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Laparoscopic Varix Ligation
0022-5347/92/1471-0077$03.00/0 Tl-iE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
LAPAROSCOPIC VARIX LIGATION JAMES F. DONOVAN AND HOWARD N. WINFIELD From the Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
ABSTRACT
Varicocele, dilated veins in the pampiniform plexus, is frequently a contributing factor in male infertility. We performed outpatient laparoscopic varix ligation in 14 patients (5 bilaterally) with clinically evident varices and persistent oligospermia and/or asthenospermia. The spermatic artery was identified and preserved in all but 1 varix ligation. Mean interval to resumption of preoperative activity levels was 3.4 days. On average, patients consumed 8.4 tablets of acetaminophen (325 mg.) with codeine (30 mg.) during the recovery period. The procedure is effective and decreases postop erative morbidity. KEY WORDS:
peritoneoscopy; infertility, male; varicocele
should be defined once the bladder and stomach are empty. The Veress needle will be directed beyond this landmark into the true pelvis. Once the stomach and bladder have been decompressed the abdomen is palpated to identify landmarks and rule out the presence of unsuspected pathology (aortic aneurysm, urachal cyst or solid mass). Pneumoperitoneum. The Veress needle is used to gain access to the peritoneal cavity for the insufflation of carbon dioxide. Veress needles are available in either a reusable or disposable form with an external diameter of 2 mm. and lengths of 70 to 120 mm. The Veress needle is composed of 2 parts, the outer sheath and inner obturator. The outer sheath is beveled and sharp to penetrate the anterior abdominal fascia and perito neum. In addition to a channel that provides for the insufflation of carbon dioxide, the blunt inner obturator retracts during advancement through dense, resistant tissues but springs for ward beyond the sharp beveled sheath once the peritoneal cavity is entered, thus protecting the underlying viscera. The patient is placed in the modified Trendelenburg position (15-degree incline) to promote movement of the abdominal viscera out of the pelvis, which is the target for subsequent insertion of instruments. A small vertical skin incision (2 to 3 mm.) is made immediately below the umbilicus. The Veress needle is passed through this incision, angled 45 degrees from vertical and directed toward the pelvis well below the bifurca tion of the aorta. The Veress needle must pass 2 points of palpable resistance, the fascia of the linea alba and the perito neum. We assess the proper position of the Veress needle by aspiration (return of blood, gas or succus entericus indicates unsatisfactory intraperitoneal placement) and by injection and aspiration of 10 mL saline (return of saline suggests preperito neal placement). Next, carbon dioxide is instilled at a rate of 1 to 2 L per minute. The intraperitoneal pressure is monitored by a pressure transducer through the insufflation channel and should be low (7 mm. Hg or less) at the start of insufflation. Higher starting pressures suggest improper placement of the Veress needle. The intraperitoneal pressure should increase gradually and be maintained at approximately 15 mm. Hg above baseline during the procedure. The peritoneal cavity in a man will accommodate 4 to 6 L, which provides adequate distension of the peritoneal cavity without compromise to controlled ventilation or venous return. In addition to providing adequate pneumoperitoneum rapidly, high flow insufflation machines maintain the pneu moperitoneum despite the loss of gas via the laparoscopic sheaths during instrument exchange. Insertion of trocar-laparoscope. After removal of the Veress needle the subumbilical incision is extended to 12 mm. to accommodate the 11 mm. trocar-sheath unit and a 3 mm. nick is made in the linea alba. The trocar-sheath assembly is then
A varicocele is an abnormal dilatation of the pampiniform plexus. The incidence of varicocele in men is approximately 15%.1 A varicocele frequently contributes to male factor infer tility and the prevalence in this select group is 34% (range 19 to 41%).2-4 Several approaches to the division or destruction of varicoceles are in current use, including operative techniques (retroperitoneal or Palomo approach, inguinal or Ivanissevich approach and microsurgical venous bypass) and nonoperative techniques (transvenous percutaneous ablation by balloons, coils, autologous clot or thermal destruction).5-7 Since Kelling reported endoscopic examination of the peritoneal contents in 1901, laparoscopy has increased in frequency of use and number of applications.8• We describe our experience with laparoscopic varix ligation. 9
MATERIALS AND METHODS
Patient selection. Varix ablation is indicated in men who present with a history of infertility, clinically evident varices and demonstrable abnormalities on seminal fluid analysis. Oc casionally, a varix may cause pain, which is a valid but less common indication for treatment. In addition to a thorough history and physical examination, patients with clinically iden tifiable varices underwent scrotal ultrasound and color Doppler examination to confirm the presence of dilated spermatic veins with reverse venous flow during Valsalva's maneuver. For each laparoscopic varicocelectomy candidate one must obtain a precise surgical history. Previous abdominal proce dures may contraindicate laparoscopy due to the possible pres ence of adhesions, which impose an increased risk of visceral injury during insertion of the Veress needle and laparoscopic trocar-sheath units. Obesity is not a contraindication to lapa roscopic varix ligation, although special care is warranted in the obese patient during insertion of the insufflating needle and establishment of the pneumoperitoneum. 10 Patient preparation. After induction of general anesthesia and intubation the skin is prepared in the standard fashion, including shaving and application of a topical antibacterial agent. Because of the small risk of injury to the abdominal contents, which might then necessitate celiotomy, a wide area is prepared extending from the subcostal margin to the mid thigh, lateral to the posterior axillary lines, and including the genitals. A nasogastric tube is usually inserted and the stomach contents are aspirated before the Veress needle is passed into the peritoneal cavity and always when one suspects gastric distension after induction of anesthesia. A Foley catheter is always inserted to empty the bladder and reduce the risk of bladder puncture by either the Veress needle or the laparoscope sheath trocar assembly. The location of the sacral promontory Accepted for publication May 10, 1991.
