GRASPING THE VAS
Grasping the vas is often the most difficult part of the procedure. The vas differs from blood vessels and connective tissue in that it is firm and tubular and feels like al dente spaghetti. It may be prudent to start with the vas that seems most difficult to mobilize. If after further manipulation the vas cannot be well positioned for the vas clamp, the patient can be referred to a specialist.
Once the vas is aligned underneath the skin wheal, switch from using 2 hands to a 3-finger grasp before applying the ring-tipped fixation clamp (Figure 1). With the tip of the vas clamp, palpate the scrotum to reconfirm the location of the vas and then apply the clamp with a firm
Figure 1 – The 3-finger grasp, in which the thumb and index finger are aligned with the middle finger below, helps isolate the vas during the administration of a vasal nerve block and the application of the vas clamp.
downward motion against the skin and vas. Keeping the middle finger underneath the scrotum is extremely important because it traps the vas against the clamp (Figure 2
). Lowering the table and “leaning into it” may help. Try not to grasp too much surrounding tissue; this will lead to unnecessary blunt dissection later. This step often determines whether anesthesia is adequate or whether additional lidocaine is needed. One way to bypass thick skin or a “tight” scrotum is to make an initial puncture before introducing the clamp.
After the vas is clamped, elevate the handle of the clamp with one hand (Figure 3). With the other hand, palpate the full length of the vas in each direction to confirm which vas has been grasped. You can also ask the patient if he feels pressure more on his right or left side. Double and triple checking the side of the grasp is essential to avoid mistakenly clamping and ligating the same vas twice. The vas should be palpable near the skin surface and within the ring of the clamp. If too much tissue has been grasped, the clamp can be reapplied to more cleanly isolate the vas bundle.
Figure 2 – A vas clamp is applied to the connective tissue around the right vas with a firm downward motion and plenty of counter pressure from the middle finger behind the scrotum.
Figure 3 – After grasping the vas, the clamp is elevated. This pulls the skin taut so that on palpation of the scrotum you can confirm whether the vas has been cleanly grasped.
Figure 4 – Here the medial blade of the dissecting forceps is inserted just cephalad to the vas clamp. To guide the forceps into the vas bundle, you can rest the instrument on the thumb of the left hand that is holding the vas clamp.
Figure 5 – By spreading both blades of the dissecting forceps within the puncture site, the connective tissue is removed and the vas is revealed.
To puncture the skin and connective tissue down to the vas, we use the medial blade of the dissecting forceps (Figure 4
). Blunt dissection of the connective tissue can be accomplished by removing the single blade and then inserting and opening both blades through the same puncture site (Figure 5
). This puncture and spreading technique may be repeated several times until the dull white vas emerges from the connective tissue. Be sure to cauterize any bleeding that may occur. Try to avoid unnecessary cautery of the skin edges. Having an assistant blot any blood immediately before cauterization will better reveal the source of bleeding.
Figure 6 – After piercing the vas with the far tip of the dissecting forceps blade angled down, the hand holding the forceps is supinated (so that the forceps blade is angled up) to raise the vas out of the skin.
Figure 7 – Grasping the exposed vas is a challenging part of the no-scalpel vasectomy. The vas clamp around the connective tissue is released and then quickly reapplied to the exposed vas with one hand, while the other hand holds the dissecting forceps with the vas. When done successfully, the vas will look like an upside-down U.
Figure 8 – To avoid blood vessels running along the vas, further blunt dissection with gauze may be needed (A). Two hemostats may be applied to the perivasal tissue to keep the loop from slipping back under the skin (B).
Once visible, the vas can be grasped with the dissecting forceps. With the forceps tips angled down, skewer the vas with the blade farthest from you and gently close the tips. To raise the vas out of its sheath, turn your right (dominant) hand clockwise so that the forceps tips are angled up (Figure 6
) and simultaneously remove the vas clamp with your left hand. This allows the vas to emerge from the skin opening with the dissecting forceps. Then quickly regrasp the vas with the vas clamp in your left hand (Figure 7
). The vas should be elevated from the skin hole in an upside-down U. To prevent losing the vas while loosening and regrasping it with the vas clamp, keep tension on the vas with the tip of the dissecting forceps. Further blunt dissection may be attempted with gauze to remove perivasal tissue; before ligation, 2 hemostats may be applied to the perivasal tissue to keep the vas from slipping back under the skin (Figure 8