NO-SCALPEL VASECTOMY An Illustrated Guide for Surgeons
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NO-SCALPEL VASECTOMY
An Illustrated Guide
for Surgeons - extracted text
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NO-SCALPEL
VASECTOMY
An Illustrated Guide
for Surgeons
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Second Edition
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© 1997 AVSC International
79 Madison Avenue, New York, NY 10016. USA
Telephone: 212-561-8000 Fax: 212-779-9439
e-mail: info@avsc.org
World Wide Web: http://www.avsc.org
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First edition printed 1992
This publication may be reproduced and excerpts from it may
be quoted without permission provided the material is
distributed free of charge and the publisher is acknowledged.
This publication was made possible, in pan. through support
provided by the Office of Population, U.S. Agency for
International Development (AID) under the terms of
cooperative agreement CCP-3068-A-00-301”-00. The
opinions expressed herein are those of the publisher and do
not necessarih- reflect the views of AID.
Printed in the United States of America
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Figures 1,5. 6. 10. and 29 are adapted from “The No
Scalpel Vasectomy" by S. Li. M. Goldstein.
J. Zhu, and D. Huber, The Journal of Urology. 1991,
vol. 145, pp. 341-344. Used by permission.
Figures 4, 8. and 9 arc adapted from “External Spermatic
Sheath Injection for Vasal Nerve Block" by P. S. Li, S. Li,
P. N. Schlegel, and M. Goldstein, Urology. 1992, vol 39
pp. 173-176.
The two figures that appear in the section “Alternative”
on page 40 are based on drawings provided by Dr. Apichart
Nirapathpongporn. Used by permission.
Library of Congress Cataloging-in-Publication Data
No-scalpel vasectomy: an illustrated guide for surgeons /
Betty Gonzales et al.; illustrations by David
Rosenzweig.—2nd ed.
p. cm.
Includes bibliographic references.
ISBN 0-960453645-0
1. Vasectomy. I. Gonzales, Betty.
[DNLM: 1. Vasectomy—methods. 2. Preoperative care
methods. 3. Anesthesia—methods. WJ 780 N739 1997]
RD585.5.N6 1997
617.4’63—dc20
DNLM/DLC
for Library of Congress
96-36490
CIP
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Contents
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Preface to the Second Edition
Foreword
Acknowledgments
Introduction.........
,vii
Facilities........................
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3 Preoperative Preparation ....
13
Counseling and informed consent 13
Preoperative history and examination 13
Preparing the client for surgery 14
Securing the penis 14
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The surgical scrub 15
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Draping the operative field 16
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2 Instruments and Supplies
Cleaning the operative area 14
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Warm room temperature needed
to relax the scrotum 7
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Optional: Administering a preoperative
tranquilizer 16
4 Anesthesia
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Preparing for anesthesia;
selecting the anesthetic and supplies 18
The three-finger technique:
Isolating the right vas 19
Raising the skin wheal 20
Creating the vasal block: Right vas 22
The three-finger technique: Isolating the left vas 23
Creating the vasal block: Left vas 25
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Pinching the skin wheal 26
If the man feels pain after surgery begins 26
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5 Surgical Approach and
Occlusion of the Vasa .
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Holding the ringed clamp 27
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Applying the ringed clamp to the scrotal skin and
underlying right vas: The tight-skin technique 28
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Elevating the underlying right vas 31
Puncturing the scrotal skin 31
Spreading the tissues 34
Delivering and elevating the right vas 37
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Grasping the vas with the ringed clamp 41
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Puncturing and stripping the sheath 43
Occluding the right vas 45
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Isolating die left vas before occlusion 48
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Applying the ringed clamp to the scrotal skin and
underlying left vas 49
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Delivering, elevating, and occluding the left vas 49
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Dressing the wound 49
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Postoperative care and instructions 50
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Appendix A: WHO eligibility criteria for
vasectomy procedures................................
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Appendix B: Sample postoperative
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instructions for the client ................
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References
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Figures
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Ringed clamp 9
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Securing the penis 15
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Cross section of the spermatic cord 17
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The three-finger technique: Isolating
Dissecting forceps 10
Determining the entry site 18
the right vas 19
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Raising the skin wheal 20
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Side view of the skin wheal 21
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Advancing the needle parallel to the vas within
the external spermatic fascial sheath toward the
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inguinal ring 22
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'Die three-finger technique: Isolating the left vas 24
Anesthesia technique: Deep infiltration
of the left vas 25
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Pinching the skin wheal 26
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Holding the ringed clamp.
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with the palm up 27
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Grasping the vas with the ringed clamp,
extracutaneously 29
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Pressing the tips of the ringed clamp onto the
scrotal skin overlying the right vas 30
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Lowering the handles of the ringed clamp to
elevate the vas 31
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Pressing the index finger lightly downward
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to tighten the scrotal skin just ahead
of the tips of the ringed clamp and over
the anesthetized area 32
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Piercing the skin with the medial blade of the
dissecting forceps 33
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Inserting both tips of the dissecting forceps into
the puncture site 35
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Spreading the tissues to make a skin opening twice
the diameter of the vas 36
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Piercing the wall of the vas with the tip of the
lateral blade of the dissecting forceps 37
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Rotation of the dissecting forceps. Pan 1 38
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Rotation of the dissecting forceps. Part 2 38
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Releasing the ringed clamp before electing the vas
with the dissecting forceps—ringed clamp open,
but still in place 39
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Grasping a partial thickness
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of the elevated vas 41
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Grasping a partial thickness of the elevated vas
at the crest of the loop, with only the ringed
clamp attached 42
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Puncturing the sheath, with one tip of the
dissecting forceps 43
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Inserting both tips of the dissecting forceps into
the punctured sheath 44
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Opening the dissecting forceps
to strip the sheath 44
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Ligation 45
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Cautery with a sharp needle electrode 46
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Cautery with a blunt wire inserted into the
hemitransected vas 47
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Isolating the left vas before occlusion 48
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Dressing the wound 50
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Preface to
the Second Edition
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Vasectomy has long been a safe, effective,
easy-to-perform method of contraception for men.
Throughout its history, people have been trying to
find ways to make the procedure simpler. In 1974,
Dr. Li Shunqiang developed the NSV technique,
and in 1986, AVSC, in cooperation with Dr. Li,
began to introduce the technique to the rest of
the world.
AVSC first published No-Scalpel Vasectomy:
An Illustrated Guide for Surgeons in 1992. The
manual has since become AVSC’s most successful
publication, with thousands having been distributed.
Meanwhile AVSC has trained doctors in over 35
countries in the NSV technique. In the United States
alone, over 600 doctors have been directly trained
by AVSC, and hundreds more have been trained by
those we trained. A recent unpublished survey
showed that nearly a third of all vasectomies in
the U.S. are now performed using the NSV
technique.
Because of the ongoing demand for this publication,
we are publishing this second edition. We have made
changes to the illustrations to provide a more detailed
representation of the anatomy and to make the
manual even more user-friendly. In addition, we have
made a few corrections to clarify material and remove
inconsistencies in the text. We have also included, as an
appendix, eligibility' criteria for vasectomy published
by the World Health Organization in 1996. What we
now have is an even more timely version of an already
terrific book.
However, as good as it is. we continue to feel that
this book alone is not sufficient preparation to
perform NSV. We strongly recommend that those
who are interested in the technique get hands-on
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training from a skilled provider. In addition to the
second edition of this guide, AVSC has also published
a training curriculum for NSV For information about
the curriculum or about training in NSV contact AVSC
at. 212-561-8000 (phone); info@avsc.org (e-mail); or
http://www.avsc.org (World Wide Web).
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I believe that this revised guide will continue to be
an important resource for making vasectomy more
accessible and acceptable throughout the world.
Charles S. Carignan, M.D.
Medical Director, AVSC International
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Foreword
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Vasectomy is widely accepted as a safe, effective,
simple, and inexpensive method of permanent
contraception for men. During the last 30 years, a
variety of vasectomy techniques have been developed
and used in countries around the world. This book
describes the no-scalpel vasectomy, a technique
introduced in China in 1974 and used in other
countries since 1986.
Men in many parts of the world are becoming
increasingly interested in no-scalpel vasectomy. More
and more doctors are seeking instruction in the
technique. This book is particularly timely because
training programs in no-scalpel vasectomy are
increasing rapidly.
