A SUWRELESS TECHNIC FOR BIlATERAL PARTIAL VASECfOMY

Transcription

1 FERTIUTY AND STERILITY Copyright 1972 by The Williams & Wilkins Co. Vol. 23, No.1, January 1972 Printed in U.S.A. A SUWRELESS TECHNIC FOR BIlATERAL PARTIAL VASECfOMY WILLIAM M. MOSS, M.D., F.A.C.S. * Assistant Clinical Professor of Surgery, University of California Medical School, Irvine, California In an attempt to make the vasectomy operation simple, quick, with no complications, and with the least discomfort to the patient; a technic has been developed using the medium sized tantalum clip (Weck Hemo-clip Surgical Instrument Division, Edward Weck & Co., Inc., st Place, Long Island City, N.Y ) and using one transverse incision measuring no more than 3 mm. in length. No sutures are used to close the skin incision. In a series of 400 consecutive bilateral partial vasectomies using this technic, there have been no failures, infections, or hemorrhage. With the increasing interest in overpopulation, pollution, and ecology, methods of birth control and sterilization have been given more interest in the lay and medical press. The ideal birth control has yet to be developed. The birth control pill, the intrauterine device, diaphragm, condom, jellies and foam, all have their disadvantages. Sterilization of the female has been a more difficult and a more expensive procedure than that performed in the male. A bilateral partial vasectomy has been a popular method of sterilization in the male for many years, and the increasing number of vasectomies performed annually reflects this growing interest in the male sterilization procedure. The Association for Voluntary Sterilization reported that 750,000 vasectomies for sterilization purposes had been performed in Both men and women are becoming informed that a bilateral partial vasectomy has proven itself to be a simple form of sterilization with a high rate of success, very little morbidity, little loss of work time, and is relatively inexpensive. Reanastomisis of the vas deferens following vasectomy has been successful in about 50% of cases. There have been various technics reported in performing the bilateral partial vasectomy. Krishnamurthyl and Hanley2 overlapped the ends of the vas 1-2 cm. and ligated them together. Vyas and Trivedi 3 made bilateral posterior incisions in the scrotum, used silk suture, and removed 1-2 cm. of each vas. Schmidt 4 reported dividing the vas without removing any portion, fulgurizing both ends, and enclosing the fascial sheath over only one end. Freund and Davis 5 made separate incisions over each vas, used silk ligatures, removed 1-2 cm., and then used absorbable skin sutures. Rolnick 6 severed the vas, folded both ends back on themselves and ligated them with nonabsorbable suture. Strode 7 excised 1-2 in. of the vas, ligated the proximal end with dermal sutures, and buried it in the surrounding fascia. The distal end was ligated with catgut and anchored outside the fascia. Perrill 8 used cotton sutures, did not remove any portion of the vas, and the lower end of the vas was folded back over itself and ligated. Carlson 9 removed 2-3 in. of the vas and simply ligated both ends with suture. Jhaver 10 makes a single midline vertical incision, excises a short segment of each and used 1 tantalum medium clip on each divided vas. The skin wound is Received August 26, * Address requests for reprints to: William M. 1 cm. in length and is closed with a single Moss, M.D., F.A.C.S., Inc., 1125 E. Seventeenth stitch which is removed from hr. Street, Suite N-554, Santa Ana, Calif postoperatively. H. C. Mossll makes a 33

