Pre-pubic vasectomy--a new approach.
Y Khanna, A Khanna, KR Heda, G Mathur, RN Jhanji
Department of Surgery, Govt. A. K. Hospital, Ajmer, Rajasthan, India., India
Department of Surgery, Govt. A. K. Hospital, Ajmer, Rajasthan, India.
Four hundred and fifty cases were operated for vasectomy by pre-pubic approach. The relative fixity of vas at this place made this approach easier than conventional scrotal approach. Mean healing duration was 6.06 days. This approach leaves the scrotum free, needs no scrotal support and scrotum is not involved in hematoma and inflammatory complications. Thus the pre-pubic approach for vasectomy provides a superior and beneficial alternative to conventional scrotal approach.
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Khanna Y, Khanna A, Heda K R, Mathur G, Jhanji R N. Pre-pubic vasectomy--a new approach. J Postgrad Med 1991;37:65-8,68A
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Khanna Y, Khanna A, Heda K R, Mathur G, Jhanji R N. Pre-pubic vasectomy--a new approach. J Postgrad Med [serial online] 1991 [cited 2022 May 24 ];37:65-8,68A
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Vasectomy is a much required surgical manoeuvre in fast populating countries. It provides an effective permanent male sterilization. It is also useful in prevention of ascending infection in prostatectomy. In present surgical practice, scrotum is a favourite site for vasectomy. The painful complications of scrotal vasectomy required a new vision approach for a new site selection. Here we are presenting our experiences of performing vasectomies in pre-pubic area just lateral to pubic tubercle.
Four hundred and fifty cases either for sterilization or prostatectomy, attending surgical unit of AK Hospital, Beawar from January 1987 to March 1988 were subjected to this technique. After through clinical, physical and laboratory examination, the operation was instituted. In case of sterilization the patient was completely made well conversed with the new approach. After complete preparation of pubic area, the operative field was painted with iodine and spirit. The part was draped. The pubic area just lateral to pubic tubercle was infiltrated with injection xylocaine 2% from skin, deep enough to reach the spermatic cord and vas deferens on both sides. Small oblique or transverse incision was applied. Occasional bleeder encountered was dealt by crushing or ligating. The subcutaneous tissues were dissected deep with the help of an artery forcep to reach the pubic bone. Once the bone was approached the finger was put inside the wound and vas was rolled against it. The vas was caught with an allis forceps. (See [Figure:1]). The vas was freed from its surrounding coverings. The clamps were applied and division of vas done. The cut ends were ligated, approximated, together and returned to wound. The wound was closed with a single skin stitch. The stitched wound was washed with spirit and tincture benzoin seal was applied. The same procedure was applied to the opposite side. No scrotal support was given to any patient. The antibiotic and analgesics were given for 3 days. The stitches were removed from 4th to 7th post-operative day. The patient was kept thoroughly ambulatory throughout the post-operative phase. In cases where vasectomy was performed as an adjunct to prostatectomy, it was done along with the main procedure.
Out of 450 cases, 390 cases belonged to male sterilization (Group I) and 60 cases as an adjunct to prostatectomy (Group II). The age ranged from 25 years to 61 years. The various associated inguinoscrotal pathologies are shown in [Table:1]. The procedure took an average time of 7.5 ? 2.1 minutes. The operative and post-operative complications are shown in [Table:2]. None of the case in this study revealed any type of scrotal or testicular complication. The mean healing duration of vasectomy was 6.06 ? 0.6 days. The delayed follow up of cases revealed no gross complications.
Vasectomy is actually a misnomer but years of use have established it as the name for surgical procedure of interrupting the continuity of vas deferens to prevent the passage of sperms or retrograde passage of bacteria. Vasectomy is the simplest and most effective surgical procedure for permanent male sterilization. In a fast developing country like ours, it is the most frequently performed operation for family welfare programme. Also the vasectomy is much desired procedure along with prostatic surgery to prevent the ascending infection to epidydimus and testis. It is highly desirable that such a common operation should be devoid of any serious complication.