In addition to sen ing as a step-by-step guide to the
procedure, this book also reviews basic medical and
surgical practices that are essential to ensure the safety
and effectiveness of any vasectomy procedure. Doctors
using either no-scalpel vasectomy or conventional
techniques will find this guide to be a helpful
reference. It can be used regardless of the occlusion
technique employed, and it can play an important role
in training.
This book is the result of the hard work of
Betty' Gonzales, Shelby Marston-Ainley, Gilberte
Vansintejan, Philip Shihua Li, and others. My
compliments to them. I believe the book will help
to make vasectomy more available and acceptable to
men around the world.
Dr. Li Shunqiang
Director, Chongqing Family Planning
Scientific Research Institute
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Acknowledgments
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This book was written byT Betty Gonzales, R.N.,
Shelby Marston-Ainley, B.S.N., M.S., Gilberte
Vansintejan, R.N.C., M.P.H., Ed.D., and Philip
Shihua Li, M.D. Betty Gonzales is the former deputy7
director of the Medical Division, AVSC International.
Shelby7 Marston-Ainley is the former assistant director
for AVSC’s National Division. Dr. Vansintejan is the
former medical technology7 advisor for AVSC’s
Medical Division. Dr. Philip Shihua Li, a consultant to
AVSC, was research investigator for the Population
Council when this book was written. He is now
director of microsurgical training at the Center for
Male Reproductive Medicine, Department of Urology,
Corneil University’ Medical College in New York. Dr.
Philip Shihua Li has performed over 5,000 no-scalpel
vasectomy procedures and is a former student and
coworker of Dr. Li Shunqiang, the originator of the
no-scalpel technique.
The illustrations that appear in this book were created
by David Rosenzweig.
Many individuals and organizations contributed to
this book. AVSC expresses special thanks to
Dr. Li Shunqiang. director of the Chongqing Family
Planning Scientific Research Institute, who originated
the technique: Dr. Li provided unwavering support
for the development of this guide and constructive
comments about its content.
AVSC is grateful to the expert team who visited
China in 1985 and first brought word of the no
scalpel vasectomy to other countries. They were
Dr. Mahmoud Fathalla, Egypt; Dr. Phaitun Gojaseni,
Thailand; Dr. Marc Goldstein, United States;
Dr. Douglas Huber, United States; Dr. Jack Lippes,
United States: Keekee Minor, United States;
Dr. Mary Rauff, Singapore; and Dr. John Sciarra,
United States.
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Terrence W Jezowski, chief operating officer for AVSC
provided the impetus needed to get the bookproduced. Lynn Bakamjian, director of field operations,
developed the proposal for the project.
The following persons read the manuscript and
provided helpful suggestions: Dr. Arnold M Belker.
United States; Dr. Joseph E. Davis, United StatesDr Marcos Paulo de Castro, Brazil: Dr. Jesus de los Rios
Colombia; Dr. Richard Fadil, United States:
Dr. Marc Goldstein, United States; Hugo Hoogenboom
United States; Dr. Stuart S. Howards, United States;
Dr. Douglas Huber, United States; Dr. Arnoldo Kormes.
Brazil; Dr. Apichart Nirapathpongporn. ThailandDr. T. Rand Pritchett, United States; Dr. David Stockton
United States.
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Dr. Amy E. Pollack, president of AVSC; Libby Antarsh.
regional director of AVSC programs in Central Asia,
Eastern Europe, and Russia; and Dr. Zein Khairullah
senior associate in AVSC s Medical Division also
reviewed the manuscript.
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Dr. Charles Carignan. AVSC s medical director, was
responsible for all revisions for the second edition
of this book. Pamela Beyer Harper, AVSC s
director of communications, edited the guide.
Renee A. Santhouse designed the book.
The following AVSC staff members participated in
the design and production of the second edition:
Joanne Tzanis, managing editor; Anna Kurica
production coordinator; Stephanie Greig, graphics
speciahst; and Margaret B. Baynes, trafficking specialist.
AVSC consultants Brandt Reiter. Margaret Scanlon, and
Tuna Aleman assisted in final production.
Funding for this book was provided bv the United
States Agency for International Development and by
individual AVSC members.
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13
1
NO-SCALPEL
VASECTOMY
An Illustrated Guide
for Surgeons
Second Edition
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Introduction
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The purpose of this guide is to provide physicians
with an easy-to-use reference for learning about the
no-scalpel approach for vasectomy. This book provides a
detailed description of each step of the approach, plus
drawings illustrating the various steps. Physician-trainees
may use it during their training for study and for later
reference to further develop proficiency in the
technique. Trainers who are using AVSC’s No-Scalpel
Vasectomy Curriculum to teach the technique to
other physicians will use this guide as a reference text.
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The guide has been designed primarily to assist two
audiences: (1) experienced vasectomists around the
world who want to change from the traditional
incisional technique to the no-scalpel approach and
(2) doctors who have never performed vasectomy and
who want to begin to provide vasectomy services
using the no-scalpel technique.
The no-scalpel vasectomy is a refined approach for
isolating and delivering the vas that uses vasal block
anesthesia: it requires unique surgical skills, including
new ways to handle special instruments. With the no
scalpel technique, the surgeon may use any of the
standard methods of occlusion that he or she prefers
(see pages 45-47). Because of the innovative features
of no-scalpel vasectomy, AVSC International
recommends that any doctor interested in learning the
approach receive hands-on training with a wellqualified and experienced trainer.
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Hands-On
Training
Recommended
From field experience in the United States, AVSC
has learned that even experienced vasectomists have
difficulty’ teaching themselves the no-scalpel technique.
Manipulating the special instruments requires manual
skills and eye-hand coordination that are different
from those used in conventional vasectomy. The skills
can be learned with hands-on. supervised training, but
even then take time and practice to master.
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A case in the United States illustrates the need for
hands-on training. A group of experienced vasectomists
attended a one-day group orientation on no-scalpel
vasectomy that consisted of a lecture, observation of
the procedure, and limited practice with a scrotal
model. They then received the special noscalpel
instruments and returned to their practices to begin
using the technique. Three months later, an AVSC
trainer evaluated the physicians’ operating
performance. The doctors understood and performed
key elements of the procedure adequatelv: thev stated
that they had mastered about 80% of the technique
without hands-on instruction. Yet the procedures
observed by the trainer still resulted in too much
bleeding; benefits of the no-scalpel technique were
11 ere fore diminished. Consequently, the AVSC trainer
provided hands-on training to help the surgeons fullv
master the no-scalpel technique.
No-scalpel vasectomy- was developed and first
performed in China in 1974 by Dr. Li Shunqiang of
t le longqing Family Planning Scientific Research
Institute, located in Sichuan Province. At that time
vasectomy was unpopular with Chinese men. and
tubal occlusion was the predominant method of
voluntary- sterilization. Today in Sichuan, vasectomy
outnumbers tubal occlusion by a ratio of five to onein the rest of China, tubal occlusion outnumbers
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vasectomy by three to one. Over 9 million Chinese
men have already- undergone no-scalpel vasectomy.
Under the sponsorship of AVSC International, an
international team of experts visited Dr. Li Shunqiaimg
in 198? and observed his refined vasectomy
technique. They were convinced that the technique
should become the standard approach for vasectomy
One of the team members, Dr. Phaitun Goiaseni.
introduced the no-scalpel technique in Thailand upon
his return, while another member of the team. Dr.
Marc Goldstein, performed the first no-scalpel
vasectomy in the United States.
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History
of No-Scalpel
Vasectomy
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Based upon the findings of the international team,
AA SC recommended that training in the no-scalpel
approach to the vas should be provided to doctors in
other countries and that this would be facilitated if the
instruction could take place outside of China. AVSC’s
initial work in no-scalpel vasectomy focused on
4 INTRODUCTION
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experienced vasectomists in large on-going vasectomy
services (Huber, 1989). In 1986, Dr. Li Shunqiang and
Dr. Goldstein traveled to Bangkok to work with
experienced vasectomists from Bangladesh, Nepal,
Sri Lanka, and Thailand. Dr. Apichart Nirapathpongporn
of Thailand was trained at this time. Dr. Goldstein and
Dr. Apichart then trained other surgeons in their home
countries. Clinical training then expanded to other
countries. In several countries in Africa, where
vasectomy is just being introduced, doctors who have
never performed vasectomy are now being trained
only in the no-scalpel technique.