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inserted into the peritoneal cavity. The trocar is a sharp, pyramidal or conical shaped instrument that must be advanced with care. The trocar-sheath assembly is grasped with the end of the instrument against the thenar eminence of the dominant hand, and the index finger is extended toward the abdominal wall to control the advance and act as a brake. Once the trocar and sheath have entered the peritoneal cavity an audible escape of carbon dioxide gas is heard through the trocar channel. The trocar is immediately removed, thus activating the trumpet (or trap door) valve in the sheath assembly, which prevents addi tional loss of carbon dioxide. The laparoscope is passed through the sheath and the abdom inal contents are examined to confirm placement within the peritoneal cavity and to inspect the viscera directly beneath the insertion flits). Incorrect placement within the preperitoneal space requires reinsertion while injury of abdominal viscera requires laparotomy. Upon completion of the initial inspection the carbon dioxide insufflation resumes through the sheath channel to maintain the pneumoperitoneum with an intraper itoneal pressure between 14 and 17 mm. Hg. Next, a full beam video camera is attached to the ocular piece of the laparoscope. This permits the operator and assistants to perform the sub sequent procedure while viewing a television monitor that is positioned at the foot of the operating table (fig. 1). Instrument insertion. In addition to the laparoscope insertion site at least 2 additional working ports are required to provide access for operating instruments. One access port is placed medial to the ipsilateral anterior iliac spine and directly ceph alad from the internal ring, while 1 is positioned through the linea alba midway between the umbilicus and the pubic sym physis. The laparoscope is directed to each insertion site. This technique provides transillumination of the abdominal wall to locate the inferior epigastric vessels as well as constant sur veillance of the intraperitoneal contents beneath the insertion site, thus decreasing the probability of injury to either the abdominal wall vessels or intra-abdominal viscera. We use a 5.5 mm. working port in the inferolateral position and an 11 mm. access port in the inferior midline position. In cases that require bilateral varix ligation, a second inferolateral 5.5 mm. working port is inserted in the right lower quadrant (fig. 2). Instruments. A variety of instruments designed for use in laparoscopic surgery are available, including scissors, curved hemostats, straight hemostats, irrigation-suction devices and hemoclip appliers. The scissors have straight blades and fit through the 5.5 mm. working ports. The hemostat devices or graspers, which we use for grasping and dissecting, can be adapted to either 5.5 or 11 mm. working ports. In addition, these instruments have insulated shafts and electrical contact adaptors that allow the use of bipolar electrocoagulation. The 5 mm. irrigation-suction instrument is a single channel cylinder
FIG. 1. Position of surgeon and assistant for left varix ligation. Surgeon stands opposite side of varix and operates both instruments. Assistant stands on side ipsilateral to varix and directs laparoscope to operative field. Both observe video monitor positioned at foot of oper ating table.
FIG. 2. Laparoscopic access sheaths in place for bilateral varix ligation. Two 11 mm. sheaths are positioned in midline-subumbilical for laparoscope, and lower midline for Maryland dissector and the hemoclip applier. Also, 5.5 mm. sheath is positioned in each lower quadrant for insertion of grasping instruments and scissors. Foley catheter is inserted and bladder is emptied before insertion of Veress needle.
but allows for attachment to suction, irrigation and injection ports, which are controlled by valves. Thus, one can use this instrument for irrigation with heparinized saline (7,500 units per 1.), injection of papaverine or aspiration of peritoneal fluid simply by adjusting the valves appropriately. One must be restrained in the use of suction, since overuse will result in deflation of the pneumoperitoneum and interfere with visibil ity. Finally, the hemoclip applier, available in disposable* and reusable models, requires an 11 mm. access port and is used for the hemoclip ligation of the varix veins. Dissection. After increasing the Trendelenburg position in cline to 30 degrees the patient is rotated away from the intended site of varix ligation, improving exposure as the abdominal viscera move to the contralateral, dependent area of the peri toneal cavity. The operator stands on the contralateral side of the operating table and manipulates the midline and ipsilateral instruments, while an assistant on the ipsilateral side controls the Japaroscope and stabilizes the instrument ports during instrument exchange. This arrangement provides the operator and assistant with a clear view of the video monitor and decreases instrument manipulation by the ipsilateral assistant who faces the laparoscope camera and, therefore, must deal with a mirror-image frame of reference (fig. 1). The scissors are inserted through the ipsilateral port and the curved dissectors are inserted through the midline port. While grasping the overlying peritoneum, the scissors make a 5 cm. peritoneal incision parallel and lateral to the spermatic vessels (fig. 3, A). The medial peritoneal edge of the incision is grasped and a second peritoneal incision is made at a right angle to the first extending medially over the spermatic vessels to produce a T incision, and expose the lateral and medial borders of the spermatic vascular packet (fig. 3, B). The medial and lateral borders of the spermatic vascular bundle are defined. The scissors are replaced by a straight grasping instrument, which grasps the loose alveolar tissue surrounding the vessels and lifts the vascular bundle away from the posterior retroperitoneum, while the curved dissector gently divides attachments to the underlying psoas muscle. Once the vascular packet is isolated the ipsilateral straight and the midline curved graspers carefully segregate the vessels into smaller bundles. At this point we observe each cluster of vessels and identify the location of the spermatic artery. The group that does not contain the artery is grasped with the ipsilateral grasper, while the hemoclip applier is inserted in the midline port replacing the curved hemostat. To the venous batch we apply 2 clips to the proximal dissection and 2 clips to the distal dissection to maintain control using the hemoclip applier. The operator inserts the scissors through * Endo Clip, United States Surgical Corp., Norwalk, Connecticut.
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FIG. 3. A, peritoneal incision. Maryland dissector grasps and elevates peritoneum lateral to spermatic vascular bundle (arrow). With scissors incision is made parallel to spermatic vessels cephalad to internal ring. B, peritoneal incision is marked with location of medial T extension, which provides exposure of medial margin of vascular packet. Vas is identified medial to internal ring (arrow) where it joins spermatic vessels in their course through abdominal wall.
