Vasectomy

1. See Also
   1. Vasectomy Counseling
   2. Vasectomy Postoperative Counseling
2. Epidemiology
   1. Vasectomy Incidence in U.S.: 500,000 per year
   2. Family Physicians perform 15% of all U.S. vasectomies
3. Step 1: Procedure Preparation
   1. See Vasectomy Counseling
   2. Consider Sedation
      1. Valium 5 to 10 mg taken 30 minutes before procedure
   3. Establish relaxing environment
      1. Warm room relaxes Scrotum
      2. Soft music
   4. Position patient supine or dorsolithotomy
   5. Retract penis
      1. Tape glans penis to Abdomen
      2. Rubber band method
         1. Loop two rubber bands together
         2. Loop one end around head of penis
         3. Loop other end through handle of hemostat
         4. Clamp hemostat to patient's gown
   6. Prep skin with warmed betadine solution
   7. Apply surgical drape
4. Step 2: Vas Deferens (spermatic cord) Positioning
   1. Non-dominant hand locates vas deferens
      1. Vas is caliber of a pen's inner ink plastic holder
   2. Three finger technique traps vas deferens
      1. Middle finger placed behind vas deferens
      2. Thumb and index finger placed over vas (2 cm apart)
   3. Maneuver vas deferens to midline (under median raphe)
      1. Use Index finger to maneuver vas deferens
      2. Position vas one third down from top of Scrotum
5. Step 3: Injection of Local Anesthesia (Perivasal block)
   1. Anesthetic: Xylocaine 2% without Epinephrine
   2. Syringe: 10 cc
   3. Needle: 27 gauge, 1.5 inch needle
   4. Technique
      1. Bending needle at base 15 degrees may help injection
      2. Inject midline skin overlying isolated vas
      3. Raise 1-2 cm wheal of Lidocaine
      4. Aspirate to confirm non-intravascular position
      5. Inject 2-3 ml into vas and along course proximally
6. Step 4: Skin penetration for no-scalpel Vasectomy
   1. Press open ring clamp perpendicular into skin over vas
   2. Vas trapped between clamp and underlying finger
   3. Ring clamp closed and locked around vas deferens
   4. Use single tine of open Sharp dissecting forceps
      1. Tine pierces scrotal skin at 45 degree angle into vas
      2. Insert forceps tine 3-4 mm into vas deferens
      3. Withdraw forceps tine
   5. Insert closed forceps into hole made by single tine
      1. Insert tines to 3-4 mm depth
      2. Spread dissecting forceps to stretch skin and fascia
   6. Insert second ring clamp through hole and grasp vas
   7. Remove first ring clamp and reattach through hole
7. Step 5: Vas Deferens Isolation
   1. Peal perivasal sheath away from vas (pealing onion)
   2. Use dissecting forceps to remove perivasal sheeth
      1. Insert forcep tines into perivasal sheeth
      2. Spread tines to clear sheath away from vas
      3. Remove and reattach ring clamps inside sheath
   3. Clear >1 cm vas of perivasal sheath
   4. Apply ring clamp at each end of cleared segment
8. Step 6: Vas Deferens Occlusion
   1. Hemitransect proximal (prostatic) vas deferens
   2. Insert cautery tip 4 mm into prostatic vas lumen
      1. Apply current while withdrawing slowly
   3. Ligation of proximal (prostatic) vas segment
      1. Surgical clip
      2. Silk 3-0 (1 or 2 separate ties)
   4. Complete transection of proximal vas deferens
   5. Close overlying fascia layer
      1. Absorbable Suture (e.g. Vicryl) purse-string or clip
      2. Fascial interposition efficacy
         1. Dramatically lowers Vasectomy failure rate
         2. Labrecque (2002) J Urol 168:2495-8
   6. Transect distal (testicular) vas deferens end
      1. Store vas deferens segment in formalin
   7. Consider avoiding distal vas deferens ligation
      1. May reduce post-operative pain (lower vasal pressure)
      2. Risk of sperm granuloma if not ligated
   8. Observe for signs bleeding (esp. pampiniform plexus)
9. Step 7: Procedure Completion
   1. Repeat from Step 2 forward with opposite vas deferens
   2. Same hole in Scrotum may be used for entry
   3. Close skin with Suture (e.g. Vicryl)
10. Follow-up and Precautions
    1. See Vasectomy Postoperative Counseling
11. Resources
    1. Choosing Vasectomy Movie (Requires Flash)
       1. VasectomyConsentSjm.htm
    2. Vasectomy: An Update (Am Fam Physician article)
       1. http://www.aafp.org/20061215/2069.html
       2. Figure 1 shows 6 techniques of vasal disruption
       3. Also compares failure rates of each technique
    3. Vasectomy Medical (Commerical Site)
       1. http://www.vasectomymedical.com
12. References
    1. Clenney (1999) Am Fam Physician 60(1):137-52
    2. Stockton (1992) Am Fam Physician 46(4):1153-64