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Clinical
Findings
Table 1 describes the low complication rates of
no-scalpel vasectomy in a study of over 170,000 cases
in China. By contrast, Table 2 describes complication
rates in 65,155 cases using the conventional vasectomy
approach in the United States.
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A study in Thailand compared the no-scalpel approach
to the conventional technique (Table 3). The
complication rates were 0.4 per 100 cases for no
scalpel vasectomy and 31 for the incisional approach.
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Clinical reports from practitioners attest that no-scalpel
vasectomy is less invasive than the conventional
technique, causes fewer complications, and can take
less time as the surgeon’s skill develops. Because there
is no incision, no-scalpel vasectomy is believed to
decrease men’s fears about vasectomy (Antarsh, 1988).
TABLE 1 Short-term complications after no-scalpel vasectomy, China
Source of
data
# of
cases
8 provinces
179,741
Infection
Hematoma
No. of cases
Ratea
No. of cases
Rate0
160
0.09
1,630
0.91
a Per 100 cases
SOURCE: Li et al.. 1991
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TABLE 2 Reported complications
after conventional vasectomy,
United States, 1982
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Complication
Rate0
Hematoma
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aPer 100 vasectomies; 65,155 cases
SOURCE: Kendrick et al., 1987
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In a series of 238 no-scalpel vasectomies performed at
the New^ork Hospital-Cornell Medical Center in the
1980s, there were no cases of either hematoma or
infection (Li et al., 1991).
AVSC has been collecting data from surgeons in the
United States who have attended AVSC-sponsored
training programs in no-scalpel \*asectomv and who
have adopted the technique. As of September 1991,
111 surgeons had performed over ",700 no-scalpel
procedures. Over 80% of those doctors reported that
the no-scalpel technique involves less bleeding than
conventional vasectomy. Over 7O°o said that men
undergoing no-scalpel vasectomy experience less pain
during and after surgery than do men undergoing
conventional vasectomy.
TABLE 3 Comparison of no-scalpel vasectomy
and conventional incisional approach,
Thailand, 1987
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Complications
Method
Cases
Number
Rotea
No-scalpel
680
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0.4
Incisional
523
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- Per 100 cases
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= 2 cases of hematoma; surgical drainage not required
1 case of infection
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- 9 cases of hematoma; 2 required admission to the hospital for
surgical drainage
7 cases of infection
SOURCE: Niiapcrthpongporn et al., 1990
6 INTRODUCTION
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Facilities
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Vasectomy can be performed in almost any facility.
There are a few minimum requirements to providing
high-quality services:
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• A waiting area with a toilet (the waiting area
may also serve as a recovery area)
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• A private space for counseling
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• An examination room for the preoperative
assessment and follow-up examination
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• A clean room for surgery, equipped with a
comfortable, clean table for the client and a
good light source
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In most countries, no-scalpel vasectomy, like
conventional vasectomy, is an outpatient procedure
performed in an office or clinic.
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Warm Room
Temperature
Needed to Relax
the Scrotum
The temperature of the room is critical because it
affects the cremasteric and the dartos muscles. The
room must be warm, even though a cooler
temperature may be more comfortable for the
physician.
By relaxing the scrotum, a warm room facilitates the
following:
• Manipulation of the vas by using the threefinger technique (see pages 19-20 and 23-24 for
a description)
• Fixation of the vas under the median raphe of
the scrotum
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• Isolation of the vas from the relaxed spermatic
cord
• Reduction of operating time
• Reduction of complications
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The temperature of the operating room should be at
least 70-80 degrees F (approximately 20-25 degrees
C). If additional warmth is needed to relax the
scrotum, a heat lamp or warm towels may be used.
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Instruments
and Supplies
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The no-scalpel technique requires two instruments
specially designed by Dr. Li Shunqiang.
1 The extracutaneous ringed forceps is a type
of clamp used to fix the vas deferens (Fig. 1). For the
sake of clarity’, the term ringed clamp will be used
throughout this manual. Throughout the operation,
the surgeon uses the ringed tip of this instrument to
encircle and to grasp the vas, without injuring the
skin. The clamp grasps the vas both extracutaneously
and directly. This instrument comes in three ring
sizes* 3-b mm. 3-5 mm, and -4.0 mm. These different
diameters accommodate different thicknesses of vasa
and scrotal skin.
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FIGURE 1 Ringed clamp
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Inside dimensions of clamp:
3.0 mm, 3.5 mm, or 4.0 mm
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FIGURE 2
Dissecting forceps
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2 The dissecting forceps (Fig. 2) is similar to a
curved mosquito hemostat, except that the tips are
sharply pointed. It is used to puncture the scrotal skin,
to spread the tissues, to dissect the sheath, and to
deliver the vas deferens. The dissecting forceps can also
be used to grasp the vas while a ligature or cautery is
applied for occlusion. Because the instrument is a
modified hemostat, it can be used to control bleeding.
Throughout this manual, the term dissecting forceps
will be used to refer to this instrument.
Additional instruments and supplies needed for no
scalpel vasectomy are:
• A 10-cc syringe with a 1^-inch, 25- or 27gauge needle (U.S. system). The syringe and
needle are used to infiltrate the local anesthetic,
both for the skin wheal and the vasal block
anesthesia (see Chapter 4).
• Straight scissors, to cut the vasa deferentia and
ligatures.
• Supplies for vasal occlusion (for example,
ligature material or a cautenr unit).
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Table 4 presents a complete list of instruments and
supplies needed for no-scalpel vasectomy.
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51
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10 INSTRUMENTS AND SUPPLIES
•H'.
TABLE 4 Instruments and supplies needed
for no-scalpel vasectomy
£
*
Instruments
-i
• Ringed clamp
i
• Dissecting forceps
3
3
• Straight scissors
Supplies
£
• Rubber band or adhesive tape and gauze for
positioning the penis away from the surgical field
(optional)
E
• Razor or scissors for removing any scrotal hair in
the small operative area
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• Soap and water or antiseptic agents for the
surgical scrub (see page 15)
• Alcohol rinse (recommended if plain soap is used
for the surgical scrub)
• Sterile gloves
• Nonirritating antiseptic solution for cleaning the
operative area (see page 14)
• Sterile drapes
. 10-cc syringe with a U-inch, 25- or 27-gauge
needle (U.S. system)
• 1% or 2% lidocaine without epinephrine0
• Supplies for vasal occlusion according to the
surgeon's preference (examples: a cautery unit;
chromic catgut or nonabsorbable silk or cotton for
ligation)
• Sterile gauze
• Adhesive tape or Band-Aid for dressing the wound
• Scrotal supper for the man to wear after the
procedure (optional)
a Synonyms and pi monetary names for generic terms used in this book
are given below Proprietary names are in brackets:
lidocaine = lignocane = [Xylocame]
epinephrine = adrenaline
a
INSTRUMENTS AND SUPPUES
1
11
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II
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Preoperative
Preparation
1
3
3
1
3
Counseling Before any vasectomy is performed, the client must
and Informed receive appropriate information and counseling and
give his informed consent. Before performing the
Consent procedure, check again with the client to be sure he
wants no more children and wishes to proceed with
the sterilization procedure.
-
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• Systemic infection or gastroenteritis
• Large hydrocele
• Filariasis: elephantiasis
• Local pathological condition (for example,
inguinal hernia, adhesions, scrotal mass)
• Bleeding disorders
• AIDS (HIV positive without AIDS is not a concern)
■
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Many of these conditions can be treated, after which
vasectomy can be performed. In cases where there is
increased risk, you and the client must weigh the risks of
the procedure against its benefits.
’See Appendix A for the WHO eligibility criteria for vasectomy
procedures.
E
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physical includes examination of the local operative
area and other examinations and tests as indicated.
Laboratory tests are usually not necessary, but if you
suspect any clinical abnormality, you will need access
to basic laboratory facilities or to a referral center for
laboratory examinations. Local skin infections or
genital tract infections must be treated before
vasectomy is performed.
The following are conditions requiring a delay or
special precautions:*
• Lt.cal infection (including scrotal skin infection,
active STD. balanitis epididymitis, or orchitis)
E
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Preoperative The preoperative history and examination may be
History and done on the day of surgery or a few days before. A
medical history should be taken. The preoperative
Examination
3
-1
13
n
Before surgery, the man washes his genital area
thoroughly with soap and water. During surgery, he
wears clean clothing or a surgical gown. The man lies
comfortably in a supine position on the table, possibly
with a small pillow under his head.