FIG. 4. A, spermatic veins are divided by scissors between hemoclips. Spermatic artery (arrow) is identified and preserved. B, after division of spermatic veins. Artery (arrow) is preserved. Peritoneum is retracted after T incision to provide necessary exposure for dissection.
the ipsilateral port and divides the veins between the clips (fig. 4,A). The process of separating veins from artery is continued with care to grasp only veins or adventitial tissue. Occasionally, the pulsation of the artery may be diminished due to spasm. We then irrigate the site of dissection with papaverine or lidocaine, restoring circulation and allowing clear visual identification of the spermatic artery (fig. 4, B). In cases of bilateral varicocele the procedure is repeated on the opposite side following inser tion of the ipsilateral 5.5 mm. instrument port and rotation of the operating table away from the dissection site. Termination of procedure. Upon completion of the varix ligation we examine each site of ligation and, when necessary, secure hemostasis with electrocoagulation. We minimize the use of electrocautery to decrease the chance of injuring the spermatic artery. The patient is rotated to a neutral position and placed in the reverse Trendelenburg position. The pelvis is inspected and any irrigant or blood that has accumulated during the procedure is aspirated. Then each instrument port insertion site is inspected to assess and treat any active hem orrhage. This includes inspection of the original subumbilical insertion site, which is examined by placing the laparoscope through the 11 mm. midline suprapubic port. With the patient returned to the supine position each sheath is removed. Before removal of the last port the insufflation valve is opened and the carbon dioxide gas is expelled from the peritoneal cavity.
A single fascial 1-zero absorbable suture is placed at the midline insertion sites that had provided access to 11 mm. access sleeves and a subcutaneous suture as needed. Sterile strips then approximate the skin of all insertion sites. A clear dressing covers each wound. RESULTS
Since June 1990 we performed laparoscopic varix ligation in 14 patients (bilaterally in 5). Each patient underwent a careful evaluation to detect factors that could contribute to male infertility. All patients demonstrated persistent oligospermia and/or asthenospermia on repeated seminal fluid analyses. Average sperm density was 9.42 million sperm per ml., average motility was 39.2% and average number of motile sperm per ejaculate was 10. 5 million. No patient exhibited endocrine abnormality. Physical examination revealed clinically evident varicocele(s) that were subsequently confirmed by ultrasound and color Doppler examination in all patients. When necessary patients were re-evaluated after elimination of gonadotoxins (for example alcohol or cimetidine). We performed laparoscopic varix ablation in patients who have undergone previous celi otomy for various operative procedures, such as appendectomy, herniorrhaphy and varix ablation (inguinal and transvenous, table 1). Patient weight (average 82.9 kg. , range 54 to 107 kg.) did not preclude laparoscopic varix ligation.
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All procedures were performed in the ambulatory surgery center and only 1 patient required postoperative hospitalization due to prolonged recovery from anesthesia. The average oper ating time was 118 minutes (range 66 to 177 minutes). We noted no complications either at the operation or during the ensuing followup. The testicular artery was identified and pre - served in 18 of 19 varix ligations (95% ). In 1 patient we did not identify the spermatic artery, which was presumably ligated with the spermatic veins. Table 1 lists the interval between operation and return to regular activity (average 3.4 days). As shown, regular activity in these patients is not limited to sedentary occupations. Fur ther evidence of the relatively benign postoperative course is provided by the minimal use of analgesics. An average of 8.4 acetinninophen (325 mg.) with codeine (30 mg.) tablets_were used during postoperative week 1. Of the 14 patients 5 discon tinued all analgesics within 3 days postoperatively. Patients who underwent bilateral varix ligation demonstrated no signif icant difference in postoperative recovery compared to patients who underwent unilateral varix ligation. Postoperative physical examination has not revealed persist ent, clinically relevant varices in any patient. In a male adoles cent with a clinically large, visible varix and testicular atrophy preoperatively the pampiniform plexus remained palpably di lated on physical examination but it has decreased in size, is no longer visible and no longer demonstrates distension with Valsalva's maneuver on physical examination or ultrasound. Evaluation of postoperative seminal fluid analyses is not complete to date. Of the 14 patients 7 have been followed at least 6 months. Preoperative and postoperative semen analyses are compared in table 2. The results demonstrate an increase in sperm density and motile sperm per ejaculate with a decrease in percentage motility. Additional followup is necessary to provide sufficient data for accurate outcome analysis with respect to changes in seminal fluid analysis and comparison with traditional forms of varicocelectomy. DISCUSSION
Laparoscopic varix ligation offers an alternative to tradi tional methods of varix ablation. Selection criteria remain unchanged, that is a clinically evident varicocele with coinci dent infertility and/or pain. While the left and right spermatic veins are accessible through the laparoscope, only clinically apparent varicoceles are ligated. We believe that the patient with a persistent varix who has been treated unsuccessfully by retroperitoneal varix ligation (the Palomo approach) is not a candidate for laparoscopic varix ligation, since both procedures are directed at the spermatic veins immediately cephalad to the
Pt.-Age RW-24 DM-28 JE-28 SM-37 TJ-34 LH-30 BS-21 PF-32 DL-29 EE-25 JL-15 EJ-35 RK-27§ BM-33
Occupation Farmer Clerk Construction Industry Disc jockey Machinist Mechanic Farmer Artist Farmer Student Industry Chemist Advertising manager
