforators and gubernacular veins have been divided, the testicle is
retruned to the scrotum and the spermatic cord remains elevated over a
large Penrose drain for stabilzation in preparation for microscopic
examination.

6. Under the operating microscope, the spermatic cord is examined. The internal and external spermatic
fasciae are incised longitudinally and retracted with the straight clamps.

7. The artery is microscopically dissected free of all surrounding tissue, tiny veins and lymphatics,
using a fine-tipped, microsurgical needle holder and forceps. The pulsation of suspected artery is
evaluated by seeing a pulsating column of blood appears just over the needle holder. Then, a 0-silk
ligature is encircled for identification and preservation of artery.

8. Periarterial veins are lighted with 4-0 silk ligature. Hemoclips placed on the internal spermatic veins.
 9. Lymphatic are clearly identified and preserved, under the operating microscope ( magnification 15x)

10. Skin incision at the termination of the procedure. After the incision has been infiltrated with Marcaine
solution with epinephrine, it is closed with a 5-0 Monocryl subcuticular closure with reinforced with
Steri-strips.

INTERNET SOURCES:

http://www.maleinfertility.org/new-varicocelectomy.html

http://www.uhmc.sunysb.edu/urology/male_infertility/VARICOCELE_AND_ITS_TREATMENT.html

http://emedicine.medscape.com/article/1016840-overview

http://en.wikipedia.org/wiki/Varicocelectomy

http://emedicine.medscape.com/article/1016840-overview

http://www.springerlink.com/content/l2616k88n0m435wk/

http://medical-dictionary.thefreedictionary.com/varicocelectomy

http://www.answers.com/topic/spinal-analgesia-1

http://www.answers.com/topic/general-anaesthesia

http://www.edward.org/AEImages/adam04/graphics/images/en/19078.jpg

http://www.isahq.org/Portals/0/Images/anesthesia.jpg

http://www.ihealthdirectory.com/varicocele-surgery/
http://books.google.com.ph/books?
id=GahMzaKgMKAC&pg=PA523&lpg=PA523&dq=positions+in+varicocelectomy&source=bl&ots
=mTZoAFp3rz&sig=3gJm67cjyCDxi4Cy9ADZK1Kz2zc&hl=tl&ei=9qMiTOqcCcG9cdnbka0F&sa=X
&oi=book_result&ct=result&resnum=3&ved=0CB8Q6AEwAg#v=onepage&q=positions%20in
%20varicocelectomy&f=false

http://www.sweethaven02.com/MedTech/NurseFund01/0906fig0102.jpg

http://www.getridofthings.com/images/snoring-3.jpg

http://www.jorvet.com/catalog/images/products/077_094_Pictures/J662.gif

http://www.plattsnisbett.com/catalogue_P125.html

A Varicocelectomy is the most common surgery for varicocele. This is also called conventional
open surgery. It is a surgery that is done on an outpatient basis. It is performed under
general anesthesia or under spinal anesthesia.

1) General anesthesia is the induction of a state of unconsciousness with the absence

of pain sensation over the entire body, through the administration of anesthetic drugs. It is
used during certain medical and surgical procedures.

2) Spinal anaesthesia, also called spinal analgesiaor sub-arcachnoid block (SAB), is a

form of regional anaesthesia involving injection of a local anaesthetic into
the Subarachnoid space, generally through a fine needle, usually 3.5 inches (9 cm) long.
For extremely obese patients, some anaesthesiologists prefer spinal needles which are
seven inches (18 cm) long. The tip of the spinal needle has a point or small bevel.
Recently pencil point needles have been made available (Whitacre, Sprotte, & others).
 http://www.faico.com.ar/fotos/Pinza_Allis_18-25.jpg

Retroperitoneal approach
Supine position

Supine position is also used in varicocelectomy.