To make the operation easier to perform, position the
penis away from the operative field. Put the penis in a
12 o clock position on the man s abdomen, so that
the median raphe is clearly visible. If it is anchored
comfortably in place, the penis will stav draped under
the sterile linen.
P l' s
Preparing
the Client
for Surgery
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Securing
the Penis
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Dr. Li Shunqiang uses a rubber band to position the
penis away from the surgical field (Fig. J). To do
this, he makes a loop in the rubber band as shown in
the illustration and places the loop around the glans.
The loop is just tight enough to hold the penis in
position, without being uncomfortable for the man
He secures the other end of the band to the man’s'
shirt or gown with a clip.
F
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Some physicians secure the penis on the abdomen
with tape and gauze, but this method mat have the
disadvantage of pulling the hair when the tape is
removed.
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If you believe that the scrotal hair is obstructing the
small operative area, shave or clip it while the patient
lies on the table.
F
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Before cleaning the area, examine the scrotal area.
Palpate the scrotum and vasa to assess the thickness of
the scrotal skin and the diameter of the vasa.
Genth’ wash the scrotum with a warm antiseptic
solution. Be sure to cleanse the area under the
scrotum where your fingers will be placed. Also scrub
the lower abdomen, the lower part of the penis, and
the upper thighs. Warmed Betadine (povidone iodine)
or chlorhexidine are the preferred agents. In hot
c imates, solutions at room temperature are usually
adequate.
7
HINT: In cool climates, it may be necessary
to warm the antiseptic solution.
14 PREOPERATIVE PREPARATION
Cleaning
the Operative
Area
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FIGURE 3 Securing the penis
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The Surgical
Scrub
No-scalpel vasectomy is a minor surgical procedure
that reQuires aseptic procedures to prevent infection.
Wash and scrub your hands and forearms either with
soap and water or preferably with antiseptic agents
(chlorhexidine, Betadine, or hexachlorophene). Use a
brush on all surfaces and under the fingernails. An
alcohol rinse is recommended when plain soap and
water are used for the scrub.
Wear a clean shirt or apron. A sterile gown, cap, and
mask are optional.
Wear sterile surgical gloves. Change gloves between
each case. If scrubbing is not feasible between each
case because of the risk of skin irritation, scrub for
g-t.a
PREOPERATIVE PREPARATION 15
M Si
three minutes every hour or at least after even’ four
or five cases (whichever comes first) to prevent
recolonization of the skin.
Cover the prepared area with a sterile fenestrated
drape, and lift the scrotum through the drape’s small
window. A set of towels can be used as an alternative
to the drape.
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Draping
the Operative
Field
4*
The window should be small enough to allow only
the scrotum to be isolated. Evemhing else, from the
client s chest to his knees, should be covered.
Also, cover a small instrument table with sterile drape.
-
HINT: Some doctors in the United States have
found that oral tranquilizers administered
preoperatively relax the muscle fibers of the
scrotum, thus allowing the scrotal skin to be
as thin as possible during vasectomy. This
suggestion is particularly relevant for
extremely nervous clients.
Optional:
Administering
a Preoperative
Tranquilizer
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16 PREOPERATIVE PREPARATION
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Good local anesthetic technique is essential for a
painfree vasectomy. It also prevents local hematoma
and injury to the testicular vessels, which may result
from multiple blind injections. Dr. Li Shunqiang’s
anesthesia procedure, which is described below,
achieves both of these objectives and also has several
other advantages. The technique, which involves a
deep injection alongside the vas, creates a vasal nerve
block. Conventional techniques anesthetize only the
area around the skin-entry site. Injection of the
anesthetic away from the vasectomy site in the
direction of the inguinal ring helps make skin entry
easier. Care is taken when injecting the lidocaine to
keep the needle away from the internal spermatic
fascia that encloses the testicular artery and veins
(Fi^. 4). Because the surgeon makes only a single
needle puncture and one smooth injection for each
vas, the risk of bleeding is reduced.
Of 111 U.S. surgeons reporting to AVSC in 1991,
"8 (70%) said they believed patients undergoing
no-scalpel vasectomy with vasal block anesthesia
experienced less operative pain than did patients
undergoing conventional vasectomy.
FIGURE 4 Cross section of the spermatic cord
Internal
spermatic
fascia
Testicular artery
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Vasal
nerves and
vessels
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External
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fascia
Cremasteric
muscle fibers
Testicular veins
Scrotal sac
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17
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NOTE: The following instructions and accompanying
illustrations are for the right-handed operator. Some
left-handed operators report that they have found it
helpful to> use a mirror when viewing illustrations
designed for right-handed operators.
Prepare a 10-cc syringe with 1% or 2% lidocaine
without epinephrine: this amount should be sufficient
for skin wheal and vasal block anesthesia in most
clients. Attach a DTinch, 25- or 27-gauge needle to
the syringe.
Epinephrine is not recommended because it contracts
the blood vessels and results in less apparent bleeding
at the time of surgery. It is best to be able to detect
and control all bleeding during surgery in order to
prevent hematoma formation after the man leaves the
surgical facility. If the lidocaine does not contain
epinephrine, small bleeding sites are more likely to
be detected and controlled during surgery.
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Preparing
for Anesthesia;
Selecting
the Anesthetic
and Supplies
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FIGURE 5
Determining the entry site
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The ideal entry site for
no-scalpel vasectomy
is found midway
between the top of the
testes and the base of
the penis.
18 ANESTHESIA
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The Three-Finger If youi are right-handed, stand on the client’s right side
Technique:. (if you are left-handed, stand on the client’s left side).
Place your left thumb approximately midway between
Isolating the top of the testes and the base of the penis on the
the Right Vas
median raphe (Fig. 5). With the middle finger of your
left hand under the scrotum, palpate the vas and sweep
it toward the raphe beneath your thumb. Hold the vas
in position between the thumb and middle finger while
placing your left index finger on top of the scrotum
slightly above the thumb (Fig. 6). Note that your fingers
should be perpendicular to the vas. You will have
created a "window" between your thumb and index
FIGURE 6
The three-finger technique: Isolating the right vas
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ANESTHESIA. 19
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The needle entry site is at the midline, over the vas
Raising
& ji
the Skin Wheal
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facmg up. inject lidocajne
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subcutaneous tissues; 0.5 cc is usuallvXuate
FIGURE 7
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Raising the skin wheal
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Left hand
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20 ANESTHESIA
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FIGURE 8
Side view of the skin wheal
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PITFALLS: Avoid two pitfalls when raising
the skin wheal. First, do not inject the lidocaine
too deeply. At this point in the procedure, you
are anesthetizing only the scrotal skin. In the
next step, you will create a vasal block that
will anesthetize deeper tissues. Second, to avoid
swelling around the vas at the puncture site,
do not inject more than 1 cc of lidocaine. A
persistent wheal will prevent the ringed clamp
from closing properly around the vas.
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ANESTHESIA 21
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Creating a vasal block is a critical difference
from the way anesthesia has been traditionally
administered for vasectomy. The steps described
below create a vasal nerve block away from the
operative site.
Creating
I
the Vasal Block:
Right Vas
After making the superficial skin wheal, advance the
needle parallel to the vas within the external spermatic
fascial sheath toward the inguinal ring (Fig. 9).
Advance the full length of the needle, 1*2 inches,
without releasing any of the anesthetic. Gently
aspirate to ascertain that the needle is not in a
blood vessel. Slowly inject 2 to 5 cc of lidocaine
within the external spermatic fascial sheath around the
right vas deferens.
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FIGURE 9 Advancing the needle parallel to the vas
within the external spermatic fascial
sheath toward the inguinal ring
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22 ANESTHESIA
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HINT: When the needle is in proper position
and the injection is performed inside the
external spermatic fascia, there is no
resistance to the injection.
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Remove the needle from the right sheath; do not
inject lidocaine while withdrawing the needle.
The Three-Finger
Technique:
Isolating
the Left Vas
Anesthetize both sides before entering the scrotum
and occluding the right vas.
HINT: To hold the client’s left vas in the
three-finger grip while standing on his right
side, you will be more comfortable if you take
a step towards the client’s head and turn a
bit to face his feet. To approach the vas from
this lateral position, reach across the man’s
abdomen with your left hand.
