Preoperative preparation: Following medical conditions must be ruled out -
  1. Local infection—including scrotal skin infection, active sexually transmitted infection (STI), balanitis, epididymitis, or orchitis
  2. Previous scrotal injury
  3. Systemic infection or gastroenteritis
  4. Large varicocele
  5. Large hydrocele
  6. Filariasis; elephantiasis
  7. Local pathological condition (e.g., intrascrotal mass, cryptorchidism, or inguinal hernia)
  8. Bleeding disorders
  9. Diabetes
  10. AIDS
Requirements: Warm room temperature to relax the scrotum - The temperature of the operating room should be at least 70 to 80 degrees F (approximately 20 to 25 degrees C)

Instruments:
  1. Ringed clamp
  2. Dissecting forceps
  3. Straight scissors
Supplies:
  1. Scissors for scrotal hair clipping
  2. Sterile gloves
  3. Antiseptic solution for cleaning the operative area
  4. Sterile drapes
  5. 10-cc syringe with a 1 & 1⁄2-inch, 25- or 27-gauge needle
  6. 1% or 2% lidocaine without epinephrine
  7. Supplies for vasal occlusion according to the surgeon’s preference (examples: a cautery unit; chromic catgut or nonabsorbable silk or cotton for ligation)
  8. Sterile gauze
  9. Adhesive tape or Band-Aid for dressing the wound
Anesthesia: 
  1. After making the superficial skin wheal, advance the needle parallel to the vas within the external spermatic fascial sheath toward the inguinal ring.
  2. Advance the full length of the needle, 1 & 1⁄2 inches, without releasing any of the anesthetic. Gently aspirate to ascertain that the needle is not in a blood vessel.
  3. Without withdrawing the syringe, slowly inject 2 to 5 cc (depending on concentration) of lidocaine within the external spermatic fascial sheath around the vas deferens.
  4. When the needle is in proper position and the injection is performed inside the external spermatic fascia, there is no resistance to the injection.
  5. Epinephrine is not recommended because it contracts the blood vessels and results in less apparent bleeding at the time of surgery
  6. The maximum individual dose of lidocaine without epinephrine should not exceed 4.5 mg/kg (2 mg/lb) of body weight.
Procedure:

1. Apply ringed clamp to scrotal skin: Using the three-finger technique, tightly stretch the skin overlying the vas. Apply the ringed clamp, with the shaft at a 90-degree angle perpendicular to the vas.

2. Elevate the underlying vas: While the ringed clamp is still grasping the scrotal skin and the underlying right vas, transfer the instrument to your left hand. Then lower the handles of the ringed clamp, causing a bend in the vas.

3. Puncture the scrotal skin:
  • Midway between the top of the testes and the base of the penis
  • Hold the dissecting forceps in the right hand, points curved downward, in preparation for puncturing the vas. Hold the instrument so that there is a 45-degree angle between the closed tips of the forceps and the lumen. Then open the forceps; using only the medial blade of the forceps, pierce the scrotal skin just superior to the upper edge of the ringed forceps.
  • Gently open the tips of the dissecting forceps transversely across the vas, to create a skin opening twice the diameter of the vas.
 4. Isolate the vas: The vas and surrounding tissue may then be elevated through the incision. After further blunt dissection, the fibrous layer surrounding the vas is incised longitudinally. Now fully isolated, the vas is ready for division.

5. Manage the vas:
  • Ligate the vas at 2 sites or use electrocautery
  • Remove the segment between two vasal ends: Removal of at least 15 mm is recommended to prevent the risk of recanalization
6. Procedure must be repeated at the contralateral side as well

7. Clean the wound and close with tapes

8. Scrotal support

No Scalpel Vasectomy (NSV) - Video

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