Primary Mother Care explains what a couple should know about vasectomy (3.18). Although it is a simple operation, it must be done well, because its success as a family planning procedure ]]depends on there being very few side-effects.

The normal vas is about 2.5 mm in diameter. When you pinch it between your finger and thumb, it has a characteristic firm feel, like partly cooked spaghetti. It is difficult to feel immediately behind a patient's testis, but between the upper pole of his testis and his inguinal ring you can feel it quite easily, and deliver several centimetres of it through a small incision in his scrotum. Rarely, it is double, which is one reason why vasectomy occasionally fails.

After you have incised his skin, you will meet his superficial fascia containing his dartos muscle. Deep to this lies the connective tissue which sheaths his spermatic cord. When you reach his vas, you will find that this also has a sheath of its own. Take care: (1) Don't injure the veins of his spermatic cord (the pampiniform plexus), which will bleed during the operation, and possibly afterwards also. (2) Don't tie his testicular artery, or his testis will atrophy.

FORCEPS, vasectomy, two only. If you are going to do many vasectomies, get these.

Fig. 15-7 VASECTOMY. A, and B, isolating a patient's vas from the other structures in his cord. C, delivering his vas with vasectomy forceps. D, incising the connective tissue over it. E, freeing it from its mesentery. F, clamping it. G, a piece of vas excised. H, the ligatures left long initially, in case the cut ends bleed.

VASECTOMY THE CONTRAINDICATIONS to vasectomy as an outpatient include: a varicocele, a large hydrocele, a local scar, an inguinal hernia, genital tract infection, diabetes, recent coronary heart disease, and filariasis.

EQUIPMENT. Ideally use the special vasectomy forceps shown in Fig. 15-6. A No. 15 scalpel and blade, mosquito forceps, equipment for local anaesthesia, No. 0 plain catgut, 1% lignocaine.

PREPARATION. Ask the patient to shave his scrotum before the operation, and bring with him a tight-fitting undergarment to support it afterwards. Take careful aseptic precautions, scrub up, and wear a mask. There is no need for a gown. Either shave the relevant part of his scrotum just before you operate, or clip it. Prepare the skin of his scrotum.

CAUTION ! Don't use iodine[md]it is painful on the scrotum.

FINDING AND ANCHORING HIS VAS. Stand on his right. Find his vas where it is easily palpable in his scrotum. Pull on his spermatic cord just above his testis, with the thumb and index finger of your right hand.

Use the thumb and fingers of your left hand to manipulate his cord, so as to push his vas upwards and medially into the anterior part of his scrotum close to its median raphe. Isolate his vas from the other structures, by squeezing them out laterally (A, in Fig. 15-7).

Hold his vas well above his testis with your thumb over it and two fingers underneath it. If his skin is thin you will be able to see it. Pulling on it will cause him some discomfort, and pain referred to his abdomen. This is a useful sign that you have indeed found it (B).

CAUTION ! Make sure you have isolated and anchored it in the manner described. This is the critical step. Doing it without causing discomfort needs practice.

ANAESTHESIA. With his vas now anchored, find an area in his skin which is free of cutaneous blood vessels, and use 1% lignocaine to raise a small wheal. Then push the needle deeper and inject 1 or 2 ml of solution as close to it as you can, while holding it away from the other structures in his cord. If he has persistent discomfort while you are handling it, inject more solution into its sheath.

CAUTION ! Don't infiltrate the other structures in his cord. This is unnecessary and dangerous, because you may injure his pampiniform plexus. If there is adrenalin in the anaesthetic solution, it will constrict the vessels, and make his testis temporarily ischaemic and painful.

Pull his testis downwards, so as to tighten his spermatic cord. Carefully feel for his vas.

If you cannot feel his vas (rare), don't give up too soon. If you still cannot feel it, leave it don't explore his cord. Proceed to operate on the other side. Very occasionally the vas is absent. If you have not been able to find it, you will know whether it is indeed absent, by examining his ejaculate later.