internal ring. Previous celiotomy for inflammatory conditions (and consequently an increased probability of adhesions) is a relative contraindication to a laparoscopic procedure, although we have encountered no difficulty in patients who have under gone limited abdominal procedures such as appendectomy, herniorrhaphy or inguinal (Ivanissevich approach) varicocelec- tomy. The use of the Hasson trocar and cannula through a small, subumbilical celiotomy permits insertion of the trocar under direct vision followed by carbon dioxide insufflation and should be considered in patients who have undergone extensive abdominal surgery.11 Dissection of the spermatic veins and preservation of the spermatic artery were not affected by obe sity. Insertion of the Veress needle and insufflation to create a pneumoperitoneum require care in the obese patient due to the proclivity in__this group for preperitoneal insufflation. 10 To date we have not experienced preperitoneal insufflation in our la- paroscopic varix ligation procedures. In general, collateral circulation to the testes is present distal to the site of laparoscopic varix ligation (that is artery to the vas and cremasteric artery), although one is not assured of its integrity or adequacy in all cases. A previous inguinal or scrotal operation may compromise these alternate routes of arterial blood flow to the testes. With care in dissection preservation of the testicular artery, not implicated as a contributing factor in the pathophysiology of varicocele, is possible in the majority of cases. We identified and preserved the testicular artery in all but 1 of the 19 laparoscopic varix ligations. In our initial experience we attempted to separate, clip and ligate the sper- matic veins without subsequent division. Currently, we clip and divide the branches of the spermatic vein. Division of the veins facilitates exposure and preservation of the artery, which is most often posterior to the majority of spermatic veins at the level of our dissection. Speed of recovery may be partly attributed to patient age (average 28.8 years). However, in our experience with tradi tional varix ligation procedures (inguinal and retroperitoneal exposure), return to regular activity before postoperative day 7 is uncommon and complete recovery typically occurs between postoperative days 10 and 14. Initially, operating time is in - creased in comparison to traditional operative varix ligation. With experience operating time decreases. Any increase in duration of operation with the use of laparoscopy is offset by a decrease in postoperative recovery time. CONCLUSION
The laparoscopic varix ligation provides a technique for varix ablation that minimizes morbidity without compromising the operative goal. Patients report minimal postoperative discom --
TABLE 1. Summary of patient information Previous Abdominal Days to Resume Procedure Normal Activity Surgery* Lt. varix ligation 4 No 3 No Bilat. varix ligation 6 Lt. varix ligation No 4 Lt. varix ligation Yes 3 Yes Lt. varix ligation 3 No Bilat. varix ligation Bilat. varix ligation No 6 No Lt. varix ligation 1 3 Bilat. varix ligation No Yes 2 Lt. varix ligation 3 Yes Lt. varix ligation Yes 1 Bilat. varix ligation 4 No Lt. varix ligation No Lt. varix ligation 5
Pregnancyt Yes
Yes Yes Yes
Analgesic Use:j: 16 5 3 23 5 6 10 12 7 16 5 2 4 4
Av. 28.4 3.4 8.4 * Previous abdominal surgery included appendectomy and left inguinal hernia repair in patient S. M., left inguinal hernia repair in patient T. S., appendectomy in patient E. E., inguinal varix ligation in patient S. L. and appendectomy in patient E. S. t In patients reporting pregnancy the average time to conception after varix ligation was 4 months (range 1 to 7 months). :j: Analgesic use was number of tablets consumed during postoperative week 1. Each tablet contained 325 mg. acetaminophen and 30 mg. codeine. § Patient R. K. remained in the hospital overnight due to prolonged recovery from anesthesia.
LAPAROSCOPIC VARIX LIGATION Results of preoperative and postoperative semen analyses in 7 patients who completed 6 months of followup with at least 2 semen analyses
TABLE 2.
Av. Preop. Semen Analysis
Av. Postop. Semen Analysis
12.8 41 13.5
22.6 33 30.7
Sperm density(million sperm/ml.) Motility(%) Motile sperm/ejaculate(million sperm)
fort and rapid return to preoperative activity (including stren uous physical work). Patients undergoing bilateral laparoscopic varix ligation experience no appreciable increase in postopera tive morbidity or interval to recovery. In appropriate patients laparoscopic varix ligation is a safe and attractive alternative to traditional operative varix ligation techniques. REFERENCES 1. Saypol, D. C.: Varicocele. J. Androl., 2: 61, 1981. 2. Pryor, J. L. and Howards, S. S.: Varicocele. In: Contemporary Management of Impotence and Infertility. Edited by E. A. Tanagho, T. F. Lue and R. D. McClure. Baltimore: Williams &
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Wilkins, chapt. 23, pp. 247-264, 1988. 3. Hendry, W. F., Sommerville, I. F., Hall, R. R. and Pugh, R. C. B.: Investigation and treatment of the subfertile male. Brit. J. Urol., 45: 684, 1973. 4. Cockett, A. T. K., Urry, R. L. and Dougherty, K. A.: The varicocele and semen characteristics. J. Urol., 121: 435, 1979. 5. Palomo, A.: Radical cure of varicocele by a new technique: prelim inary report. J. Urol., 61: 604, 1949. 6. Ivanissevich, 0.: Left varicocele due to reflux. Experience with 4,470 operative cases in forty-two years. J. Int. Coll. Surg., 34: 742, 1960. 7. Lipshultz, L. I. and Howards, S. S.: Surgical treatment of male infertility. In: Infertility in the Male. New York: Churchill Liv ingstone, chapt. 17, pp. 343-366, 1983. 8. Winfield, H. N. and Ryan, K. J.: Experimental laparoscopic sur gery: potential clinical applications in urology. J. Endourol., 4: 37, 1990. 9. Gunning, J. E.: The history of laparoscopy. In: Gynecological Laparoscopy: Principles and Techniques. Edited by J. M. Phillips and L. Keith. Miami: Symposia Specialists, pp. 57-66, 1974. 10. Borten, M.: Laparoscopic Complications: Prevention and Manage ment. Philadelphia: B. C. Decker Inc., 1986. 11. Hasson, H. M.: Open laparoscopy: a report of 150 cases. J. Reprod. Med., 12: 234, 1974.