2 34 MOSS Vol. 23 single midscrotal incision and uses 3 medium sized hemo-clips on each divided end. No portion of the vas is removed. MATERIAL AND METHODS Preoperative Preparation. Prior to performing a vasectomy a consultation is carried out with the husband and wife. This consists of a complete interview to determine the desirability of permanent birth control, and whether vasectomy would be the best method of final birth control. Many cases have a recommendation from their obstetrician or family physician. Maturity, age, number of children, number of years of marriage, religion, and attitude all are factors to consider in the counseling. Vasectomy is certainly questionable for men who have had several marriages, appear immature, who have no children, those having sexual problems, and those who belong to religions that object to permanent sterilization. If a man is selected for vasectomy both he and his wife are informed of the entire operation including its purpose, technics, and nmction. An operative permit is signed by both the husband and wife, which states the operation is not guaranteed, and the operation is being performed to produce sterility. All questions are answered prior to scheduling the patient for surgery. Preoperative instructions include bathing with medicated soap daily for at least 3 days prior to surgery, and shaving of the scrotum, penis, and inner thighs. It has been found the patient can shave himself better at home in the evening before surgery with more ease and comfort than having it done immediately prior to surgery. The patient is instructed to bring in an athletic supporter and jockey type undershorts. Both are used for support and to hold a gauze bandage in place following surgery. Surgical Technic. A local anesthesia is administered by infiltrating 6-8 cc. of 1% lidocaine, epinephrine added into the mediam raphe in the midanterior scrotum. A 27-gauge needle is used to infiltrate the skin and the tissues around the right and left vas deferens in the upper one-third of the scrotum. About min. is allowed for the local anesthetic to spread through the tissues of the scrotum, and if this is done no further sensation should be felt other than the surgeon handling the scrotum. The scrotum, penis, and the pubic area are thoroughly prepped with surgical soap and draped with sterile towels. The vas deferens from one side is brought over to the midline where the skin was first anesthetized and held in place with a towel clip. A 3-mm. incision is made in the skin as it is held under tension (Fig. 1), and the vas deferens is dissected enough to be secured by a second towel clip which this time does pierce the skin. By alternating the 2 towel clips and with careful dissection, the vas deferens is finally delivered through the small incision as a loop 1-2 cm. in length (Fig. 2). Two medium tantalum clips are placed on the proximal and the distal ends of the loop (Fig. 3), and the vas is then divided (Fig. 4). The clips placed next to the cut ends are firmly closed. The other clips are applied to occlude the lumen of the vas only, and are not crushing in their application. If a specimen is desired, 5 mm. of the vas may be excised, but this has been found unnecessary. By pulling on the testicle the divided ends of the vas are brought into their normal position in the scrotum, and the same procedure is carried out on the opposite side through the same midline incision. The skin of the scrotum is merely moved over to the area of the opposite vas deferens which has been anesthetized. No skin sutures are used in the scrotal incision; however, the patient is asked to place pressure over a gauze sponge placed on the incision for min. With this technic there is no need to use any suture

3 January 1972 BILATERAL PARTIAL VASECTOMY 35 material, needle holders, or suture needles. At the end of this period of compression, the incision is well stuck together and many times it is difficult to see in the folds of the scrotum. A gauze dressing is placed over the incision and is held in place with the jockey shorts and athletic supporter. The patient is given instructions to do no heavy work for 24 hr., and to rest quietly for a few hours following surgery. He may shower the next day. The athletic supporter is worn for 2 weeks night and day following the operation. A semen specimen is collected and examined 8 weeks following the operation, and if FIG. 1. A 3 mm. skin incision being made in the midline of the scrotum with a No. 15 blade as the vas deferens is secured beneath the skin with a towel clip. FIG. 3. A tantalum clip is being applied to the distal portion of the loop of vas deferen~. FIG. 2. The vas deferens is brought out as a loop 2-3 cm. in length. FIG. 4. Four tantalum clips have been applied and the vas divided. Mter replacing the ends into the scrotum, the other vas is treated in a similar fashion using the same incision.

