What are the standard steps for subinguinal microsurgical varicocelectomy?

Subinguinal Microsurgical Varicocelectomy: Standard Surgical Steps

The standard approach involves subinguinal incision with microscopic dissection to identify and ligate all internal spermatic, cremasteric, and gubernacular veins while meticulously preserving the testicular artery, lymphatic vessels, and vas deferens. 1, 2

Preoperative Preparation

• Anesthesia: Perform the procedure under local anesthesia with or without oral sedation, using the smallest available needle (25-32 gauge) for local anesthetic injection to minimize pain 3
• Patient positioning: Position the patient supine on the operating table 1
• Preoperative imaging: Confirm diagnosis with physical examination and Doppler ultrasound 1

Surgical Technique

Incision and Exposure

• Make a subinguinal incision approximately 2-3 cm in length, located just below the external inguinal ring, lateral to the pubic tubercle 1, 2
• Identify the spermatic cord as it exits the external inguinal ring without opening the external oblique aponeurosis 4
• Deliver the spermatic cord through the incision using gentle traction 4

Microscopic Dissection

• Use an operating microscope (typically 8-15x magnification) for the entire dissection to ensure precise identification of structures 2, 5
• Systematically identify and preserve the following structures under magnification:
  • Testicular artery (typically 1-2 arteries, appearing as pulsatile vessels with thicker walls) 2, 6
  • Lymphatic vessels (thin-walled, translucent channels containing clear or milky fluid) 2, 5
  • Vas deferens and deferential vessels (the vas appears as a thick white cord with accompanying vessels) 6, 5

Vein Ligation

• Ligate all dilated veins in three distinct groups:
  • Internal spermatic veins (within the spermatic cord proper) 6, 5
  • External cremasteric veins (surrounding the cord) 6, 4
  • Gubernacular veins (small veins at the inferior pole) 6, 4
• Use 4-0 or 5-0 silk sutures for individual vein ligation, or apply hemoclips for smaller vessels 1, 5

Testicular Delivery (Optional Enhanced Technique)

• Deliver the testis through the incision to access and strip gubernacular and external cremasteric veins directly 5, 4
• Apply continuous double traction on the spermatic cord away from the external ring to facilitate complete visualization 4
• This maneuver allows identification of all potential venous collaterals and reduces recurrence risk 5, 4

Closure and Postoperative Care

• Close the incision in layers: Scarpa's fascia with absorbable suture, followed by subcuticular skin closure 1
• Operating time: Typically 20-45 minutes 1
• Postoperative stay: Can be performed as outpatient surgery with 3-7 hours observation 1
• Follow-up: Schedule physical examination, Doppler ultrasound, and semen analysis (for infertility patients) at appropriate intervals 1, 5

Critical Technical Points

• Artery preservation is mandatory: The testicular artery must be identified and preserved in all cases to prevent testicular atrophy 2, 6
• Lymphatic sparing reduces hydrocele risk: Meticulous identification and preservation of lymphatic vessels minimizes postoperative hydrocele formation (reported rate 0.7%-2.1%) 1, 2, 5
• Complete venous ligation prevents recurrence: Failure to ligate all three venous groups (internal spermatic, cremasteric, and gubernacular) increases recurrence risk 6, 4
• Microscopic magnification is essential: The subinguinal approach requires microscopic visualization to reliably distinguish arteries from veins and identify lymphatic channels 2, 5

Expected Outcomes

• Recurrence rate: 1.3%-6% with proper microsurgical technique 1, 2
• Complication rates: Hydrocele 0.7%-2.1%, testicular atrophy 0%, wound infection minimal 1, 2, 5
• Semen improvement: 80% of patients show improved semen parameters 1
• Pregnancy rates: 40%-46% in couples with male factor infertility 1, 5