LAPAROSCOPIC VARIX LIGATION JAMES F. DONOVAN AND HOWARD N. WINFIELD From the Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
ABSTRACT
Varicocele, dilated veins in the pampiniform plexus, is frequently a contributing factor in male infertility. We performed outpatient laparoscopic varix ligation in 14 patients (5 bilaterally) with clinically evident varices and persistent oligospermia and/or asthenospermia. The spermatic artery was identified and preserved in all but 1 varix ligation. Mean interval to resumption of preoperative activity levels was 3.4 days. On average, patients consumed 8.4 tablets of acetaminophen (325 mg.) with codeine (30 mg.) during the recovery period. The procedure is effective and decreases postop erative morbidity. KEY WORDS:
peritoneoscopy; infertility, male; varicocele
should be defined once the bladder and stomach are empty. The Veress needle will be directed beyond this landmark into the true pelvis. Once the stomach and bladder have been decompressed the abdomen is palpated to identify landmarks and rule out the presence of unsuspected pathology (aortic aneurysm, urachal cyst or solid mass). Pneumoperitoneum. The Veress needle is used to gain access to the peritoneal cavity for the insufflation of carbon dioxide. Veress needles are available in either a reusable or disposable form with an external diameter of 2 mm. and lengths of 70 to 120 mm. The Veress needle is composed of 2 parts, the outer sheath and inner obturator. The outer sheath is beveled and sharp to penetrate the anterior abdominal fascia and perito neum. In addition to a channel that provides for the insufflation of carbon dioxide, the blunt inner obturator retracts during advancement through dense, resistant tissues but springs for ward beyond the sharp beveled sheath once the peritoneal cavity is entered, thus protecting the underlying viscera. The patient is placed in the modified Trendelenburg position (15-degree incline) to promote movement of the abdominal viscera out of the pelvis, which is the target for subsequent insertion of instruments. A small vertical skin incision (2 to 3 mm.) is made immediately below the umbilicus. The Veress needle is passed through this incision, angled 45 degrees from vertical and directed toward the pelvis well below the bifurca tion of the aorta. The Veress needle must pass 2 points of palpable resistance, the fascia of the linea alba and the perito neum. We assess the proper position of the Veress needle by aspiration (return of blood, gas or succus entericus indicates unsatisfactory intraperitoneal placement) and by injection and aspiration of 10 mL saline (return of saline suggests preperito neal placement). Next, carbon dioxide is instilled at a rate of 1 to 2 L per minute. The intraperitoneal pressure is monitored by a pressure transducer through the insufflation channel and should be low (7 mm. Hg or less) at the start of insufflation. Higher starting pressures suggest improper placement of the Veress needle. The intraperitoneal pressure should increase gradually and be maintained at approximately 15 mm. Hg above baseline during the procedure. The peritoneal cavity in a man will accommodate 4 to 6 L, which provides adequate distension of the peritoneal cavity without compromise to controlled ventilation or venous return. In addition to providing adequate pneumoperitoneum rapidly, high flow insufflation machines maintain the pneu moperitoneum despite the loss of gas via the laparoscopic sheaths during instrument exchange. Insertion of trocar-laparoscope. After removal of the Veress needle the subumbilical incision is extended to 12 mm. to accommodate the 11 mm. trocar-sheath unit and a 3 mm. nick is made in the linea alba. The trocar-sheath assembly is then
A varicocele is an abnormal dilatation of the pampiniform plexus. The incidence of varicocele in men is approximately 15%.1 A varicocele frequently contributes to male factor infer tility and the prevalence in this select group is 34% (range 19 to 41%).2-4 Several approaches to the division or destruction of varicoceles are in current use, including operative techniques (retroperitoneal or Palomo approach, inguinal or Ivanissevich approach and microsurgical venous bypass) and nonoperative techniques (transvenous percutaneous ablation by balloons, coils, autologous clot or thermal destruction).5-7 Since Kelling reported endoscopic examination of the peritoneal contents in 1901, laparoscopy has increased in frequency of use and number of applications.8• We describe our experience with laparoscopic varix ligation. 9
MATERIALS AND METHODS
Patient selection. Varix ablation is indicated in men who present with a history of infertility, clinically evident varices and demonstrable abnormalities on seminal fluid analysis. Oc casionally, a varix may cause pain, which is a valid but less common indication for treatment. In addition to a thorough history and physical examination, patients with clinically iden tifiable varices underwent scrotal ultrasound and color Doppler examination to confirm the presence of dilated spermatic veins with reverse venous flow during Valsalva's maneuver. For each laparoscopic varicocelectomy candidate one must obtain a precise surgical history. Previous abdominal proce dures may contraindicate laparoscopy due to the possible pres ence of adhesions, which impose an increased risk of visceral injury during insertion of the Veress needle and laparoscopic trocar-sheath units. Obesity is not a contraindication to lapa roscopic varix ligation, although special care is warranted in the obese patient during insertion of the insufflating needle and establishment of the pneumoperitoneum. 10 Patient preparation. After induction of general anesthesia and intubation the skin is prepared in the standard fashion, including shaving and application of a topical antibacterial agent. Because of the small risk of injury to the abdominal contents, which might then necessitate celiotomy, a wide area is prepared extending from the subcostal margin to the mid thigh, lateral to the posterior axillary lines, and including the genitals. A nasogastric tube is usually inserted and the stomach contents are aspirated before the Veress needle is passed into the peritoneal cavity and always when one suspects gastric distension after induction of anesthesia. A Foley catheter is always inserted to empty the bladder and reduce the risk of bladder puncture by either the Veress needle or the laparoscope sheath trocar assembly. The location of the sacral promontory Accepted for publication May 10, 1991.
