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Surgery Illustrated - Surgical Atlas: Microsurgical Varicocelectomy

uretroplasty

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194 views8 pages

Surgery Illustrated - Surgical Atlas: Microsurgical Varicocelectomy

uretroplasty

Uploaded by

nugroho akhbar
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© © All Rights Reserved
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BAAZEEM and ZINI

Surgery Illustrated – Surgical Atlas


BJUI BJU INTERNATIONAL
Microsurgical varicocelectomy
Abdulaziz Baazeem and Armand Zini
Division of Urology, Department of Surgery, McGill University, Montreal, QC, Canada

ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com

PLANNING AND PREPARATION 2


1

The indications for microsurgical a

varicocelectomy are: (i) in men with infertility,


abnormal semen values and a clinical 3 2

varicocele; (ii) in those with scrotal pain b

related to a clinical varicocele; (iii) in children


with a clinical varicocele associated with
ipsilateral testicular atrophy; and in cases of
hypogonadism with clinical varicocele. Thus 2
1

patients with a clinical varicocele and no a


a
3

contraindications to surgery are those


selected. 2

4 5

Specific equipment/materials required are b


b

an operating microscope (×12–20), and


microsurgical instruments (needle driver,
jeweller’s forceps).

The only specific patient preparation required


is shaving or clipping of the pubic hair on the
day of surgery; no other specific measures are
necessary.

© 2009 THE AUTHORS


420 JOURNAL COMPILATION © 2 0 0 9 B J U I N T E R N A T I O N A L | 1 0 4 , 4 2 0 – 4 2 7 | doi:10.1111/j.1464-410X.2009.008768.x
BJUI SURGERY ILLUSTRATED – SURGICAL ATLAS

Figure 1

The patient is placed supine; Fig. 1a shows


the location of the inguinal (1) and
subinguinal (2) incisions for microsurgical
varicocelectomy (The position of the external
inguinal ring is shown).

Figure 1b shows the position of the right and


left subinguinal incisions (≈2.5 cm long) for
microsurgical varicocelectomy, and the cross 1
indicates the location of the right external 2
inguinal ring. The left spermatic cord is
grasped with a Babcock clamp and delivered
though the incision.

© 2009 THE AUTHORS


JOURNAL COMPILATION © 2009 BJU INTERNATIONAL 421
BAAZEEM and ZINI

Figure 2

The testicle is delivered through the


subinguinal incision. The spermatic cord (1)
and the gubernaculum (2) are shown.
Delivering the testicle helps to identify any
external spermatic veins which might be
present (3). It also facilitates cautery of the
small gubernacular veins.

3 2

© 2009 THE AUTHORS


422 JOURNAL COMPILATION © 2009 BJU INTERNATIONAL
BJUI SURGERY ILLUSTRATED – SURGICAL ATLAS

Figure 3

During the procedure, surgical clips are used


before dividing structures, such as with the
external spermatic veins shown here.
Alternatively, 2–0 silk ties can be used instead
of the clips to ligate the relatively large veins.

© 2009 THE AUTHORS


JOURNAL COMPILATION © 2009 BJU INTERNATIONAL 423
BAAZEEM and ZINI

Figure 4

Figure 4a: The testicle is repositioned into the


scrotum and the spermatic cord is placed over
a large (2.5 cm) Penrose drain.

Figure 4b: The external spermatic fascia is


lifted with two smooth forceps in preparation
for longitudinal incision under the operative
microscope. The thin underlying internal
spermatic fascia is also incised afterwards.

© 2009 THE AUTHORS


424 JOURNAL COMPILATION © 2009 BJU INTERNATIONAL
BJUI SURGERY ILLUSTRATED – SURGICAL ATLAS

Figure 5

Figure 5 shows the spermatic cord after


longitudinal incision of the external (1) and
internal spermatic fasciae (2), and the vas
deferens (3).

© 2009 THE AUTHORS


JOURNAL COMPILATION © 2009 BJU INTERNATIONAL 425
BAAZEEM and ZINI

Figure 6

The contents of the internal spermatic fascia


are separated from the contents of the
external spermatic fascia by blunt dissection,
thus forming two packages. A second 2.5 cm
Penrose drain is placed between these
packages: the structures that are naturally
contained within the internal spermatic fascia
(1) and the structures that are naturally
situated between the external and internal
layers of spermatic fascia (2), in addition to
the vas deferens (3) are shown. 2
1
The lymphatics (4) and artery(ies) (5) in the 3
internal spermatic package are isolated and
preserved (encircled with loops of 2–0 silk).
This part of the cord is skeletonized by
dividing the remaining structures between a
clips or 4–0 silk suture ligatures. Inadvertent
injury or division of a lymphatic channel is not
a serious event, so long as several lymphatics
have been preserved. Inadvertent injury or
division of an artery is significant if this
represents the main or major artery. This
should be repaired by re-anastomosis with
fine (8–0 Nylon) sutures. Afterwards, the
external package is brought forward. The
external spermatic arteries and the vas
deferens are preserved and all of the
remaining structures are divided in a similar
manner to the internal package.
4 5

© 2009 THE AUTHORS


426 JOURNAL COMPILATION © 2009 BJU INTERNATIONAL
BJUI SURGERY ILLUSTRATED – SURGICAL ATLAS

POSTOPERATIVE CARE arterial or lymphatic injury. In these cases, Support strategies for intraoperative
percutaneous embolization of the varicocele problems: Ensuring that the patient has
Dressing is with sterile strips, covered by a dry might be a safer option. a good intraoperative blood pressure
dressing. The only specific medication is with (>100 mmHg systolic) can improve the
analgesics (acetaminophen or codeine) as Things to make life easier: Division of the cord pulsatility (and ease the detection) of the
needed. The patient is instructed to use ice- package as described above has simplified the spermatic arteries. Intraoperative papaverine
packs and scrotal elevation as needed procedure. (to dilate the arteries) or micro-Doppler
evaluation might be used in the rare case
Lows: a personal worst case: Re-operation where the subtle pulsations of the artery are
FROM SURGEON TO SURGEON after a previous subinguinal varicocelectomy not easily seen.
is very difficult. One such case was associated
The difficult case: A history of previous with a difficult dissection and with failure to Correspondence: Armand Zini, Division of
inguinal or subinguinal surgery (particularly, identify even a single internal spermatic Urology, Department of Surgery, McGill
varicocelectomy) will make the dissection artery (two external spermatic arteries were University, Montreal, QC, Canada.
more difficult, with a greater potential for identified). e-mail: ziniarmand@yahoo.com

© 2009 THE AUTHORS


JOURNAL COMPILATION © 2009 BJU INTERNATIONAL 427

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