Overview
Definition:
Open subinguinal varicocelectomy is a surgical procedure aimed at ligating dilated veins (pampiniform plexus) within the spermatic cord to correct a varicocele
The subinguinal approach involves an incision below the inguinal ligament, allowing access to the spermatic cord structures above the internal inguinal ring, facilitating precise identification and ligation of varicosed veins while preserving essential structures like the vas deferens and testicular artery
This technique is historically significant and remains a widely used method for managing varicoceles, particularly those causing pain or infertility.
Epidemiology:
Varicocele is a common condition, affecting approximately 15% of the general male population and 35-40% of men presenting with primary infertility
It is most prevalent in adolescents and young adults, typically developing on the left side (90% of cases) due to anatomical factors related to the left testicular vein's drainage into the left renal vein
Bilateral varicoceles occur in about 10-15% of cases.
Clinical Significance:
Varicocele is a leading reversible cause of male infertility
Its management through varicocelectomy can improve semen parameters and positively impact fertility rates
Furthermore, varicoceles can cause significant scrotal pain, discomfort, and testicular atrophy, leading to a reduced quality of life
Understanding open subinguinal varicocelectomy is crucial for surgeons managing male reproductive health and infertility, forming a key part of the DNB and NEET SS surgical curriculum.
Indications
Indications:
Primary indications for varicocelectomy include palpable varicoceles associated with male infertility
Evidence of impaired spermatogenesis (abnormal semen analysis) in the presence of a palpable varicocele is a strong indication
Varicoceles causing significant testicular pain or discomfort unresponsive to conservative management are also indications
Progressive testicular atrophy in a varicocele-affected testis, especially during adolescence, warrants surgical consideration
Subclinical varicoceles (non-palpable but detected on ultrasound) are generally not treated unless there is a clear indication like very poor semen parameters in conjunction with other fertility treatments.
Contraindications:
Absolute contraindications are rare but include severe coagulopathy, active local infection, or patient refusal
Relative contraindications may include significant comorbid conditions that increase surgical risk
Previously failed varicoceles surgery or significant scarring in the inguinal region might necessitate alternative approaches.
Preoperative Preparation
History And Physical Exam:
Detailed history regarding pain characteristics (location, severity, aggravating/relieving factors), scrotal swelling, impact on sexual function, and fertility status
A thorough physical examination is paramount, including assessment for the Valsalva maneuver to elicit or confirm the varicocele
Palpation of the spermatic cord is performed to identify dilated veins and assess their grade (subclinical, palpable at rest, palpable with Valsalva)
Scrotal ultrasound may be used to confirm diagnosis and grade, especially for subclinical varicoceles or to assess testicular volume.
Investigations:
Semen analysis is essential to evaluate semen parameters (sperm count, motility, morphology)
Hormonal assays (FSH, LH, Testosterone) may be considered in infertile men to rule out other endocrine causes
Doppler ultrasound of the scrotum is useful for confirming the diagnosis, grading the varicocele, and assessing testicular blood flow, especially in cases of uncertainty or subclinical varicoceles.
Informed Consent:
Thorough discussion with the patient about the diagnosis, rationale for surgery, alternative treatment options (including observation), the surgical procedure itself (open subinguinal approach), potential risks, benefits, and expected outcomes
This includes explaining the possibility of recurrence, chronic scrotal pain, hydrocele formation, testicular artery injury, and impact on fertility
Pre-operative counseling regarding semen cryopreservation may be offered.
Anesthesia And Medications:
The procedure can be performed under general anesthesia, spinal anesthesia, or local anesthesia with sedation, depending on patient factors and surgeon preference
Prophylactic antibiotics are usually administered
Anticoagulation status is reviewed, and appropriate management is planned.
Procedure Steps
Surgical Technique:
A skin crease incision is made approximately 2-3 cm superior to the scrotum, lateral to the pubic tubercle, just below the inguinal ligament
The external oblique aponeurosis is divided longitudinally to expose the spermatic cord
The cord is mobilized and elevated
The internal spermatic fascia is opened to identify the pampiniform plexus of veins
Dissection aims to isolate all dilated veins
Careful identification and preservation of the vas deferens, testicular artery, lymphatic vessels, and cremasteric vessels are critical to minimize complications
All identified dilated veins are ligated with non-absorbable sutures or clips
The spermatic cord is returned to the inguinal canal, and the external oblique aponeurosis is closed
Subcutaneous tissue and skin are then closed in layers
Modern variations may use magnification (loupes or microscope) for meticulous dissection.
Identification Of Structures:
The vas deferens, with its accompanying artery and veins, is usually identified first
The testicular artery is identified by its pulsating nature and location relative to the veins
Lymphatic vessels are identified by their appearance and behavior during manipulation
their preservation is key to preventing hydrocele formation.