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inserted into the peritoneal cavity. The trocar is a sharp, pyramidal or conical shaped instrument that must be advanced with care. The trocar-sheath assembly is grasped with the end of the instrument against the thenar eminence of the dominant hand, and the index finger is extended toward the abdominal wall to control the advance and act as a brake. Once the trocar and sheath have entered the peritoneal cavity an audible escape of carbon dioxide gas is heard through the trocar channel. The trocar is immediately removed, thus activating the trumpet (or trap door) valve in the sheath assembly, which prevents addi tional loss of carbon dioxide. The laparoscope is passed through the sheath and the abdom inal contents are examined to confirm placement within the peritoneal cavity and to inspect the viscera directly beneath the insertion flits). Incorrect placement within the preperitoneal space requires reinsertion while injury of abdominal viscera requires laparotomy. Upon completion of the initial inspection the carbon dioxide insufflation resumes through the sheath channel to maintain the pneumoperitoneum with an intraper itoneal pressure between 14 and 17 mm. Hg. Next, a full beam video camera is attached to the ocular piece of the laparoscope. This permits the operator and assistants to perform the sub sequent procedure while viewing a television monitor that is positioned at the foot of the operating table (fig. 1). Instrument insertion. In addition to the laparoscope insertion site at least 2 additional working ports are required to provide access for operating instruments. One access port is placed medial to the ipsilateral anterior iliac spine and directly ceph alad from the internal ring, while 1 is positioned through the linea alba midway between the umbilicus and the pubic sym physis. The laparoscope is directed to each insertion site. This technique provides transillumination of the abdominal wall to locate the inferior epigastric vessels as well as constant sur veillance of the intraperitoneal contents beneath the insertion site, thus decreasing the probability of injury to either the abdominal wall vessels or intra-abdominal viscera. We use a 5.5 mm. working port in the inferolateral position and an 11 mm. access port in the inferior midline position. In cases that require bilateral varix ligation, a second inferolateral 5.5 mm. working port is inserted in the right lower quadrant (fig. 2). Instruments. A variety of instruments designed for use in laparoscopic surgery are available, including scissors, curved hemostats, straight hemostats, irrigation-suction devices and hemoclip appliers. The scissors have straight blades and fit through the 5.5 mm. working ports. The hemostat devices or graspers, which we use for grasping and dissecting, can be adapted to either 5.5 or 11 mm. working ports. In addition, these instruments have insulated shafts and electrical contact adaptors that allow the use of bipolar electrocoagulation. The 5 mm. irrigation-suction instrument is a single channel cylinder
FIG. 1. Position of surgeon and assistant for left varix ligation. Surgeon stands opposite side of varix and operates both instruments. Assistant stands on side ipsilateral to varix and directs laparoscope to operative field. Both observe video monitor positioned at foot of oper ating table.
FIG. 2. Laparoscopic access sheaths in place for bilateral varix ligation. Two 11 mm. sheaths are positioned in midline-subumbilical for laparoscope, and lower midline for Maryland dissector and the hemoclip applier. Also, 5.5 mm. sheath is positioned in each lower quadrant for insertion of grasping instruments and scissors. Foley catheter is inserted and bladder is emptied before insertion of Veress needle.
but allows for attachment to suction, irrigation and injection ports, which are controlled by valves. Thus, one can use this instrument for irrigation with heparinized saline (7,500 units per 1.), injection of papaverine or aspiration of peritoneal fluid simply by adjusting the valves appropriately. One must be restrained in the use of suction, since overuse will result in deflation of the pneumoperitoneum and interfere with visibil ity. Finally, the hemoclip applier, available in disposable* and reusable models, requires an 11 mm. access port and is used for the hemoclip ligation of the varix veins. Dissection. After increasing the Trendelenburg position in cline to 30 degrees the patient is rotated away from the intended site of varix ligation, improving exposure as the abdominal viscera move to the contralateral, dependent area of the peri toneal cavity. The operator stands on the contralateral side of the operating table and manipulates the midline and ipsilateral instruments, while an assistant on the ipsilateral side controls the Japaroscope and stabilizes the instrument ports during instrument exchange. This arrangement provides the operator and assistant with a clear view of the video monitor and decreases instrument manipulation by the ipsilateral assistant who faces the laparoscope camera and, therefore, must deal with a mirror-image frame of reference (fig. 1). The scissors are inserted through the ipsilateral port and the curved dissectors are inserted through the midline port. While grasping the overlying peritoneum, the scissors make a 5 cm. peritoneal incision parallel and lateral to the spermatic vessels (fig. 3, A). The medial peritoneal edge of the incision is grasped and a second peritoneal incision is made at a right angle to the first extending medially over the spermatic vessels to produce a T incision, and expose the lateral and medial borders of the spermatic vascular packet (fig. 3, B). The medial and lateral borders of the spermatic vascular bundle are defined. The scissors are replaced by a straight grasping instrument, which grasps the loose alveolar tissue surrounding the vessels and lifts the vascular bundle away from the posterior retroperitoneum, while the curved dissector gently divides attachments to the underlying psoas muscle. Once the vascular packet is isolated the ipsilateral straight and the midline curved graspers carefully segregate the vessels into smaller bundles. At this point we observe each cluster of vessels and identify the location of the spermatic artery. The group that does not contain the artery is grasped with the ipsilateral grasper, while the hemoclip applier is inserted in the midline port replacing the curved hemostat. To the venous batch we apply 2 clips to the proximal dissection and 2 clips to the distal dissection to maintain control using the hemoclip applier. The operator inserts the scissors through * Endo Clip, United States Surgical Corp., Norwalk, Connecticut.
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LAPAROSCOPIC VAJ:UX LIGATION
FIG. 3. A, peritoneal incision. Maryland dissector grasps and elevates peritoneum lateral to spermatic vascular bundle (arrow). With scissors incision is made parallel to spermatic vessels cephalad to internal ring. B, peritoneal incision is marked with location of medial T extension, which provides exposure of medial margin of vascular packet. Vas is identified medial to internal ring (arrow) where it joins spermatic vessels in their course through abdominal wall.
