MicroSurgery

Varicocelectomy

Microscopic subinguinal technique

  1. Position supine with arms out, shave operative field, prep/drape, give cefazolin for antibiotic coverage
  2. Palpate inguinal ring and mark on skin
  3. Incise skin and underlying layers, once cord visible grasp with fingers or babcock
  4. Place penrose drain under cord, stretch and clip to drape with hemostats, then bring in microscope
  5. Identify vas and avoid!
  6. Identify testicular artery via doppler and visible pulse, isolate using vessel loop (there can be more than one testicular artery)
  7. Identify veins, isolate from surrounding tissue via blunt dissection with Jake hemostat, place right-angle underneath vessel and place silk tie x2
  8. Once all veins have been identified and isolated, confirm artery location and begin tying off and cutting veins - can confirm artery location with doppler prior to cut/tie

MicroTESE

Technique

  1. Position supine with arms out, shave patient, prep/drape, give cefazolin for antibiotic coverage
  2. Make midline anterior scrotal incision, open dartos on either side, divide layers over testis and deliver testicle into field
  3. Bring microscope into field, identify transverse incision site on mid-testis, place prolene stitch at end of incision (to make it easier to close afterwards)
  4. Insert 18g angiocath to protect tubules while dividing tunica albuginea, divide tunica albuginea with cautery, taking care not to pass point into tubules
  5. Once incision completed, grasp both edges of tunica and evert testicular contents completely
  6. Using high precision forceps, lay the edge along area with the most robust tubules and grab and pull tubules away (grab from the side not the tip), send in test tube, 3-4mL tubules desired
  7. Obtain hemostasis, then close tunica with pre-placed prolene taking care not to include tubules into closure
  8. Repeat on the contralateral side
  9. Place testes back into scrotum, close dartos with 3-0 vicryl and skin with 4-0 monocryl (any preferred technique)