The next step will be to position the left vas under
the anesthetized puncture site. To do this, begin by
placing your thumb in the upper third of the scrotum
while the index finger is in the middle third (this is
different from the three-finger hold on the right side).
As with the right side, position the middle finger
beneath the scrotum to identify the vas and sweep it
to the puncture site. Once again, use the middle
finger to elevate the vas, while your thumb and index
finger press downward to create a bend in the vas at a
point directly under the puncture site. Now, however,
the thumb is superior to the index finger (Fig. 10).
Note the differences between Figures 6 and 10.
For a right-handed operator, isolating the left vas may
be more difficult and awkward than the right vas. It
may take time and practice to master. A left-handed
operator will need to reverse these positions and thus
may fmd isolation of the right vas more difficult.
t.
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ANESTHESIA 23
ML------
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FIGURE 10 The three-finger technique: Isolating the left vas
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24 ANESTHESIA
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FIGURE 11 Anesthesia technique:
Deep infiltration of the left vas
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Creating
the Vasal Block:
Left Vas
Reintroduce the needle through the same hole
previously used; a second skin wheal is not needed.
Advance the needle parallel to the left vas into the
external spermatic fascia (Fig. 11). As with the right
vas. inject 2 to 5 cc of lidocaine within the external
spermatic fascial sheath around the left vas deferens.*
The total administered dose of 1% lidocaine should not exceed
20 cc {Physician s Desk Reference, 1991)-
tL
ANESTHESIA 25
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FIGURE 12
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Pinching the skin wheal
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After removing the needle, gently pinch the skin
wheal between the thumb and forefinger for a few
seconds to reduce the size of the skin wheal and to
soften and thin the local tissues (Fig. 12).
Pinching
F
the Skin Wheal
k
PITFALL: Remember, a persistent wheal
will prevent the ringed clamp from closing
F
properly around the vas; gentle compression
helps to reduce the size of the wheal.
If 2 to 5 cc (of lidocaine has been injected into each
side and the■ man still feels pain when the surgical
procedure begins, repeat the vasal block on the
painful side.
Doo not raise another skin wheal.
--------
26 ANESTHESIA
g
If the Man
Feels Pain
After Surgery
Begins . . .
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and Occlusion
of the Vasa
Although the no-scalpel technique is almost
bloodless, an occasional superficial bleeder may be
encountered. Ensure adequate hemostasis to help
prevent the development of scrotal hematoma and
subsequent risk of infection. Take all necessary
precautions to avoid cross-contamination by strictly
following the rules and guidelines for prevention of
infection.
E
NOTE: The following instructions and accompanying
illustrations are for a right-handed operator. Some
left-handed operators report that they have found it
helpful to use a mirror when viewing illustrations
designed for right-handed operators.
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Holding
the Ringed
Clamp
Wlien holding the ringed clamp, it is important to
remember three points. First, for the greatest control
and accuracy, hold the ringed clamp with the palm
facing up and the wrist extended (Fig. 13)- Second,
apply the clamp at a 90-degree angle perpendicular to
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FIGURE 13 Holding the ringed clomp, with the palm up
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the vas (Fig. 14a)‘, the palm-up hand position helps
make this easier to do. Third, hold the shaft of the
ringed clamp in line with the axis of the vas—parallel
to and directly over the vas (Fig. 14c).
* 1 <
f: 3«
PITFALL: If you fail to follow these three
points, the clamp may not fix the vas
completely (Figs. 14b and 14d)f or it may
grasp too much skin. The ringed clamp
must encircle the entire vas.
Using the three-finger technique (as described on
page 19 of the anesthesia chapter), tightly stretch the
skin overlying the vas—where the needle entered for
anesthesia infiltration. The skin should be as thin as
possible. Apply the ringed clamp, as described earlier,
with the shaft at a 90-degree angle perpendicular to
the vas (Fig. 14a). Open the ringed clamp, and press
the tips onto the skin immediately overlying the vas
(Fig. 15). Apply upward pressure with the middle
finger underneath the scrotum to resist the downward
push of the ringed clamp and to press the vas from
below into the ring. Slowly and gently close the
clamp around the vas, up to the first click-stop.*
PITFALLS: Avoid two pitfalls when applying
the ringed clamp. First, be sure to elevate
the middle finger underneath the scrotum.
Otherwise, the finger will give way under the
downward pressure of the ringed clamp, and
you will have difficulty stabilizing the vas.
Second, do not grab too much skin with the
ringed clamp. Otherwise, you will have
difficulty dissecting and delivering the vas,
and slight bleeding may occur. The skin
should be stretched out over the vas just
before the ring clamp is applied. If you do
grab too much skin, stabilize the vas with
E : *
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Applying
the Ringed
Clamp to the
Scrotal Skin
and Underlying
Right Vas:
The Tight-Skin
Technique
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*The cantilevered feature of the ringed clamp that is manufactured
in China is specially designed to prevent damage to the scrotal
skin even when the clamp is locked tightly.
£
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28 SURGICAL APPROACH AND OCCLUSION OF THE VASA
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your left hand, then loosen the clamp slightly,
without entirely releasing it. Use the fingers of
the left hand to ease some of the skin away
from the clamp’s hold, while retaining the
clamp’s grasp on the vas.
1
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3
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FIGURE 14 Grasping the vas with the ringed clamp,
extracutaneously (scrotal skin not shown for clarity)
a) Applying the ringed clamp
at a 90-degree angle,
perpendicular to the vas.
b) If the ringed clamp does not
grasp the vas at a 90-degree
angle, the surgeon may
grasp the vas incompletely.
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c) Holding the shaft of the ringed
clamp in line with the axis of
the vas (parallel to and directly
over the vas).
d) If the ringed clamp is not
held parallel to the vas,
the surgeon may grasp
the vas incompletely.
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Incorrect
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SURGICAL APPROACH AND OCCLUSION OF THE VASA 29
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FIGURE 15 Pressing the tips of the ringed clamp onto
the scrotal skin overlying the right vas
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30 SURGICAL APPROACH AND OCCLUSION OF THE VASA
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ALTERNATIVE: Instead of the tight-skin technique
described on page 28, some surgeons apply the ringed
clamp in a different way when they are first learning no
scalpel vasectomy. With the ringed clamp in the right hand,
the surgeon gently pinches the scrotal skin with the ringed
clamp, intentionally encircling more skin than is grasped
with the tight-skin technique. With the left hand, the
surgeon then eases out excess tissue from the tips of the
ringed clamp. The surgeon may wish to use this alternative
if he or she is having difficulty isolating only the vas.
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Elevating
the Underlying
Right Vas
Puncturing the
Scrotal Skin
While the ringed clamp is still grasping the scrotal
skin and the underlying right vas, transfer the
instrument to your left hand. Then lower the handles
of the ringed clamp, causing a bend in the vas (Fig.
16). This motion elevates the vas. Continue to keep
the shaft of the clamp in line with the longitudinal
axis of the vas.
The skin should be punctured in the previously
anesthetized spot, midway between the top of the
testes and the base of the penis (Fig. 5, page 18). With
the left index finger, press downward lightly to tighten
the scrotal skin just ahead of the tips of the ringed
clamp and over the anesthetized area (Fig. 17).
FIGURE 16 Lowering the handles of the ringed clamp
to elevate the vas
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SURGICAL APPROACH AND OCCLUSION OFJCHK^SA 31
05892
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FIGURE 17 Pressing the index finger lightly
downward to tighten the scrotal skin
just ahead of the tips of the ringed
clamP and over the anesthetized area
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Left hand
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Hold the dissecting forceps in the right hand, points '
curved downward, in preparation for puncturing the
vas Hold the instrument so that there is a -15-degree
angle between the closed tips of the forceps and the
lumen Then open the forceps; using only the medial
blade (see box on page 34) of the forceps, pierce the
scrotal skin just superior to the upper edge of the
^Std forccps-where the vas is most prominent
fn
fe
PierCing Sh0uld result in a Puncture of
e rmdlme of the vas, preferably at the point where
the need e entered for anesthetic infiltration. When
making the puncture, do not slowly push the
dissecting forceps forward. Instead' use a quick, sharp
single movement to make a clear puncture of the skin’
own into the vas. Advance the medial blade of the
forceps into the vas lumen.
