VASECTOMY

Vasectomy is a method of sterilization in the male. Explain to the patient that the operation is irreversible and permanent. Emphasize that the operation is almost always successful, but that sterility cannot be guaranteed since there is a small chance of failure. Spontaneous recanalization can occur, even after meticulous surgery. Stress that sterility will not be immediate; it can take up to 8 weeks for the patient to become completely sterile. Always observe local legal formalities. Following vasectomy, carry out a semen analysis at 6–8 weeks to confirm sterility.

Technique

1	Vasectomy is usually carried out with the patient under local anaesthesia.
2	Place the patient in a supine position. Cleanse and shave the pubis and external genitalia. If you are using local anaesthesia, inject a weal of 1% lidocaine and make an incision of 2–3 cm in the scrotal raphe (Figure 9.54). Infiltrate the deeper tissues, picking up each layer in turn to inject anaesthetic. At each stage, allow a few minutes for the local anaesthetic to take effect.
Figure 9.54
3	Hold up the vas from one side with a pair of tissue forceps and infiltrate its connective tissue sheath with lidocaine (Figure 9.55). Open the sheath, isolate the vas with artery forceps (Figure 9.56) and excise about 1 cm (Figure 9.57). The cut ends will be characteristically conical, with the outer fibromuscular tissues retracting from the lumen.
Figure 9.55
Figure 9.56
Figure 9.57
4	Ligate the testicular end and replace it within the connective tissue sheath (Figure 9.58). Turn the proximal end back on itself and ligate it so that it lies outside the sheath. Repeat the procedure on the other vas. Close the scrotal wound with a few 2/0 absorbable stitches, making sure to include the dartos layer (Figure 9.59).
Figure 9.58
Figure 9.59

This technique is widely used and allows a rapid turnover of patients in outpatient clinics. The less experienced practitioner may find it easier to identify the vas by pinching it between the thumb and finger at the lateral side of the neck of the scrotum, incising the skin directly above it, catching the vas with a pair of tissue forceps before it slips away.

As an alternative, fix each vas under the skin by inserting a hypodermic needle after effecting local anaesthesia with 1% lidocaine. Make a vertical incision 1 cm long over the vas on one side, and hook it out with forceps. Proceed to divide and ligate the vas, as described above. Then make an incision over the other vas and repeat the procedure.