Ligation Techniques:
Individual ligation of dilated veins using fine sutures (e.g., 3-0 or 4-0 non-absorbable) is a common method
Alternatively, vessel sealing devices or clips can be employed for hemostasis and ligation
The goal is to achieve complete venous occlusion without compromising arterial supply or lymphatic drainage.
Postoperative Care
Immediate Postoperative Period:
Patients are typically monitored for a few hours post-operatively for vital signs and pain
Pain management is initiated with analgesics, often multimodal
Scrotal support is strongly recommended to reduce swelling and discomfort
Patients are usually discharged on the same day or the next day.
Wound Care:
Surgical site should be kept clean and dry
Patients are advised to shower after 24-48 hours
Dressings are usually removed within 24-48 hours
Signs of infection (redness, increased pain, discharge) should be monitored.
Activity Restrictions:
Strenuous physical activity, heavy lifting, and sexual intercourse should be avoided for approximately 2-4 weeks, depending on the patient's recovery and surgeon's recommendation
Gradual return to normal activities is encouraged.
Follow Up:
A follow-up appointment is typically scheduled within 2-4 weeks post-operatively to assess wound healing, pain, and to discuss semen analysis results if indicated for fertility concerns
Subsequent follow-up depends on the indication for surgery (e.g., fertility evaluation often requires follow-up semen analyses at 3-6 month intervals).
Complications
Early Complications:
Hematoma formation in the scrotum or operative site is relatively common, usually resolving spontaneously
Wound infection can occur, requiring appropriate antibiotic treatment
Postoperative pain can range from mild to severe and may require aggressive management
Injury to the vas deferens or testicular artery is a rare but serious complication, potentially leading to testicular atrophy or infertility
Hydrocele formation can occur due to disruption of lymphatic drainage.
Late Complications:
Recurrence of varicocele is possible, especially if not all dilated veins were ligated or if new collateral veins develop
Chronic scrotal pain (post-varicocelectomy pain syndrome) can be a debilitating complication, occurring in a small percentage of patients
Testicular atrophy, though rare after meticulous dissection, remains a concern
Infertility may persist if spermatogenesis does not recover sufficiently or if other factors contribute.
Prevention Strategies:
Meticulous surgical technique with magnification, careful identification and preservation of the testicular artery and lymphatic vessels, and thorough ligation of all dilated veins are crucial
Postoperative scrotal support helps minimize swelling and pain
Appropriate antibiotic prophylaxis reduces infection risk
Patient selection and counseling are vital to manage expectations and identify contraindications.
Prognosis
Factors Affecting Prognosis:
The success of varicocelectomy, particularly for infertility, is influenced by the patient's age, baseline semen parameters, the severity and duration of the varicocele, and the presence of associated testicular damage
The skill and experience of the surgeon also play a significant role
Successful surgical repair can lead to improvement in semen quality in 60-80% of men.
Outcomes:
For pain relief, varicocelectomy offers significant improvement in the majority of patients (80-90%)
For infertility, pregnancy rates after varicocelectomy typically range from 30-50% over a 1-2 year period, with improvements in sperm count, motility, and morphology observed in many patients
However, conception is not guaranteed, and other factors affecting fertility must also be considered.
Recurrence And Reoperation:
Recurrence rates vary widely depending on the technique and surgeon experience, often reported between 5-15%
Reoperation may be considered for persistent pain or infertility in selected cases.
Key Points
Exam Focus:
Understand the indications for varicocelectomy, particularly the triad of palpable varicocele, infertility, and abnormal semen parameters
Differentiate between open subinguinal, inguinal, and laparoscopic approaches
Recognize the critical structures to preserve: vas deferens, testicular artery, lymphatic vessels
Be aware of the common complications: hematoma, infection, recurrence, chronic pain, hydrocele, and testicular atrophy
The definition and grading of varicocele are essential.
Clinical Pearls:
Always perform a thorough physical examination with the patient standing and performing Valsalva
Use magnification (loupes or microscope) for meticulous dissection to reduce recurrence and complication rates
Preserve lymphatic channels to minimize hydrocele formation
Testicular artery identification is paramount
look for its pulsation and its distinct anatomical location
Consider subfertility workup and patient counseling before surgery
Post-operative scrotal support is crucial for patient comfort and recovery.
Common Mistakes:
Incomplete ligation of all dilated veins leading to recurrence
Inadvertent ligation or injury to the testicular artery causing testicular atrophy
Disruption of lymphatic vessels leading to hydrocele formation
Failure to identify and preserve the vas deferens
Treating subclinical varicoceles without clear indications
Insufficient postoperative pain management or activity restriction leading to complications.