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32 SURGICAL APPROACH AND OCCLUSION OF THE VASA
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FIGURE 18 Piercing the skin with the medial blade
of the dissecting forceps
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Left hand
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Vas
lumen
! Scrotal skin
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PITFALLS: Avoid three pitfalls when puncturing
the scrotal skin. First, be sure to penetrate the
anterior wall of the vas with the dissecting
forceps. Otherwise, intact overlying fascia will
prevent elevation of the vas out of the puncture
wound. Second, if puncturing is too deep,
transection of the vas might occur and the vas
artery may be damaged, and bleeding will
follow. Third, be sure to puncture the vas just
superior to the upper edge of the ringed
forceps; if the puncture is made in the tissue
that is grasped by the ringed forceps, you will
not be able to spread the tissues adequately
(see next page).
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fe '3
SURGICAL APPROACH AND OCCLUSION OF THE VASA 33
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After making the puncture, withdraw the medial blade
of the dissecting forceps. Close the tips of the forceps.
At the same -^-degree angle as before, insert both
tips of the forceps in the same puncture hole, in the
same line, and at the same depth as when you made
e puncture with the single blade fF/n
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The ringed clamp remains in place and locked while
tne skin is punctured.
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a) When puncturing the scrotal skin
If you are r
’
right-handed,
the medial (inner) blade
is the left blade. Conversely, if you are lefthanded, the medial (inner) blade iis the right
blade. If you use the medial blade‘ to pierce the
scrotal skin, your hand will not obstruct your
line of vision.
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Identifying
the Medial and
Lateral Blades
I
of the Dissecting
Forceps
I
b) When elevating the vas deferens
If you are right-handed, the lateral (outer) blade
is the right blade. Conversely if vou are left
handed. the lateral (outer) blade is the left blade.
} ou use the lateral blade to pierce the wall of
the yas deferens, you will easily be able to rotate
the forceps and deliver the vas
■!
HINT: Right-handed operators should
stand on the client’s right side.
Conversely, left-handed operators
I
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should stand on the client’s left side.
Gently open the tips of the dissecting forceps
tonsversely across the vas, to create a skin opening
twice the diameter of the vas (Fig. 20). In one
tion. spread all layers of tissue from the skin to the
deSeoeenoenhThe “P" °f
f°rCepS ShouJd Pen«rate
done -f
tO expose bare vas waU- No harm is
Hn h
enter thC lumen- Be careful t0 keep the
va°
CS °f the dissecting forceps paraUel to the
Spreading
the Tissues
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34 SURGICAL APPROACH AND OCCLUSION OF THE VASA
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FIGURE 19 Inserting both tips of the dissecting
forceps into the puncture site
Left hand
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The skin and \-as sheath will remain stretched open
after the tissues are spread. By contrast, the opening
in the vas will close after spreading; as it closes, the
puncture site in the vas may look like a longitudinal
groove. The stretched opening in the skin and sheath,
which should be twice the diameter of the vas, will
enable you to lift out a loop of the vas.
The ringed clamp remains in place and locked while
the tissues are spread.
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SURGICAL APPROACH AND OCCLUSION OF THE VASA 35
! :
FIGURE 20
Spreading the tissues to make a skin
opening twice the diameter of the VOS
f
Left hand
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PITFALLS: Watch out for two pitfalls when
spreading the tissues. First, if you fail to
open the blades of the forceps transversely at
a right angle to the vas, one blade could slip
out of the puncture site. This could cause an
unnecessary skin tear. Second, be sure to
apply appropriate counterforce to prevent
the dissecting forceps from slipping out of
the puncture hole. Maintain depth of puncture,
but do not push down further than the
original puncture.
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36 SURGICAL APPROACH AND OCCLUSION OF THE VASA
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FIGURE 21 Piercing the wall of the vas with the tip of
the lateral blade of the dissecting forceps
Left hand
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lumen
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Delivering
and Elevating
the Right Vas
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Remove the dissecting forceps from the puncture
hole. With the tip of the lateral blade of the
dissecting forceps facing downward, pierce the wall of
the vas deferens at a 45-degree angle (Fig. 21). (See
the box on page 34 for the definition of “lateral
blade.”) Use of the lateral blade enables the operator
to rotate his or her wrist more easily.
is.
£ M
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SURGICAL APPROACH AND OCCLUSION OF THE VASA 37
r
W ith the lateral blade skewering the vas and the
ringed clamp still grasping the scrotal skin, rotate the
handle of the dissecting forceps clock-wise 180 degrees
so that the tips face upward, to deliver a loop of the
vas deferens (Figs. 22 and 23). As vou rotate the
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FIGURE 22 Rotation of the dissecting forceps
Part 1
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NOTE: Ringed clamp is
affixed but not shovm
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FIGURE 23 Rotation of the dissecting forceps
Part 2
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NOTE: Ringed clamp is
affixed but not shown
here for clarity.
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38 SURGICAL APPROACH AND OCCLUSION OF THE VASA
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dissecting forceps with the right hand, slowly release
the ringed clamp with the left hand, thus allowing the
forceps to elevate the vas through the puncture hole
(Fig. 24). This simultaneous rotation with one hand
and release of the ringed clamp with the other hand
requires practice and coordination. Note, the ringed
clamp is not shown in the illustrations, in order to
give a clearer view, but it is in place when the
rotation begins. At the beginning of the rotation,
your hand will be palm side down; after rotation it
will be palm side up.
If the vas is difficult to deliver, more extensive
spreading of the sheath may be required.
£
1
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FIGURE 24 Releasing the ringed clamp before
elevating the vas with the dissecting
forceps—ringed clamp open, but still
in place
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NOTE: Clamp is
opening
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SURGICAL APPROACH AND OCCLUSION OF THE VASA 39
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ALTERNATIVE: There is an alternative way to deliver
an e evate the vas; instead of skewering the vas with the
dissecting forceps, the surgeon uses the forceps to grasp the
iv nd'^
eCtl- ThC fOU°Win8 dCSCriP-n Lor the nght
handed surgeon. The doctor begins by spreading the tissue as
iJthe U
BU‘ after StretChin«
opting
in the skin and sheath, the surgeon does not remove the
dissecting forceps from the puncture hole. Instead the
surgeon gradually withdraws the forceps, holding them in
hne with the longitudinal axis of the vas. until ht or she
expoZV •aV1'’5
The doctor th
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d°WnWard) at thc ^es of the bare
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moves the rjght hand
the dissecting forceps, and the right elbow toward the
right away from his or her side, until the dissecting forceps
e at about a 45-degree angle to the longitudinal axis of
the vaS (See a below). This movement causes the medial
ade to slip out of the wound, while the tip of the l iteral
blade continues to touch the right side of the vas
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45°
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180°
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Next, the doctor gently closes the tips of the forceps,
grasping the right half of the bare vas, with the tips of the
forceps facing to the side. The surgeon then starts to rotate
he dissecting forceps in a clockwise direction about 90
to bees (se:B above): he or she st°ps -X XL
to be sure that no fascia is between the tips of the forceps
The
--- surgeon then birther rotates the forceps, completing a'
180-degree turn, After the rotation, the cun’ed tips of rhe
forceps are .facing up. The rotational movement slightly
elevates the vas out of the wound.
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PITFALLS: With either technique described
above, watch out for two pitfalls while
delivering the vas. First, do not attempt to
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40 SURGICAL APPROACH AND OCCLUSION OF THE VASA
t
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deliver the vas while the ringed clamp is still
locked; if you do, the vas may be severed.
Second, if fascial tissue is caught between
the tips of the dissecting forceps, you will not
be able to rotate and elevate the vas.
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Grasping
the Vas
with the
Ringed Clamp
Once a loop of the vas has been delivered, gently
close the dissecting forceps on the vas to prevent its
slipping back into the scrotum while the ringed clamp
is removed from the skin. Grasp a partial thickness of
the loop of tire vas with the ringed clamp. Sometimes
you will see a groove on the vas—created when the
vas was punctured (Fig. 25). After you have grasped
a partial thickness of the vas. release the dissecting
forceps.
