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A simple vas approximator
A SIMPLE VAS APPROXIMATOR
STANWOOD
S. SCHMIDT,
M.D.
From the Department of Urology, University of California School of Medicine, San Francisco, California
Many of the tools used by surgeons to facilitate their work start as simple, homemade devices. The recently publicized vas deferens scoop started as a blunt, shallow ground hypodermic needle.’ Another, simply made tool assists me to approximate the ends of the vas when I anastomose it. Sharlip2 recently has shown that a “modified one-layer” technique is as effective as the more complicated two-layer method of Owen.3 Fuchs4 concurs, and I have used this technique for years, l although I now do a more meticulous anastomosis. Basically, I employ six to eight full thickness, “triangle” sutures of 9-O nylon, with additional muscular sutures of the same material. These full thickness sutures course diagonally through the wall of the vas, entering
1. (A) Vas approximator zith tcmion sutures in place. (B) Placing full thickness sutures, 11men exposed. one suture placed. second placed through one vas wall into lumen. (C) Adjustment of traction sutures to turn va.s over und cxpose other side for suturing.
the lumen next to the cut edge of the mucosa, making a triangle with the apex at the mucosal interface and the base outside the vas, where the suture is tied. This accomplishes a mucosato-mucosa approximation in the same manner as the two-layer method, and is simpler to complete. To do a vas anastomosis, the ends of the vas are brought facing each other, and the sutures are placed. The approximator of Strauch5 as used by BelkeP is the finest approximator for the two-layer method, but sometimes it is difficult to use. Several years ago Belker recommended that I place sutures and tag them with Kleinert-Kutz microvessel clips before tying them. This led to the present idea, which simplified the “one-layer” technique.
F1c:u1w
C
The \ras ends are freed from their fascial sheaths, and the ends are transected, as usual. Full thickness, “triangle” sutures are placed in the vas at 180 degree positions and are cut with the ends 2 inches long. These sutures are then held under slight tension by a pair of rubbershod alligator clips, joined by a piece of curved light spring wire. This balanced lateral traction brings the ends of the vas exactly together. positioned as the!. will be after the anastomosis is complete (Fig. 1A). Two or three additional full thickness sutures are next placed in the upper side and are tied (Fig. 1B). One of the lateral traction sutures is released, passed beneath the \‘as, and regrasped to turn the vas over and expose the other side for suturing (Fig. 1C). Muscular sutures are placed and tied after the full thickness sutures are completed, to give additional strength to the anastomosis and to prevent leakage of sperm. The traction sutures are tied last, after the need to rotate the anastomosis and to inspect it has ceased. The approximator is simple, inexpensive, and easy to construct. requiring only two alligator clips, a\railable at any electronic supply store,
kvith their ends covered \+ith fine rubber tubing so as to grip the sutures better. The bases of the clips are soldered to a U-shaped piece of light spring lvire. A similar device could be constructed b?. soldering the clips to a Weitlaner or an Alm self-retaining retractor. The spring lvire, however, has the advantage of providing mild tension and the cut edges of the vas are easily exposed for suturing without the risk of tearing out the traction sutures. San Francisco. (.:alifornia 94143 (DR. SCHMIDT) References 1. Schmidt SS: Vas anastomosis: a return to simplicity ISr j Ural 47: 309 (1975). 2. Sharlip ID: Vasovasmtomy: comprisorl of t\\o microsurgicd kchniques. Uroloa 17: 347 (1881). 3. Oxven ER: Microsurgical \xso\xsostom v: R reliable vasrctom>. re\Yrsal. Aust NZ Surg 47: 305 (1977). 1. Fuch< EF: Microsurgical vaso~asostom~: rrsuit< of a singlela!w techniqur. Presented at \Vestcrn Section. 4.V.A.. Salt I,& <:ity. Utah. July 1. 1981. 5. Strauch B: Folding-approximating clamp to simplify micro~asovasostom!: Vrolo~q. 16: 295 (1980). 6. Belker Ahl: \licroaurgical t\vo-layer vawawstom!: ibid 16: 376 (1980).