Scrotum is the most preferred site for vasectomy in present era due to easy palpability of vas deferens,,. Various disadvantages and complications associated with scrotal vasectomy required a new site selection for this common operation. Pre-pubic area just lateral to pubic tubercle was selected for vasectomy in this study. Here the deferens as a content of spermatic cord lies superficial and its anatomical position is more or less fixed. The scrotal skin is wrinkled, rugosed and dirty. In Indian rural population where hygiene standards are less maintained, the scrotum provides an unhealthy site for surgery. Further more iodine cannot be applied to scrotal skin. Pre-pubic area is comparatively cleaner, unwrinkled and can be painted with iodine thus ensuring a better sterilized site for vasectomy. Pre-pubic incision is applied just lateral to pubic tubercle and it is virtually bloodless zone. Occasional bleeder may be encountered which can be dealt by crushing or figating. The vas deferens is a fixed structure at pre-pubic area and there is no necessity of holding it between the thumb and the finger. In scrotum it is highly essential to fix the vas before isolation, as it is highly mobile. It is a bit difficult for beginners and requires some experience to become used to it. In family welfare camps where sometimes, large number of cases are encountered, even the experienced surgeons may some times feel cramps, pain or stiffness of fingers. At pre-pubic area such holding of vas is not at all required. The stability of vas makes this approach highly suitable even for the freshers. The avoidance of an assistant to hold the vas and for local anaesthesia, make it highly feasible for camp vasectomies. The retraction of testis towards abdominal wall is common in cold weather, apprehension and sometimes after spirit application. This causes bunching up of scrotal contents and vas isolation becomes difficult in scrotal approach. Pre- pubic site omits this difficulty.
The number of vessels surrounding the vas in scrotum are more, so the chances of operative trauma increases. At the pre-pubic site vessels are less in number, more prominent and can be avoided more easily. It reduces the danger of subsequent haematoma formation. In scrotal vasectomy if haematoma occurs, it soon involves the whole scrotum. A big scrotal swelling causes great psychological and physical harassment of patient and hospitalisation becomes mandatory. In pre-public area any post-operative swelling remains exclusively localised to public are and does not travel to scrotum at all. (See [Figure:2]). The wound of pre-pubic vasectomy is easily closed by a single stitch without the fear of inversion of skin margins. The wound is covered with benzoin seal or band-aid. There is no need of scrotal support as the dissection is purely in the fixed part and scrotum is not touched. In scrotal vasectomy the restriction of testicular movements is compulsory to reduce the pain and other complications,. Avoidance of scrotal support in pre-public vasectomy saves lot of time and also provides a psychological boost to the patient. The free painless movements of scrotum allows the patient to have an early ambulation just after the surgery and to carry out even heavy work. In the immediate post-operative phase all the persons were encouraged to carry out their routine work whereas in scrotal vasectomy some rest and ice fomentation is advised,,. None of the person complained of any dragging pain during hanging of scrotum. All felt a sense of security and comfort in scrotal area.
Minimum early post-operative complications were noticed. Mild cellulitis was noticed in 11 cases and abscess formation in 4 cases. Local abscess formation occurred in two cases each of sterilization and prostatectomy groups. The suppurative phenomenon on was exclusively localised in the pubic area. The scrotum, epidydimus and testis were completely spared (See [Figure:2]). In scrotal vasectomy the infection travels fast to involve the whole of epidydiums testis and scrotum,. Occasionally the scrotum is converted into a bag of pus and even testis has to be sacrificed. All these dreaded complications were completely absent in our study. This is due to different tissue planes, and attachment of fascia scarpa. The infection usually spreads towards abdominal wall.
The ligated knots and tied together cut ends of vas deferens are easily palpable to the patient through the thin coverings of scrotum. This may lead to psychological trauma to the patient and he always remains conscious to the fact that he is vasectomised one. Unfortunate formation of inflammatory granuloma in the scrotum poses again a threat to the patient. The constant pain, mild fever occasional pus discharge and in some cases sinus formation makes the hospitalisation essential. The subclinical granuloma, though painless normally, may become painful in winter season and especially during intercourse. All these problems are eliminated in pre-pubic vasectomy, where the granuloma, if formed is not subjected to hanging movements of scrotum. The tied cut ends of vas are securely buried under the pad of fat of pubic. The completely free hanging scrotum provides no hindrance in post-vasectomy sexual life.
The pre-pubic approach may pose some problem in obese patients. A little bit of patience in separating the thick pad of fat is required. Once the pubic bone is approached, a finger is put in the wound and contents of spermatic cord are rolled to find out vas. Though it may be time consuming, but the associated advantages make the technique highly suitable for obese patients. The scrotal approach is contraindicated in presence of multiple sebaceous cysts, hydrocele, vericocele, dermatitis or inguinal hernia. These may lead to temporary or permanent rejection of the case. The criticism of pre-pubic approach lies in the impression that such persons may again get operated, as the previous nodules could not be felt in the scrotum. A careful delayed follow up of cases revealed prominent bilateral scars, which were, easily appreciable to gross naked eye examination. In another complication, one of the patients of our series had button holing of the peritoneum which was readily detected and repaired. This was probably due to lean thin physique of the patient and over-zealous separation of the tissues. A meticulous dissection towards the pubic tubercle is the key to prevent the damage.
I am highly grateful to Dr CL Paliwal, Chief Medical Officer of Ajmer district for allowing us to publish this work. I extend my gratitude to Shri Priotum Shoring, operation theatre assistant for his nice co-operation.
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