RU2632808C1 - Method of microsurgical treatment of varicocele - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: discission of the skin and a subcutaneous fat of 2-3 cm in the projection of the external hole of the inguinal canal is performed. Spermatic cord is isolated and is taken on the holder. It is separated by a conventional longitudinal median line into the medial and lateral halves, followed by Doppler locating of each of them to reveal the testicular artery. Shells of the spermatic cord are dissected. A separate isolation and detailed Doppler exploration of each of the vessels of the half in which the artery was previously identified with the identification and preservation of all its branches are performed, as well as the ligation of all the remaining vessels of this and the opposite half of the spermatic cord.

EFFECT: method allows to reduce the frequency of the postoperative atrophy of the testicle and to reduce the likelihood of recurrences of varicocele.

2 cl, 1 ex, 4 dwg

Description

The invention relates to medicine, namely to andrology, and can be used in the treatment of varicocele.

Over the past 200 years, interest in surgical treatment of varicocele has repeatedly increased, or almost completely disappeared. Currently, most manuals and scientific papers indicate the need for surgical treatment of varicocele. The most widespread surgical treatment of varicocele began to be used in the 50s of the XX century, when it was first proved that bilateral intersection of the seminal veins in a patient with azoospermia led to a successful pregnancy [Tulloch W.S. Varicocele in subfertility; results of treatment. BrMedJ. 1955 Aug 6; 2 (4935): 356-8].

To date, there are many surgical procedures for treating varicocele, one of which is Palomo surgery, which is a type of high ligation of the spermatic vein. The essence of the method consists in a section 4 cm long, carried out 3 cm above the inner ring of the inguinal canal parallel to theparticular ligament; the aponeurosis of the external oblique muscle of the abdomen is opened, then the internal oblique and transverse muscles are diluted above the inner ring of the inguinal canal, after which the seminal veins and artery between the abdominal and muscle walls are compressed by two Kocher clamps, ligated and intersected [Palomo A. Radical cure of varicocele by a new technique; preliminary report. J. Urol. 1949 Mar; 61 (3): 604-7].

The disadvantage of this technique is the fact that ligation of the testicular artery poses a significant risk for testicular atrophy [Goldstein M, Gilbert BR, Dicker AR, Dwosh J, Gnecco C. Microsurgical inguinal varicocelectomy with delivery of the testis: anartery and lymphatic sparing technique. J. Urol. 1992 Dec; 148 (6): 1808-11].

A known method of laparoscopic ligation of the internal spermatic vein, its intersection [Patent RU No. 2324439, class. A61B 17/12, publ. 05/20/2008]. In this case, a sclerosing substance is introduced into the distal part of the internal spermatic vein, for which a puncture needle is inserted through the working trocar into the abdominal cavity and the vein is punctured below the clipping site. However, laparoscopic varicocelectomy is often offered as an alternative to conventional surgery, and it is believed that laparoscopic varicocelectomy is potentially more dangerous than high ligation, as it may be complicated by damage to the testicular artery and lymphatic vessels [Tauber R, Johnsen N. Antegradescrotal sclerotherapy for of varicocele: technique and lateresults. J Urol. 1994 Feb; 151 (2): 386-90].

A known method that allows intraoperatively differentiating testicular vessels by staining the lymph vessels located in the immediate vicinity of the testicular vein. For this purpose, preliminary 0.2-0.3 ml of indigo carmine is introduced under the testicle shells on the side of the operation [Isakov Yu.F., Erokhin A.P. Comparative characteristics of the results of the operations of Ivanisevich and Palomo in children. Urology and Nephrology. 1979. No. 5. S. 30-34].

However, the main drawback of this method is its invasiveness, since after administration of the drug there is a likelihood of developing orchitis.

A known method of microsurgical treatment of varicocele according to the method of Marmara. The essence of the operational technique is to perform a cut of the skin and subcutaneous fat 2-3 cm long in the projection of the external opening of the left inguinal canal; sequential dissection of the external seminal, cremaster fascia, the muscle that raises the testicle, and the internal seminal fascia; identification, isolation and capture of the testicular artery; separate isolation and intersection of the trunks of the vesicles of the plexiform plexus, vas deferens and cremasterous venous vessels [Marmar JL, DeBenedictis TJ, Praiss D. The management of varicoceles by microdissection of the spermatic cord at the external inguinal ring. Fertil Steril. 1985 Apr; 43 (4): 583-8].