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FIGURE 25 Grasping a partial thickness
of the elevated vas
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SURGICAL APPROACH AND OCCLUSION OF THE VASA 41
■
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PITFALLS: Watch out for three pitfalls when
grasping the vas with the ringed clamp. First,
be careful not to release the dissecting forceps
until you have grasped a portion of the loop of
the vas with the ringed clamp (Fig. 25). This
will prevent the vas from slipping back into the
scrotum. Second, to avoid damaging the vas
artery, be sure to grasp the vas at the crest of
the loop (Fig. 26). Grasping elsewhere leads to
asymmetrical stripping of the sheath from the
vas. Third, grasp only a partial thickness of the
vas. If the ringed clamp is placed around the
entire circumference of the vas, the vas could
slip back into the scrotum when it is divided.
FIGURE 26
Grasping a partial thickness of the
elevated vas at the crest of the loop,
with only the ringed clamp attached
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42 SURGICAL APPROACH AND OCCLUSION OF THE VASA
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Puncturing
and Stripping
the Sheath
With one tip of the dissecting forceps (tips facing
up), gently puncture the vas sheath just below the
vas, taking care not to injure the vas artery (Fig. 27).
Then remove the tip.
a
Close the tips of the dissecting forceps. Insert both
tips (tips facing to the side) into the punctured sheath
(Fig. 28).
£ a
Gently open the dissecting forceps (Fig. 29). Strip the
sheath and surrounding tissues downward for at least
a 1 cm length of vas. This is a longitudinal, not a
transverse, motion.
a
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Be careful to avoid blood vessels. Clamp or cauterize
bleeders immediately. When checking for bleeding,
pay particular attention to the abdominal segment of
the vas, which is where bleeding from the vas artery
could occur (a common reason for hematoma
formation).
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FIGURE 27 Puncturing the sheath with one tip of the
dissecting forceps
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SURGICAL APPROACH AND OCCLUSION OF THE VASA 43
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FIGURE 28 Inserting both tips of the dissecting
forceps into the punctured sheath
(tips fc -ing to the side)
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FIGURE 29 Opening the dissecting forceps
to strip the sheath
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44 SURGICAL APPROACH AND OCCLUSION OF THE VASA
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FIGURE 30 Ligation
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Occluding
the Right Vas
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Now occlude the right vas in your preferred manner.
Remember, no-scalpel vasectomy is a surgical
approach for isolating and delivering the vas that
uses conventional methods of vas occlusion. While
many methods of occlusion have been used, two
common ones—ligation and cautery—are described
below.
Ligation fFzg. 30). Before beginning, the surgeon
makes certain that all sheath and vasal vessels have
been stripped away from the segment of vas to be
occluded. Up to 1 cm of the vas can be removed.
While removal of a segment of the vas is not
mandatory, some operators prefer to do so for vas
identification or legal purposes. The surgeon ligates
the cut ends tightly enough to occlude the vas. Some
operators use absorbable suture material such as
chromic catgut; others prefer nonabsorbable silk or
cotton. There have been no studies done to determine
the best material for ligating the vas.
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SURGICAL APPROACH AND OCCLUSION OF THE VASA 45
i
Cautery (Figs. 31 and 32). Another popular
occlusion technique is cautery with a needle electrode
or hot wire, hereafter called the cautery tip. This
method desiccates the lumenal mucosa of the vas to
create a scar that effectively occludes the ends of the
divided vas.
i
There are variations in the cautery' technique,
depending on the equipment used. When a sharp
needle electrode is used, the surgeon pierces the vas
wall with the needle and directs it into the lumen
(F’g- 31). When a blunt wire cauterv unit is used the
surgeon hemitransects the vas to permit the cauterv
tip to enter into the lumen (Fig. 32). If the vas is
only partially transected, it cannot slip back into
the scrotum. Once the cautery' tip is in the vas,
the surgeon may first direct it toward either the
abdominal or testicular end of the vas: the operator
will eventually cauterize a segment of the vas in both
directions.
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PITFALL: When using cautery, avoid damaging
the muscle of the vas; muscle damage can lead
to necrosis, with subsequent sperm leakage,
E
granuloma, and recanalization.
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FIGURE 31 Cautery with a sharp needle
electrode (done in each direction)
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46 SURGICAL APPROACH AND OCCLUSION OF THE VASA
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FIGURE 32 Cautery with a blunt wire
inserted into the hemitransected
vas (done in each direction)
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To achieve a graded desiccation of only the mucosal
layer, the surgeon inserts 1.0 to 1.5 cm of the cold
cautery tip into the lumen before the current is
applied. Current is then applied, and the tip is slowly
withdrawn. Depending on the equipment, electrical
current, or strength of the battery, the time needed to
cauterize the mucosal layer will van: In some cases, it
may take five seconds. Doctors who are experienced
with cautery usually note changes in the vas that
indicate the mucosa has been desiccated. For
example, the mucosa blanches and a small bit of
smoke escapes from the tissue. This signifies time to
withdraw the tip.
After cauterizing in one direction, the surgeon turns
off the cauten unit. This lets the tip cool before the
surgeon reverses direction and cauterizes the other
segment. The vas is then divided. No ligature or clip
need be applied in addition to the cautery. The same
procedure is followed for the second (that is, the left)
vas.
Fascial interposition. With both ligation and
cautery, a fascial barrier may be created by pulling the
sheath over one of the vas ends and securing it.
Surgeons use several different methods of fascial
interposition; there is no evidence that one method is
superior to another.
SURGICAL APPROACH AND OCCLUSION OF THE VASA 47
FIGURE 33 Isolating the left vas before occlusion
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Left hand
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Adjust the left hand to grasp the left vas deferens,
using the three-finger technique (Fig. JJ). As
descnbed on page 23 of the anesthesia chapter, place
the middle finger below the scrotum, with the thumb
and index fingers above the scrotum; position the vas
directly under the previously opened puncture site.
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Isolating
the Left Vas
before Occlusion
3
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9
This position may be awkward at first, but with
practice the right-handed operator will be able to
isolate the left vas as smoothly as the right. Holding
the vas with the left hand frees the right hand to
handle the instruments (vice versa for the left-handed
operator).
4
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48 SURGICAL APPROACH AND OCCLUSION OF THE VASA
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Applying
the Ringed
Clamp to the
Scrotal Skin
and Underlying
Left Vas
t
Occasionally, the sheath and underlying vas cannot be
fixed with the clamp because of local edema. Insertion
of the clamp into the scrotal tissue may increase the
risk of both trauma and infection. However, if the vas is
directly under the puncture hole, inserting the clamp
into the scrotal tissue probably will not contribute to
trauma and infection. If the operator probes for the vas
with the ringed clamp inside the scrotum, the risk of
trauma and infection probably increases.
3
L
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£ £3
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Grasping the left vas and sheath directly with the
ringed clamp can make vasectomy easier to perform,
particularly when the scrotal skin is thick.
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Still using the three-finger technique, tightly stretch
the skin overlying the vas so that it is as thin as
possible. Open the ringed clamp, and press the tips
onto the vas through the puncture site. Lock the clamp
around the vas and overlying sheath (Fig. 339- As with
the right vas, use the “palm-up” approach to ensure that
the instrument is applied perpendicular to the vas (90
degrees) (Fig. 13, pcige 27).
Delivering, Elevating,
and Occluding
the Left Vas
Follow the steps for delivering, elevating, and occluding
the vas as described on pages 37-47.
Dressing
the Wound
After both vasa have been occluded and returned to
the scrotum, pinch the puncture site tightly for a
minute, or ask the client to hold the gauze and apply
pressure himself. Inspect for bleeding. If bleeding is
present, hemostasis must be achieved. No skin sutures
are necessary. Wash the small wound by swabbing
with an antiseptic solution. A sterile gauze dressing
can be held in place with a scrotal supporter or tape,
or a Band-Aid can be used to cover the small wound.
In Figure 34. note that the width of each end of the
tape has been divided in half, allowing the tape to fit
better on the round scrotum.
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SURGICAL APPROACH AND OCCLUSION OF THE VASA 49
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FIGURE 34 Dressing the wound
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Men who have undergone vasectonn mav leave the
health facility after resting 30 minutes. If sedation has
been used, monitor the patient s vital signs even- 15
minutes after surgery until stable.
In simple language, explain to
t_ the
.1. man how to care
for the wound, what side effects to expect, what to do
if complications occur, where to go for emergenev
care, and when and where to return for a follow-up
visit. Tell the patient that minor pain and bruising are
to be expected and do not require medical attention,
he man should seek medical attention if he has fever,
i ood or pus oozes from the puncture site, or if he
experiences excessive pain or swelling. Give the man a
brief, simply written summary of the instructions.
