Surgical methods and steps of high ligation of spermatic vein

High ligation of internal spermatic vein is a classic operation for varicocele. Its theoretical basis is that there is blood reflux in varicocele, which can be effectively prevented by high ligation. Usually through the groin or retroperitoneum.

Inguinal approach:

1, supine position, oblique incision above groin;

2. Incise the aponeurosis of the external oblique abdomen and levator testis, open the inguinal canal, free the spermatic vein plexus, and carefully separate the branches of the spermatic vein, usually 3-4 branches;

3. When varicocele is relieved, double ligation should be performed respectively, and the middle part should be removed to protect the vas deferens, testicular arteries and lymphatic vessels.

4. After making sure that there is no venous leakage, the spermatic cord will flow back, suture the levator testis fascia and the aponeurosis of the external oblique abdomen, reconstruct the external ring orifice (only for the little finger), and suture the skin.

Retroperitoneal route:

1, supine position, 3 ~ 5 cm long incision at the inner ring;

2. Incite the aponeurosis of the external oblique abdomen, and separate the internal oblique abdomen from the transverse abdominis and transverse abdominis fascia.

3. Push the peritoneum inward to expose the spermatic vein. When pushing the peritoneum, be careful not to push the spermatic cord together, which will make it difficult to find the spermatic vein. The thick internal spermatic vein is usually 1 vein, but it can be as many as 3 ~ 4 veins.

4, carefully separate each vein, double ligation, resection of the middle section. Pay attention to protect the spermatic artery and try to avoid injury or stab wound.

5, check no venous leakage, layered closed incision. In the past, it was considered that there were too many transverse veins to ensure that all the barracuda veins in the venous plexus were ligated. In recent years, the application of microsurgery technology has solved this problem. Theoretically, all the veins anastomosing with the internal spermatic vein can be blocked by low ligation, and the veins outside the internal spermatic vein system can be treated at the same time. Microdissection can ensure the ligation effect without damaging arteries and lymphatic vessels.

1, epidural anesthesia or local anesthesia, make a 3cm long incision under the inguinal outer ring.

2. Separate and lift the spermatic cord, dissect and separate the spermatic cord to the scrotum, and lift the testis away from the incision.

3. Ligate all external spermatic veins with surgical microscope or magnifying glass. If the testicles have dilated veins, they should also be ligated.

4. Return to the testis, lift the spermatic cord, cut off the levator testis muscle and fascia inside and outside the spermatic cord, if there is expansion, ligate the levator testis muscle vein, pay attention to protect the lymphatic vessels, separate the internal spermatic vein, double ligation, and cut off the middle section. Pay attention to protect testicular arteries, lymphatic vessels and nerves. The nutrient vessels of the vas deferens should be preserved, the veins around the vas deferens should be ligated if the diameter is greater than 1 mm, and finally only the testicular artery, lymphatic vessels, vas deferens and accompanying nutrient vessels, and tiny veins with the diameter less than 1mm should be left.

5, check no leakage vein, spermatic cord, suture levator testis fascia and incision. 1, indications ① All patients are suitable for high ligation of spermatic vein. ② Infertility: those with low sperm count or high mortality rate in semen examination, and azoospermia with individual testicular volume close to normal.

2. Preoperative preparation ① Patients with varicose great saphenous vein are not suitable to choose branches of great saphenous vein for anastomosis and circulation. ② Take the patient's semen for routine examination and keep it as postoperative control.

3. Key points of operation According to the degree of varicose veins and the difficulty of surgical operation, which blood vessel to bypass: ① Third-degree varicose veins have a serious impact on sperm, and inferior epigastric vein plus external iliac vein is selected for bypass. ② Inferior epigastric vein bypass was used for patients with mild varicose veins and great influence on sperm. ③ For patients with mild varicose veins and little effect on sperm, superficial abdominal vein bypass was used; The choice of vascular branches in spermatic vein bypass should be the trunk or branch with similar caliber, high blood flow speed and good elasticity; Microsurgical techniques were used.

4, surgical steps ① Position and incision: supine position, the incision near the inner ring is about 3 ~ 5 cm long through the inguinal canal. ② Anesthesia: 1% lidocaine local infiltration or epidural anesthesia.

5. Surgical Steps ① The superficial epigastric vein is located in the superficial fascia under the incision, with a diameter of about 2 ~ 3 mm The inferior epigastric vein is located between the transverse abdominis muscle and the fascia of the transverse abdominis muscle in the inner ring, and the inferior epigastric artery of the fish is accompanied by a bifurcation state with a diameter of about 2 ~ 4 mm Attention should be paid to preserving superficial abdominal vein during operation. Once the inferior epigastric vein condition does not allow or obese patients choose superficial vein; ② When the inferior epigastric vein was diverted, the anastomosis was located in the space between spermatic cord and fascia of oblique muscle outside abdomen; ③ When the superficial abdominal vein flows, the anastomosis is located in the gap between the deep layer of the superficial abdominal fascia and the superficial layer of the oblique muscle tendon to prevent the vein from being compressed; ④ The operation is complicated when the spermatic vein is anastomosed with the external iliac vein near the heart. The incision is slightly larger, and the proximal end is anastomosed with the external iliac vein end-to-side; Clamp the anastomosis with a three-wing vascular clamp and sew 6 stitches with 7-0 non-invasive suture; ⑤ Squeeze scrotal spermatic cord after anastomosis to check whether it is unobstructed, promote reflux and prevent thrombosis.

6. Postoperative complications are generally without any complications. Stay in bed for 3 days after operation, hold the scrotum high and gently rub the affected scrotum several times a day to promote blood return and prevent venous thrombosis. The common complications after varicocele ligation mainly include postoperative edema, testicular artery injury and varicocele recurrence.

1, edema edema after varicocele ligation is the most common complication, the incidence rate is 3% ~ 33%, with an average of 7%. Lymphatic injury or ligation is the main cause of edema.

2. testicular atrophy or sperm deficiency after testicular artery injury is mostly caused by ligation or injury of testicular artery during operation. Animal experiments and human studies show that testicular artery ligation can cause testicular damage to a great extent, especially in infertile patients.

3. Recurrence of varicocele The recurrence rate after ligation of spermatic vein is 0.6% ~ 45%. Most common in adolescent patients. Due to technical or anatomical factors, most external veins of internal spermatic vein system cannot be treated at the same time, which leads to recurrence. Microdissection was used to treat all the veins under the outer ring, and the recurrence rate was low. Choose wrapped underwear that can prevent scrotum from falling off and can ventilate and dissipate heat. Some doctors and experts suggest wearing tight underwear or using scrotal support to prevent scrotal sagging. 1) Don't wear tight underwear. At present, all traditional underwear on the market is double-layered. When a man wraps his baby tightly, it is easy to cause the temperature inside to rise, especially in summer, which makes the scrotum wet for a long time and prone to eczema and other skin diseases. Although it prevents the scrotum from descending, it leads to the increase of scrotum temperature, which is even more unfavorable for the prevention of diseases and the recovery and improvement after operation. 2) The scrotum holder can prevent the scrotum from sagging and is breathable. The only inconvenience is wearing it. Based on the above two improved methods, the prevention and care of varicocele can not be well satisfied.