DELIVERING HIS VAS. While still firmly anchoring it, incise the skin over it vertically. Push the tip of mosquito forceps, or blunt dissecting forceps through the incision, and split his dartos vertically. Then push vasectomy forceps into the incision. Confirm that his vas has not slipped away by feeling it with these forceps. Open them just wide enough to grip it. Release your fingers, which are holding his testis and cord, and pull his cord gently into the incision (C).

CAUTION ! Don't mistake his vas for thickened bands of cremaster muscle, thrombosed veins, thickened lymphatics, or calcified worms.

TO ISOLATE HIS VAS FROM ITS SHEATH lever the tip of the forceps upwards by lowering their handle. Use a No. 15 blade to incise the connective tissue over his vas vertically in line with it. Make sure that the connective tissue is completely divided by continuing the incision into the vas itself (D).

Hold a segment of his exposed vas with a second pair of vas forceps, or with a special vasectomy hook. Meanwhile, release the first forceps. If you have judged the site and depth of your incision correctly, you can now easily pull out his vas, leaving only a thin mesentery on its medial surface (E).

Use mosquito forceps to make a small window in a piece of the mesentery of his vas which is free of blood vessels. Isolate a 1 to 5 cm segment of vas between clamps. Tie its clamped ends with catgut, placing your ties beyond the clamped area (F). Excise the isolated segment (G).

CAUTION ! (1) Don't put the ligatures over the crushed area. (2) Don't tie them too tight, or they will cut out. (4) To begin with, leave the ends of the sutures long, so that, if the cut ends of his vas bleed, you can pull them back into the wound. (5) Leave a reasonable length of vas above his epididymis. If a reanastomosis has to be done later, this will make it easier. Keep the ligatures away from his epididymis.

Pull on his testis to separate the ends of his vas. Inspect the wound. If it bleeds, pull out the ends of his vas, and tie any bleeders with plain catgut. Then cut the ends of the ligatures short and drop them back.

CAUTION ! (1) Don't damage his pampiniform plexus. (2) Control all bleeding carefully. A small vessel can form a big haematoma later. He can also bleed from the skin edges, from the fascial sheath covering his vas, or from his pampiniform plexus.

If the incision is less than 1 cm, the skin edges may come together without any sutures. If necessary, suture them with catgut, using a mattress suture if they need to be everted. Place a swab on the wound, and hold it with strapping.

Repeat the same procedure on the other side of his scrotum through a separate incision.

Alternatively it is not obligatory to wears gloves. If you choose not to wear them, handle his vas only with sterile instruments, using a strict no-touch technique.

POSTOPERATIVELY, the sutures will fall out by themselves. Ask him to rest after the operation, and not to do any heavy manual work for a day or two.

CHECKUP. Warn him that he may not become sterile for up to 3 weeks. He should continue to use a contraceptive: (1) until two examinations of his ejaculate have shown no sperm, or (2) until he has had 15 ejaculations after vasectomy.

To examine his ejaculate, ask him to produce a specimen by masturbation, or from a condom after intercourse. Put several loopfuls under a microscope, and examine them for sperm under the low power. There should be none.

DIFFICULTIES [s7]WITH VASECTOMY If you CANNOT FIND HIS VAS, don't continue the operation under local anaesthesia as an outpatient.

If YOU LOSE THE CUT ENDS of his vas after sectioning them, try to recover them by systematically palpating his vas, and feeling for them with forceps. The ligature may have slipped, or you may have released the forceps holding his vas too soon, and let them be drawn quite a distance into his scrotum. Don't injure any blood vessels. If you cannot find the cut ends, the operation will still probably succeed. Tell him that you have had difficulty, and watch for haematoma formation. Check to see that his ejaculate becomes sperm-free.

If a HAEMATOMA FORMS, it may spread into his scrotum, his thighs, or his abdominal wall. If it is small, it will disappear spontaneously. If it is larger, you may have to admit him and evacuate it.

If his WIFE BECOMES PREGNANT, either vasectomy has failed, or he is not the father. If sperms are present in his ejaculate, you can re-explore his vas under general anaesthesia, and divide it again. Consider carefully what you should tell him! A more diplomatic alternative than testing his sperm count is to tell the couple that his vasectomy has presumably not worked, and to offer the wife sterilization.