No-Scalpel Vasectomy

Vasectomy is an easy-to-perform and effective form of permanent contraception. The no-scalpel technique offers an alternative to standard procedures, providing shorter operating time, less pain and swelling, and faster recovery. Because there is no incision, this technique may decrease fear of the procedure. About one-third of all vasectomies performed in the U.S. use the no-scalpel technique.
The no-scalpel vasectomy technique uses a 2- to 3-mm midline puncture into the scrotum using special sharp-tipped vasectomy dissecting forceps. The instrument has the appearance of a curved hemostat sharpened to a fine point and is used to elevate vas through the skin.
The three-finger isolation technique (i.e., thumb and index finger on top and middle finger beneath scrotum) is used to manipulate the vas to just beneath the midline skin and throughout the procedure. After vas is elevated from the skin, a second special instrument, the atraumatic vas clamp or ring clamp, is used to hold the vas.
All other tissues are separated from the vas, and 2 partial incisions are made into the vas on both sides of the clamp. The tip of a battery cautery unit is inserted within the cut vas, and the ends that will remain within the body (not held in the clamp) are thermally sealed. The short piece of vas (1/4 to 1/2 in.) held by the ring clamp can be removed.
The cut ends of the vas are separated by pulling fascial tissue over 1 end and placing a small metal clip on the fascia (not the vas). The metal clip also limits or prevents bleeding from the vas artery. The tissues are then replaced within the scrotum, the other vas is swung under the midline puncture site, and these techniques are repeated on the second side.
1 of the complications of vasectomy is formation of sperm granulomas. These granulomas are usually 0.5–2 cm, firm, sometimes exquisitely tender nodules that develop at the end of the cut vas. Although granulomas often resolve over time, they can produce significant postoperative distress. The method of handling the cut ends of the vas influences the rate of formation of sperm granulomas. Metal clips placed directly on the vas or tying the vas with suture increases the rate of granuloma formation. Heat cautery (not electrosurgery) appears to produce the lowest rates of granulomas.
Removal of a small piece of vas during the procedure allows for histologic confirmation that vas was severed. Such reassurance is expensive, costing $150–200 in some settings. 1 alternative is to send specimens home with the patient (i.e., avoiding specimen storage by physician). The specimens, which are placed in formalin, are kept in a secure location until postoperative semen checks are clear. If semen analysis does not clear, the specimens can then be evaluated histologically.
Adequate local anesthesia can produce pain-free procedures for most patients. After administration of anesthetic into the midline skin, the 3-finger technique is used to slide the right vas below this site. External spermatic sheath injection is performed, infiltrating anesthetic around the vas and vasal nerves. The anesthesia needle is directed adjacent to the vas toward the external inguinal ring (abdominal end) and 1–2 mL of 1% lidocaine is infiltrated proximal to the surgical site. The left side is anesthetized similar to the right side. This technique provides superior results and is more popular with patients than are older anesthetic techniques.
Preoperative counseling is essential to determine the appropriateness of a candidate (or couple) for a permanent procedure (Table 46-1). Studies have determined that up to 10% of couples may express regret after permanent sterilization and that 1–2% request reversal.
Vasectomy reversal procedures are expensive and have relatively low success rates (20–60%) in facilitating pregnancy. It is important to have both partners present for the counseling session; if either partner is not in agreement for the permanent procedure, this choice of contraception should be deferred.
Patients should clip the hair on the anterior and lateral sides of scrotum the night before the procedure. Instruction should be given to avoid aspirin and aspirin-containing medications for 10 days before vasectomy. The patient should bring an athletic supporter to the procedure. After the procedure, gauze is laid over both sides of scrotum, and the supporter is placed to secure gauze and to provide elevation and comfort to the scrotal tissues.
Patients are instructed to limit strenuous activities for 1 wk after the procedure. Sex may be attempted for the first time 1 wk after the procedure. After 25 ejaculations (usually 3–4 months after procedure), instruct the patient to bring a specimen to the office to ensure the absence of sperm. Repeat exams of specimens usually are unnecessary, but they can be performed at the patient's request or if the first specimen is not completely clear of sperm.