The patient may resume normal activities and sexual
intercourse with temporary contraception within two
to three days, if he feels comfortable. The patient and
s partner will need to use temporary contraception
for 12 weeks or 20 ejaculations, whichever comes
first. Every man should be offered the opportunity- to
have a semen analysis. Ideally; one or two sperm-free
semen specimens should be obtained from the man
after vasectomy in order to be reasonably sure the
operation has been a success.
See Appendix B for sample written instructions for
the client.
50 SURGICAL APPROACH AND OCCLUSION OF THE VASA
Postoperative
Care and
Instructions
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APPENDIXES
AND REFERENCES
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Appendix A
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WHO Eligibility Criteria for Vasectomy Procedures*
Introduction
Considering the irreversibility or permanence of sterilization procedures, special
care must be taken to assure the client’s voluntary informed choice of the method.
Particular attention must also be given in the case of young people, men who have
not yet been parents, and clients with mental health problems, including
depressive conditions. The national laws and existing norms for the deliver}' of
sterilization procedures must be considered in the decision process.
There is no medical reason that would absolutely restrict a person’s
eligibility for sterilization. There may be conditions and circumstances
that indicate that certain precautions should be taken.
The classification of the conditions into the different categories is based on an indepth review of the epidemiological and clinical evidence relevant to medical
eligibility. The programmatic implications of these updated medical criteria are
still to be addressed taking into account the various levels of service delivery.
However, for the particular case of sterilization procedures, the following category
definitions were developed.
Definitions
A (Accept):
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C (Caution):
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D (Delay):
S (Special):
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NA:
There is no medical reason to deny sterilization to a person with
this condition.
The procedure is normally conducted in a routine setting, but with
extra preparation and precautions.
The procedure is delayed until the condition is evaluated and/or
corrected. Alternative temporary' methods of contraception should
be provided.
The procedure should be undertaken in a setting with an
experienced surgeon and staff, equipment needed to provide
general anesthesia, and other back-up medical support. For these
conditions, the capacity' to decide on the most appropriate
procedure and anesthesia regimen is also needed. Alternative
temporary methods of contraception should be provided if referral
is required or there is otherwise any delay.
Not applicable.
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•Adapted from: World Health Organization (WHO). 1996. Improving Access to Quality Care in Family
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Planning: Medical Eligibility Criteria for Contraceptive Use. Geneva.
53
Appendix A
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Male Sterilization
Condition
Category
Rationale/Comments
Local infections
scrotal skin infection
active STD
balanitis
epididymitis or orchitis
D
D
D
D
Previous scrotal injury
C
Systemic intection or
gastroenteritis
D
There is an increased risk of
postoperative infection0
Large varicocele
C
The vas may be difficult or impossible
to locate; a single procedure to
repair varicocele and perform a
vasectomy decreases the risk of
complications.
Large hydrocele
Filariasis; elephantiasis
Intrascrotal mass
C
D
D
There is an increased risk of
postoperative infection0
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s a
The vas may be difficult or impossible
to locate; a single procedure
decreases the risk of complications.
The scrotum may be involved in
severe elephantiasis making it
impossible to palpate the cord
structure and testis.
This may indicate an underlying
disease.
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Appendix A
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Male Sterilization (continued)
Condition
r a
Category
Cryptorchidism
c
If cryptorchidism is bilateral, and
fertility has been demonstrated, this
will require extensive surgery to
locate the vas, making the condition
category S. If cryptorchidism is
unilateral and fertility has been
demonstrated, vasectomy may be
performed on the normal side and
the spermogram checked, as per
routine. If sperm continue to be
persistently present, more extensive
surgery may be required to locate the
other vas, and the condition becomes
category S.
Inguinal hernia
S
Vasectomy can be performed
concurrent with hernia repair.
Sickle cell disease
A
Coagulation disorders
S
Bleeding disorders lead to an
increased risk of postoperative
hematoma formation which, in turn,
leads to an increased nsk of infection.
Diabetes
C
Diabetics are more likely to get
postoperative wound infections. If
signs of infection appear, treatment
with antibiotics needs to be given.
HIV\AIDSb
HIV positive
high risk of HIV
AIDS
A
A
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Rationale/Comments
E H
Proper infection prevention
procedures must be followed. If the
man is currently suffering an AIDSrelated illness, the procedure should
be performed in an appropriate
setting.
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Cohn, I., Bornside G. H. Injections. In Schwartz. S. I.. Shires, G. T., Spencer, F. C. (eds.). 1989. Principles
of Surgery. Sth ed. New York: McGraw-Hill Book Co.. 181-215.
b
Bamer methods, especially condoms, are always recommended for prevention of sexually
transmitted diseases, including HTV prevention.
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55
Appendix B
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Sample Postoperative Instructions
for the Client
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• You may bathe on the day after surgery, but do not
let the wound get wet. After three days, you may
w’ash the wound with soap and water.
• Do not pull or scratch the wound while it is
healing.
• Wear a snug undergarment or scrotal support for at
least two days after surgery. This will help you be
comfortable.
• Keep the bandage on for three days after the
operation.
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• Rest at home until the day after surgery; You may
resume your normal activities after one or two days.
But avoid work and strenuous exercise for at least
48 hours. This will help the wound heal.
• You may have sex with your partner as soon as it is
comfortable for you. litis is usually two or three
days after the operation. Remember, vasectomy does
not work immediately, and you can still get your
partner pregnant. Sperm should be gone after 20
ejaculations. Use condoms, or ask your partner to
use another family planning method until after 20
ejaculations.
• You may have a little pain, bruising, or swelling
where the wound is. Watch to be sure that it does
not get worse. A small amount of pain, bruising, or
swelling that does not get worse is normal. Take the
medication provided (recommended) by the doctor.
Be sure to follow the instructions given to you. An
ice pack may help relieve the pain, bruising, or
swelling.
• Return to the clinic or call:
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— If you have a fever within one week of surgery
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Appendix B
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If there is any bleeding or pus in the wound
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If there is pain or welling around the wound
that gets worse or does not go away
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— If your partner ever misses a period or thinks
she is pregnant. This is ven’ important. It may
mean the operation has failed, and your partner
may be pregnant.
9*
3
Stitches are not usually required in no-scalpel
vasectomy But if you do have stitches that must be
removed, you must go to a health center for a
follow-up visit. This should be done about one
eek after the operation. A health worker will
remove the stitches and check to see how the
wound is healing.
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• Vasectomy does not provide protection against
HIV infection or other sexually transmitted diseases.
Aside from abstinence, latex condoms offer the best
protection against these infections.
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• Your follow-up appointment is:
E
Day and Date
Time_
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References
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Antarsh, L. 1988. Men and their worries about vasectomv:
Will a new surgical technique help? AVSC News 26 (2):
5-6.
Huber. D. 1989. No-scalpel vasectomy: The transfer of a
refined surgical technique from China to other
countries. Advances in Contraception 5: 217-218.
Kendrick, J. S.: Gonzales, B.; Huber, D. H.; et al. 1987.
Complications of vasectomies in the United States.
Journal of Family Practice 25: 245-248.
Li. P S.; Li. S.; Schlegal, P N.; and Goldstein, M. 1992.
External spermatic sheath injection for vasal nerve
block. Urology 39: 173-176.
Li, S. 1989. Some experience with vasal sterilization
training programme. Paper presented at the First
International Symposium on No-Scalpel Vasectomy,
Bangkok. December 4-6.
Li, S.; Goldstein. M.; Zhu. J.; and Huber, 1). 1991.The
no-scalpel vasectomy. Journal of Urology' 145: 341-344.
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Nirapathpongpom. A.; Huber. D.; and Krieger. J. N.
1990. No-scalpel vasectomy at the King s birthday
vasectomy festival. Lancet 335: 894-895.
Physician ’s Desk Reference. 1991. Oradell, N.J.: Medical
Economics Data.
World Federation for Voluntary^ Surgical Contraception.
1995. Safe and voluntary' surgical contraception.
New York: AVSC International.
World Health Organization. 1988. Technical and managerial
guidelines for vasectomy services. Geneva.
£
World Health Organization. 1996. Improving access to
quality' care in family planning: Medical eligibility'
criteria for contraceptive use. Geneva.
59
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