The drawback of this surgical aid, despite the optical enlargement, is the lack of an alternative to visual control during differentiation and isolation of the testicular artery, since often due to the lack of pulsation, small size and intimate fit to the venous collectors, the testicular artery intersects with the spermatic veins.

The objective of the invention is to reduce the number of postoperative complications due to malnutrition of the testicular tissue, reducing the likelihood of relapse of varicocele. The technical result, due to which this problem is solved, is the preservation and holding of the identified testicular artery and the more complete intersection of the venous vessels of the spermatic cord.

In practice, the method is as follows: after isolation of the spermatic cord, the latter is divided by the median longitudinal line (1 in figures 1-4) into the medial (2 in figures 1-4) and lateral (3 in figures 1-4) halves, each of which is separate investigated by application of the Doppler sensor (4 in figures 1-4) with the aim of preliminary localization of the testicular artery. The membranes of the spermatic cord are dissected with a separate isolation and Doppler study of the central departments of each blood vessel of that half of the spermatic cord in which the testicular artery was located with identification of the latter (5 in Figures 1-4) and taking it to the holder in order to guarantee its preservation with a complex structure adjacent venous vessels and prophylaxis of testicular atrophy. The remaining vascular structures (veins) (6 in figures 1-4) of this and the opposite half of the spermatic cord are ligated and cut, thereby minimizing the risk of disease recurrence. The wound is sutured in layers.

Clinical example

Patient A. went to the clinic 06/25/2014.

Complaints about the absence of pregnancy in the spouse within 1 year. In the spermogram from 05/21/2014, asthenoteratozoospermia. Ultrasound and dopplerography of the scrotum revealed a varicocele on the left. I went to the clinic for examination and treatment.

Performed infiltration and conduction anesthesia of the skin, subcutaneous fat and left spermatic cord with 30 ml of 0.75% solution of napropin. An incision of the skin and subcutaneous adipose tissue 2 cm long in the projection of the external opening of the left inguinal canal. Hemostasis of bleeding vessels using bipolar coagulation. Diffuse bleeding of pronounced subcutaneous fat was noted. The left spermatic cord is bluntly highlighted and taken on a gauze holder. Conducted division of the spermatic cord by the longitudinal median line (1 in figures 1-4) into the lateral (3 in figures 1-4) and medial (2 in figures 1-4) parts, an alternate Doppler study of both halves using a miniature Doppler sensor ( 4 in figures 1-4) (Minidop "Bios"). The location of the testicular artery in the lateral part of the cord was revealed (3 in figures 1-4). The shells of the spermatic cord along the specified conditional longitudinal midline are dissected in layers, separate isolation and Doppler study of each vessel of the lateral half of the spermatic cord (3 in figures 1-4). Two branches of the testicular artery were identified (5 in figures 1-4) and taken on hold for the purpose of subsequent preservation due to the complex venous angioarchitectonics of the spermatic cord. All other vessels (veins) (6 in figures 1-4) of the lateral and medial halves of the cord are bandaged and crossed. Suturing with a continuous suture of the membranes of the left spermatic cord with Vikril 4/0 on an atraumatic needle. Comparison of subcutaneous fat with a continuous suture with Vikril 4/0 thread on an atraumatic needle. Bipolar coagulation of bleeding vessels. Hemostasis control is dry. Imposing intradermal cosmetic suture with Proline 2/0 thread on an atraumatic needle.

The method was tested on 44 patients, relapse and complications in the near and in the remote postoperative period was not observed.

The method according to the invention allows to reduce the incidence of postoperative testicular atrophy and to reduce the likelihood of relapse of varicocele.

Claims (2)

1. The method of microsurgical treatment of varicocele, consisting in a section of the skin and subcutaneous fatty tissue 2-3 cm long in the projection of the external opening of the inguinal canal, isolating and holding the spermatic cord on a holder, conditionally dividing it with the longitudinal median line into the medial and lateral half, followed by Doppler by locating each of them with the detection of the testicular artery, dissection of the membranes of the spermatic cord, separate isolation and a detailed Doppler study of each of the vessels of the half in which redvaritelno artery was detected with the identification and preservation of all its branches, and all other vessels ligation and opposite halves of the spermatic cord. 2. The method according to p. 1, characterized in that the identified artery is taken on a holder.

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