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STANWOOD
S. SCHMIDT,
M.D.
From the Department of Urology, University of California School of Medicine, San Francisco, California
Many of the tools used by surgeons to facilitate their work start as simple, homemade devices. The recently publicized vas deferens scoop started as a blunt, shallow ground hypodermic needle.’ Another, simply made tool assists me to approximate the ends of the vas when I anastomose it. Sharlip2 recently has shown that a “modified one-layer” technique is as effective as the more complicated two-layer method of Owen.3 Fuchs4 concurs, and I have used this technique for years, l although I now do a more meticulous anastomosis. Basically, I employ six to eight full thickness, “triangle” sutures of 9-O nylon, with additional muscular sutures of the same material. These full thickness sutures course diagonally through the wall of the vas, entering
1. (A) Vas approximator zith tcmion sutures in place. (B) Placing full thickness sutures, 11men exposed. one suture placed. second placed through one vas wall into lumen. (C) Adjustment of traction sutures to turn va.s over und cxpose other side for suturing.
the lumen next to the cut edge of the mucosa, making a triangle with the apex at the mucosal interface and the base outside the vas, where the suture is tied. This accomplishes a mucosato-mucosa approximation in the same manner as the two-layer method, and is simpler to complete. To do a vas anastomosis, the ends of the vas are brought facing each other, and the sutures are placed. The approximator of Strauch5 as used by BelkeP is the finest approximator for the two-layer method, but sometimes it is difficult to use. Several years ago Belker recommended that I place sutures and tag them with Kleinert-Kutz microvessel clips before tying them. This led to the present idea, which simplified the “one-layer” technique.
F1c:u1w
C
The \ras ends are freed from their fascial sheaths, and the ends are transected, as usual. Full thickness, “triangle” sutures are placed in the vas at 180 degree positions and are cut with the ends 2 inches long. These sutures are then held under slight tension by a pair of rubbershod alligator clips, joined by a piece of curved light spring wire. This balanced lateral traction brings the ends of the vas exactly together. positioned as the!. will be after the anastomosis is complete (Fig. 1A). Two or three additional full thickness sutures are next placed in the upper side and are tied (Fig. 1B). One of the lateral traction sutures is released, passed beneath the \‘as, and regrasped to turn the vas over and expose the other side for suturing (Fig. 1C). Muscular sutures are placed and tied after the full thickness sutures are completed, to give additional strength to the anastomosis and to prevent leakage of sperm. The traction sutures are tied last, after the need to rotate the anastomosis and to inspect it has ceased. The approximator is simple, inexpensive, and easy to construct. requiring only two alligator clips, a\railable at any electronic supply store,
kvith their ends covered \+ith fine rubber tubing so as to grip the sutures better. The bases of the clips are soldered to a U-shaped piece of light spring lvire. A similar device could be constructed b?. soldering the clips to a Weitlaner or an Alm self-retaining retractor. The spring lvire, however, has the advantage of providing mild tension and the cut edges of the vas are easily exposed for suturing without the risk of tearing out the traction sutures. San Francisco. (.:alifornia 94143 (DR. SCHMIDT) References 1. Schmidt SS: Vas anastomosis: a return to simplicity ISr j Ural 47: 309 (1975). 2. Sharlip ID: Vasovasmtomy: comprisorl of t\\o microsurgicd kchniques. Uroloa 17: 347 (1881). 3. Oxven ER: Microsurgical \xso\xsostom v: R reliable vasrctom>. re\Yrsal. Aust NZ Surg 47: 305 (1977). 1. Fuch< EF: Microsurgical vaso~asostom~: rrsuit< of a singlela!w techniqur. Presented at \Vestcrn Section. 4.V.A.. Salt I,& <:ity. Utah. July 1. 1981. 5. Strauch B: Folding-approximating clamp to simplify micro~asovasostom!: Vrolo~q. 16: 295 (1980). 6. Belker Ahl: \licroaurgical t\vo-layer vawawstom!: ibid 16: 376 (1980).
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