Instruct the patient about proper location of hair to be clipped (not shaved) the night before the procedure. Have the patient shower after the hair clipping.
Pitfall: Patients may incorrectly clip all the hair over the symphysis pubis onto the abdomen. Give proper instruction to avoid unnecessary clipping.
Pitfall: Shaving traumatizes skin and increases surgical infection rates. Instruct patients to clip, not shave the hairs.
Instruments for the procedure are the atraumatic ring clamp and the vas dissecting forceps. The right vas is palpated; it feels like a firm, thin cord running from the testicle into the inguinal area. Although other structures can feel like vas, they usually flatten as the tissue is rolled between the fingers.
The index finger and thumb grasp the vas above the scrotum, and the middle finger is placed beneath. Grab the vas at the junction of the middle and upper thirds of the scrotum. A cross section of spermatic cord structures is shown in Fig. 46-1A. Nonsterile gloves can be used for this part of the procedure (Table 46-2).
Raise a skin wheal in the midline skin above the vas (Fig. 46-1B). Now slide the needle alongside the vas, directing the needle to about 1 in. above the planned surgical site (Fig. 46-1C). The needle is directed toward the external inguinal ring (toward the abdomen). Administer 1–2 mL of anesthetic inside the external spermatic fascia, immediately adjacent to the vas. The needle is withdrawn, the left vas is swung to the midline, and the procedure is repeated on the opposite side. The right-handed operator often finds it easier to face the patient's feet and to perform isolation of the left vas with the left hand (Fig. 46-1D).
Pitfall: Handle the vas gently. Rough manipulation, especially if traction is applied on the vas, will produce significant discomfort and unnecessary anxiety for the patient.
Pitfall: Failure to achieve adequate anesthesia often results from failure to administer anesthetic within external spermatic fascia. Use the posterior middle finger to feel the needle as it slides immediately adjacent to the vas.
Pitfall: It is possible to direct the needle through the posterior scrotum and into the practitioner's middle finger. Slow and careful advancement of the needle should avoid this problem.
Prep the skin with povidone-iodine, place a sterile drape, and use sterile gloves (Table 46-3). Bring the right vas to immediately below the midline with the 3-finger technique. Hold the clamp in the right hand (palm up), slightly open the tips of the clamp, and grasp the vas and skin inside the clamp (Fig. 46-2A). Lower the handles of the ring clamp (Fig. 46-2B). Place the middle finger of the left hand under the clamp, and place the index finger above the clamp to stretch the skin over the vas (Fig. 46-2C).
Grasp the vas-dissecting forceps in the right hand with tips pointed down toward the scrotum. Make a puncture into the vas using 1 blade of the forceps (Fig. 46-3A). Both tips are used to spread the skin immediately over the vas (Fig. 46-3B). The lateral blade of the forceps pierces the wall of the vas (Fig. 46-3C), and the palm is rotated to lift the vas outside the scrotum (Fig. 46-3D).
Some physicians have trouble elevating the vas from the scrotum using the single blade of the forceps. After puncturing and stretching the skin, forceps can be used to laterally swing under the vas and lift the vas from the scrotal skin.
Remove the ring clamp while the vas is held above the scrotum with dissecting forceps. Grab the center of the vas with the ring clamp (Fig. 46-4A), and use the vas-dissecting forceps to separate the vasal fascia and artery (Fig. 46-4B) from the vas (Fig. 46-4C). The vas should be completely isolated (Fig. 46-4D).
Pitfall: When dissecting the vas free, the vasal artery may bleed. A small hemostat can be placed on the bleeding artery, if needed.
Make 2 partial incisions (i.e., hemitransection) into the vas using straight iris scissors. The cut is made low (near fascia) on the testicular side and high up (near the clamp) on the abdominal side (Fig. 46-5A). The tip of the battery cautery unit is placed in both ends beneath the hemitransections (portions that will remain within the body) (Fig. 46-5B). Activate cautery for just a few seconds; withdraw the tip after it begins to heat tissue. Proper cautery results in minimal white formation in the end of the tissue, and the tip of the cautery unit tends to "stick'' to vas as it is withdrawn.
Pitfall: Do not cut more than halfway across the vas. If a full wall incision is made, the cut vas will retract back into the scrotum before it can be cauterized.
Pitfall: If both cuts are made high near the clamp, it will be difficult to interpose fascia over one end.
Pitfall: Do not create full-thickness burn in wall of vas. Full-thickness burn will result in necrosis, end of vas will be resorbed, and the result will be an untreated free end of the vas.
Complete a partial cut on the vas on the testicular end only (Fig. 46-6A). The testicular vas often retracts back into the scrotum. Lift up the fascia, and pull it over the testicular end of the vas. A small metal clip is used to seal the fascia over the testicular end (Fig. 46-6B). The clip must extend across to the abdominal end of the vas but should not clamp onto the vas.
Bleeding complications can be reduced if the vasal artery is occluded in the fascia clip immediately adjacent to the vas (Fig. 46-6C). After the metal clip is placed, inspect to ensure a bloodless field. Complete the cut on the abdominal vas, and remove the specimen in the clamp (Fig. 46-6D). The right side is returned to the scrotum, and the left side is slid medially with the same technique performed on the left. After the left side is completed, wash povidone-iodine off the skin, place antibiotic ointment and gauze over the site, and apply an athletic supporter.

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Outline ⬇

Introduction ⬆ ⬇

Indications ⬆ ⬇

Contraindications ⬆ ⬇

Procedure ⬆ ⬇

Coding Information ⬆