FIG. 4. A, spermatic veins are divided by scissors between hemoclips. Spermatic artery (arrow) is identified and preserved. B, after division of spermatic veins. Artery (arrow) is preserved. Peritoneum is retracted after T incision to provide necessary exposure for dissection.
the ipsilateral port and divides the veins between the clips (fig. 4,A). The process of separating veins from artery is continued with care to grasp only veins or adventitial tissue. Occasionally, the pulsation of the artery may be diminished due to spasm. We then irrigate the site of dissection with papaverine or lidocaine, restoring circulation and allowing clear visual identification of the spermatic artery (fig. 4, B). In cases of bilateral varicocele the procedure is repeated on the opposite side following inser tion of the ipsilateral 5.5 mm. instrument port and rotation of the operating table away from the dissection site. Termination of procedure. Upon completion of the varix ligation we examine each site of ligation and, when necessary, secure hemostasis with electrocoagulation. We minimize the use of electrocautery to decrease the chance of injuring the spermatic artery. The patient is rotated to a neutral position and placed in the reverse Trendelenburg position. The pelvis is inspected and any irrigant or blood that has accumulated during the procedure is aspirated. Then each instrument port insertion site is inspected to assess and treat any active hem orrhage. This includes inspection of the original subumbilical insertion site, which is examined by placing the laparoscope through the 11 mm. midline suprapubic port. With the patient returned to the supine position each sheath is removed. Before removal of the last port the insufflation valve is opened and the carbon dioxide gas is expelled from the peritoneal cavity.
A single fascial 1-zero absorbable suture is placed at the midline insertion sites that had provided access to 11 mm. access sleeves and a subcutaneous suture as needed. Sterile strips then approximate the skin of all insertion sites. A clear dressing covers each wound. RESULTS
Since June 1990 we performed laparoscopic varix ligation in 14 patients (bilaterally in 5). Each patient underwent a careful evaluation to detect factors that could contribute to male infertility. All patients demonstrated persistent oligospermia and/or asthenospermia on repeated seminal fluid analyses. Average sperm density was 9.42 million sperm per ml., average motility was 39.2% and average number of motile sperm per ejaculate was 10. 5 million. No patient exhibited endocrine abnormality. Physical examination revealed clinically evident varicocele(s) that were subsequently confirmed by ultrasound and color Doppler examination in all patients. When necessary patients were re-evaluated after elimination of gonadotoxins (for example alcohol or cimetidine). We performed laparoscopic varix ablation in patients who have undergone previous celi otomy for various operative procedures, such as appendectomy, herniorrhaphy and varix ablation (inguinal and transvenous, table 1). Patient weight (average 82.9 kg. , range 54 to 107 kg.) did not preclude laparoscopic varix ligation.
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DONOVAN AND WINFIELD
All procedures were performed in the ambulatory surgery center and only 1 patient required postoperative hospitalization due to prolonged recovery from anesthesia. The average oper ating time was 118 minutes (range 66 to 177 minutes). We noted no complications either at the operation or during the ensuing followup. The testicular artery was identified and pre - served in 18 of 19 varix ligations (95% ). In 1 patient we did not identify the spermatic artery, which was presumably ligated with the spermatic veins. Table 1 lists the interval between operation and return to regular activity (average 3.4 days). As shown, regular activity in these patients is not limited to sedentary occupations. Fur ther evidence of the relatively benign postoperative course is provided by the minimal use of analgesics. An average of 8.4 acetinninophen (325 mg.) with codeine (30 mg.) tablets_were used during postoperative week 1. Of the 14 patients 5 discon tinued all analgesics within 3 days postoperatively. Patients who underwent bilateral varix ligation demonstrated no signif icant difference in postoperative recovery compared to patients who underwent unilateral varix ligation. Postoperative physical examination has not revealed persist ent, clinically relevant varices in any patient. In a male adoles cent with a clinically large, visible varix and testicular atrophy preoperatively the pampiniform plexus remained palpably di lated on physical examination but it has decreased in size, is no longer visible and no longer demonstrates distension with Valsalva's maneuver on physical examination or ultrasound. Evaluation of postoperative seminal fluid analyses is not complete to date. Of the 14 patients 7 have been followed at least 6 months. Preoperative and postoperative semen analyses are compared in table 2. The results demonstrate an increase in sperm density and motile sperm per ejaculate with a decrease in percentage motility. Additional followup is necessary to provide sufficient data for accurate outcome analysis with respect to changes in seminal fluid analysis and comparison with traditional forms of varicocelectomy. DISCUSSION
Laparoscopic varix ligation offers an alternative to tradi tional methods of varix ablation. Selection criteria remain unchanged, that is a clinically evident varicocele with coinci dent infertility and/or pain. While the left and right spermatic veins are accessible through the laparoscope, only clinically apparent varicoceles are ligated. We believe that the patient with a persistent varix who has been treated unsuccessfully by retroperitoneal varix ligation (the Palomo approach) is not a candidate for laparoscopic varix ligation, since both procedures are directed at the spermatic veins immediately cephalad to the
Pt.-Age RW-24 DM-28 JE-28 SM-37 TJ-34 LH-30 BS-21 PF-32 DL-29 EE-25 JL-15 EJ-35 RK-27§ BM-33
Occupation Farmer Clerk Construction Industry Disc jockey Machinist Mechanic Farmer Artist Farmer Student Industry Chemist Advertising manager
