SHERGILL ET AL.
BJUI
BJU INTERNATIONAL
Surgery Illustrated – Surgical Atlas
Vasectomy illustrated
Iqbal Shergill, Manit Arya†* and Asif Muneer†
Department of Urology, Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board, Wales, †University
College Hospital, London and *Barts Cancer Institute, London, UK
ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com
INTRODUCTION
Vasectomy is the most effective form of
male sterilisation and is performed
worldwide by urologists, general surgeons
and family practitioners [1]. Various
techniques for vasectomy have been
described, but the underlying principle is to
remove a satisfactory segment of the vas
deferens, followed by closure of the
proximal and distal ends, to ensure that the
patient achieves azoospermia whilst
minimising the chances for late
re-canalisation. Importantly, whilst
vasectomy is widely recognised as a very
cost-effective form of male sterilisation, it
has been implicated as one of the five most
common procedures after which litigation
may result [2].
PREOPERATIVE CARE
Men are counselled highlighting how the
procedure will be performed, the benefits
and risks as well as the alternative
contraceptive options, as the procedure is
deemed irreversible. Apart from the risk of
developing a scrotal haematoma, wound
infection or epididymitis, men should also be
warned about the risk of re-canalisation,
granuloma formation at the transected ends
and the risk of ‘post-vasectomy pain
syndrome’.
ANAESTHESIA AND SURGICAL
EQUIPMENT
One of the main advantages of vasectomy is
that it can be performed as a day case or
office procedure under local anaesthetic,
usually within 20–30 min. Contraindications
to local anaesthetic include: allergy to local
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SURGERY ILLUSTRATED
anaesthetic agents, anxious patients and a
rugose scrotum which makes the vas
deferens localisation difficult. Previous
scrotal surgery, e.g. orchidopexy for
undescended testis or the presence of a
large varicocoele, can also make palpation of
the vas deferens difficult and therefore
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general anaesthesia may be preferred in
these men. General anaesthesia may also be
considered in men requiring surgery for
concomitant pathology, e.g. hydrocoele
repair. The patient is positioned supine on a
standard operating table and a Minor Basic
Operative Instrument Set can be used for
the procedure, provided that a vasectomy
clamp is also available. Although two
separate incisions over the vas deferens are
commonly used, an alternative single
puncture using Li forceps in the midline,
termed the ‘no scalpel’ technique, is an
alternative.
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Figure 1
The patient is positioned supine, and the
skin is prepared from the suprapubic area to
the mid-thighs. In some cases, to prevent
encroachment, the penis can be secured
away from the operative field, using surgical
gauze and tape. Each side is performed in
turn. The vas is identified by rolling it
between the fingers, and is then gently
grasped and fixed using a ‘three-finger grip’.
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Figure 2
Typically, the thumb is placed posteriorly
and then the index and middle fingers are
placed anteriorly, to fix the vas in position.
Depending on the surgeon’s preference, the
‘three-finger grip’ can have the middle
finger placed dorsally and the thumb and
forefinger anteriorly. Then, using a 24-G
needle, the skin is infiltrated using local
anaesthetic (5 mL 1% lidocaine).
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Figure 3
A 1-cm transverse skin incision is made over
the vas whilst maintaining traction on the
skin and gently pushing the vas and
overlying dartos through the incision with
the ‘three-finger grip’. The dartos layer is
spread using dissecting scissors or
vasectomy forceps until the fascia over the
vas is seen. At this point, care should be
taken to prevent the vas from slipping out
of position.
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Figure 4
The vas and the fascial layers are then
grasped using an Allis clamp or vasectomy
forceps.
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Figure 5a,b
The overlying external and internal
spermatic fascia is incised longitudinally,
gently dissecting it away from the vas. The
vas is then isolated, allowing it to be pulled
through the incision.
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Figure 6a,b
Between 1–2 cm of the vas is isolated on
the straight part of the vas and this
segment is transected between two artery
clips. The specimen is sent for
histopathological analysis.
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Figure 7a,b
The transected ends are tied with 2/0 or 3/0
polyglactin 910 (Vicryl) ties. The transected
ends can also be coagulated with bipolar
diathermy forceps, or a monopolar point
diathermy, although this may occasionally
result in subsequent sloughing of tissue
and/or loosening of the ties.
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Figure 8a,b
The remaining stumps are placed back into
the scrotum and secured in different fascial
planes. This is the key step to prevent
re-canalisation. The internal spermatic fascia
is used to close over the proximal stump,
whilst the distal stump is buried outside this
fascia. The stump ends can also be tied on
themselves, to create a ‘shepherd’s hook’. In
the authors’ experience, if the stumps are
sutured in separate fascial layers, there is no
requirement to transect excessive lengths of
vas or to create a ‘shepherds hook’.
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Figure 9
The skin is sutured using absorbable
interrupted sutures, e.g. 4/0 polyglactin 910
(Vicryl Rapide). After application of a
transparent and quick-drying film to protect
the wound (Opsite spray), a tight-fitting
scrotal support is applied. The procedure is
then replicated on the contralateral side.
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POSTOPERATIVE CARE
REFERENCES
The scrotal support is recommended for 1
week or until comfortable, together with a
gradual return to daily activities. Patients
are advised to continue to practice
protected sexual intercourse, as sperm may
still be viable for 72 days and until the
semen analysis tests at 14 and 16 weeks are
clear.
1
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2
Sokal DC, Labrecque M. Effectiveness
of vasectomy techniques. Urol Clin North
Am 2009; 36: 317–29
Osman NI, Collins GN. Urological
litigation in the UK National Health
Service (NHS): an analysis of 14 years of
successful claims. BJU Int 2011; 108:
162–5
Correspondence: Mr Iqbal S Shergill BSc
(Hons) MRCS FRCS (Urol), Department of
Urology, Wrexham Maelor Hospital, Betsi
Cadwaladr University Health Board,
Croesnewydd Road, Wrexham LL13 7TD,
Wales, UK.
e-mail: [email protected]
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