4 36 MOSS Vol. 23 completely free of the sperm, the patient is notified that he is sterile. Other sperm counts are recommended at 4 months and 1 year intervals to rule out the presence of recanalization of the vas deferens. RESULTS In 400 bilateral, partial vasectomies there has been no infection, hemorrhage, spermatic granulomas, and no failures in resulting sterilization. The operation exclusive of the time used to infiltrate local anesthesia takes between 5 and 10 min. Preoperative medication or sedation was not administered to any patient. Hyperventilation occurred in 3 patients which produced tingling and cramping in the fingers. This was relieved by rebreathing into a paper bag. Ampules of spirits of ammonia were used in several patients who appeared pale, or complained of lightheadedness during the procedure. Questionnaires were given to the patients at the time of their first semen examination at 8 weeks. Fifty-three per cent described the operation as painless, 43% as mildly uncomfortable, 3% slightly painful, and 1% as moderately painful. No patient described the operation as "very painful," 58% found the operation easier than they expected, and 42% about as they expected. No patient thought the operation was "worse than they expected." Eighty-eight per cent of the patients did not take aspirin or any other medication postoperatively. Twelve per cent took aspirin numbering 1-12 tablets in amount. Medication stronger than aspirin was not necessary. Twenty-one per cent returned to work the same day. 58% the following day, 17% returned to work in 2 days, and 4% took 3-4 days off from work following vasectomy. The average age of the patient was 35, the average age of the wife was 32, and average years of marriage was 9 V2 years. The average number of children in the family was 2V2. The religion of the patient did not appear to be a factor in selection. Twenty per cent were Catholic, 2% Jewish, 55% Protestant, 14% gave no reply, 7% had no religion, and 2% were miscellaneous. DISCUSSION Prior to this technic of an occluding tantalum clip behind a firmly compressed clip, a series of 169 consecutive vasectomies were performed in a similar fashion using only 1 firmly closed medium sized tantalum clip on each of the divided ends. There were two failures which I believe were due to the clips cutting through the vas on each end and then recannulization taking place. Both of these cases were reoperated successfully with the present technic. Because of these two failures it was decided to place an occluding, but noncrushing clip just behind the original firmly applied clip. Three patients requested the vas not be divided or removed, and in 1 case 3 tantalum clips were placed close together without dividing the vas deferens bilaterally. In the other 2 cases 2 tantalum clips were placed close together, on each side, without dividing the vas deferens. In 2 cases, complete sterility was produced; however 1 of the patients in which 2 clips were placed close together with the clips closed tightly so that crushing probably did occur, there is a persistence of 1-2 motile sperm per high power field in the semen examination after 1 year. The ultimate manner in obstructing the vas deferens may be a type of clip that could be applied and then be reopened later without making another incision, allowing the vas deferens to be unobstructed and fertility to occur again. Research on the reversability of sterilization produced by tantalum clip is in progress. 12 There appears to be several advantages of the medium sized tantalum clip (Weck

5 January 1972 BILATERAL PARTIAL VASECTOMY 37 hematoma formation, infection, or spermatic granuloma. Prior to this series a group of 169 bilateral vasectomies were performed using 1 tantalum clip on each of the severed ends of the vas. In this series there were 2 failures which brought about the present series of cases. FIG. 5. hemo-clip) (Fig. 5) over other suture material. 13 As a strong nonabsorbable material, tantalum, has proven itself to be biologically inert. With the applying forceps, the clip may be applied to visually determine the amount of external pressure desired around the vas in an easier fashion than any other type of suture material. The clip may be applied much more rapidly than suture material can be tied and cut. SUMMARY A simple suture less method of bilateral partial vasectomy is described using a 3 mm. single midline scrotal incision and 2 tantalum clips on each of the divided ends of the vas, of which the clip next to the divided end is applied firmly and the adjacent clip is applied in an occluding noncrushing manner. No skin sutures have been necessary in over 600 vasectomies. A series of 400 consecutive vasectomies have been performed in this fashion without failure of sterility, without hemorrhage or REFERENCES 1. KRISHNAMURTHY, M. S. New technique for vasectomy and tubal ligation. J Indian Med Ass 49:30, HANLEY, H. G. Vasectomy for voluntary male sterilisation. Lancet 2:207, VYAS, B. K., AND TRIVEDI, D. R. A singlehanded method of vasectomy. J Indian Med Ass 49:28, SCHMIDT, S. S. Vasectomy: indications, technic, and reversibility. Fertil Steril 19: 192, FREUND, M., AND DAVIS, J. E. Disappearance rate of spermatozoa from the ejaculate following vasectomy. Fertil Steril 20:163, ROLNICK, H. C. Some observations of the seminal ducts. J Urol 72:915, STRODE, J. E. A technique of vasectomy for sterilization. J Urol 37:733, PERRILL, C. V. Vasectomy-A simplified procedure using a midline incision. J. Christ Med Ass India 36:181, CARLSON, H. E. Vasectomy of election. Southern Med J 63:766, JHAVER, P. S. Personal communication. 11. Moss, H. C. Vanadium clips for sterilization operations. JAMA 215:639, JHAVER, P. S., DAVIS, J. E., LEE, H., HULKA, J. F., AND LEIGm, G. Reversibility of sterilization produced by vas occlusion clip. Fertil Steril 22:263, SAMUELS, P. B., ROEDIJNG, H., KATZ, R., AND CONCOTTI, J. A new hemostatic clip. Ann Surg 163:427, 1966.