internal ring. Previous celiotomy for inflammatory conditions (and consequently an increased probability of adhesions) is a relative contraindication to a laparoscopic procedure, although we have encountered no difficulty in patients who have under gone limited abdominal procedures such as appendectomy, herniorrhaphy or inguinal (Ivanissevich approach) varicocelec- tomy. The use of the Hasson trocar and cannula through a small, subumbilical celiotomy permits insertion of the trocar under direct vision followed by carbon dioxide insufflation and should be considered in patients who have undergone extensive abdominal surgery.11 Dissection of the spermatic veins and preservation of the spermatic artery were not affected by obe sity. Insertion of the Veress needle and insufflation to create a pneumoperitoneum require care in the obese patient due to the proclivity in__this group for preperitoneal insufflation. 10 To date we have not experienced preperitoneal insufflation in our la- paroscopic varix ligation procedures. In general, collateral circulation to the testes is present distal to the site of laparoscopic varix ligation (that is artery to the vas and cremasteric artery), although one is not assured of its integrity or adequacy in all cases. A previous inguinal or scrotal operation may compromise these alternate routes of arterial blood flow to the testes. With care in dissection preservation of the testicular artery, not implicated as a contributing factor in the pathophysiology of varicocele, is possible in the majority of cases. We identified and preserved the testicular artery in all but 1 of the 19 laparoscopic varix ligations. In our initial experience we attempted to separate, clip and ligate the sper- matic veins without subsequent division. Currently, we clip and divide the branches of the spermatic vein. Division of the veins facilitates exposure and preservation of the artery, which is most often posterior to the majority of spermatic veins at the level of our dissection. Speed of recovery may be partly attributed to patient age (average 28.8 years). However, in our experience with tradi tional varix ligation procedures (inguinal and retroperitoneal exposure), return to regular activity before postoperative day 7 is uncommon and complete recovery typically occurs between postoperative days 10 and 14. Initially, operating time is in - creased in comparison to traditional operative varix ligation. With experience operating time decreases. Any increase in duration of operation with the use of laparoscopy is offset by a decrease in postoperative recovery time. CONCLUSION
The laparoscopic varix ligation provides a technique for varix ablation that minimizes morbidity without compromising the operative goal. Patients report minimal postoperative discom --
TABLE 1. Summary of patient information Previous Abdominal Days to Resume Procedure Normal Activity Surgery* Lt. varix ligation 4 No 3 No Bilat. varix ligation 6 Lt. varix ligation No 4 Lt. varix ligation Yes 3 Yes Lt. varix ligation 3 No Bilat. varix ligation Bilat. varix ligation No 6 No Lt. varix ligation 1 3 Bilat. varix ligation No Yes 2 Lt. varix ligation 3 Yes Lt. varix ligation Yes 1 Bilat. varix ligation 4 No Lt. varix ligation No Lt. varix ligation 5
Pregnancyt Yes
Yes Yes Yes
Analgesic Use:j: 16 5 3 23 5 6 10 12 7 16 5 2 4 4
Av. 28.4 3.4 8.4 * Previous abdominal surgery included appendectomy and left inguinal hernia repair in patient S. M., left inguinal hernia repair in patient T. S., appendectomy in patient E. E., inguinal varix ligation in patient S. L. and appendectomy in patient E. S. t In patients reporting pregnancy the average time to conception after varix ligation was 4 months (range 1 to 7 months). :j: Analgesic use was number of tablets consumed during postoperative week 1. Each tablet contained 325 mg. acetaminophen and 30 mg. codeine. § Patient R. K. remained in the hospital overnight due to prolonged recovery from anesthesia.
LAPAROSCOPIC VARIX LIGATION Results of preoperative and postoperative semen analyses in 7 patients who completed 6 months of followup with at least 2 semen analyses
TABLE 2.
Av. Preop. Semen Analysis
Av. Postop. Semen Analysis
12.8 41 13.5
22.6 33 30.7
Sperm density(million sperm/ml.) Motility(%) Motile sperm/ejaculate(million sperm)
fort and rapid return to preoperative activity (including stren uous physical work). Patients undergoing bilateral laparoscopic varix ligation experience no appreciable increase in postopera tive morbidity or interval to recovery. In appropriate patients laparoscopic varix ligation is a safe and attractive alternative to traditional operative varix ligation techniques. REFERENCES 1. Saypol, D. C.: Varicocele. J. Androl., 2: 61, 1981. 2. Pryor, J. L. and Howards, S. S.: Varicocele. In: Contemporary Management of Impotence and Infertility. Edited by E. A. Tanagho, T. F. Lue and R. D. McClure. Baltimore: Williams &
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Wilkins, chapt. 23, pp. 247-264, 1988. 3. Hendry, W. F., Sommerville, I. F., Hall, R. R. and Pugh, R. C. B.: Investigation and treatment of the subfertile male. Brit. J. Urol., 45: 684, 1973. 4. Cockett, A. T. K., Urry, R. L. and Dougherty, K. A.: The varicocele and semen characteristics. J. Urol., 121: 435, 1979. 5. Palomo, A.: Radical cure of varicocele by a new technique: prelim inary report. J. Urol., 61: 604, 1949. 6. Ivanissevich, 0.: Left varicocele due to reflux. Experience with 4,470 operative cases in forty-two years. J. Int. Coll. Surg., 34: 742, 1960. 7. Lipshultz, L. I. and Howards, S. S.: Surgical treatment of male infertility. In: Infertility in the Male. New York: Churchill Liv ingstone, chapt. 17, pp. 343-366, 1983. 8. Winfield, H. N. and Ryan, K. J.: Experimental laparoscopic sur gery: potential clinical applications in urology. J. Endourol., 4: 37, 1990. 9. Gunning, J. E.: The history of laparoscopy. In: Gynecological Laparoscopy: Principles and Techniques. Edited by J. M. Phillips and L. Keith. Miami: Symposia Specialists, pp. 57-66, 1974. 10. Borten, M.: Laparoscopic Complications: Prevention and Manage ment. Philadelphia: B. C. Decker Inc., 1986. 11. Hasson, H. M.: Open laparoscopy: a report of 150 cases. J. Reprod. Med., 12: 234, 1974.