How is a no-scalpel vasectomy (NSV) performed?

Updated: Jan 19, 2016
  • Author: M David Stockton, MD, MPH; Chief Editor: Edward David Kim, MD, FACS  more...
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Answer

See the list below:

  • After positioning, the skin is prepared with any number of bacterial surgical scrubs; the preferable choice is chlorhexidine. Povidine-iodine solutions tend to become sticky when dry and make mobilization of the vas difficult, whereas chlorhexidine remains slippery. Gently warming the preparatory solution in a microwave for approximately 10 seconds before application helps to prevent cremasteric muscle contractions and scrotal shortening.

  • Drape the operative site with sterile surgical towels, leaving only the scrotum exposed. Palpation should then be performed to confirm the presence and mobility of both the right and left vas within the scrotum.

  • The 3-finger vas fixation technique of the NSV method is critical to proper application of the surgical instruments. The practitioner’s nondominant hand is first used to manipulate the first vas to an area below the median raphe of the scrotum. This area is located at the juncture of the superior and medial third of the scrotum, along the darkened strip of the median raphe.

  • In this area, a small wheal of 1% lidocaine with epinephrine should be raised to anesthetize the site of instrument application. The subsequent skin blanching from the epinephrine allows for easy identification of the anesthetized area. For more details, see Anesthesia.

  • After the wheal is raised, gauze should be used to gently pinch and massage out the excess lidocaine to assist in applying the ring forceps. Lidocaine with epinephrine should not be used for the deeper vas block technique, so as not to mask any later uncontrolled bleeding of constricted small vessels.

  • The vas is then tensed over the middle finger, using the 3-finger technique, and the vas block is accomplished by advancing a 1.5-inch, 27-gauge needle through the anesthetized skin wheal along the course of the vas and toward the inguinal ring while fixated with the 3 fingers. At the approximate depth of 1-2 inches, administer 2-3 mL of lidocaine 1-2% without epinephrine in the perivasal sheath.

    The 3-finger technique and perivasal block. The 3-finger technique and perivasal block.
  • Before the solution is injected, careful aspiration is important to prevent intravenous injection. After withdrawing the needle, reach across the table with the nondominant hand and bring the second vas underneath the anesthetized skin wheal in a similar fashion. Repeat the same vas block on the opposite vas.

  • After the anesthetic technique is accomplished, bring the first vas underneath the skin wheal using the 3-finger technique.

  • The open ring clamp is then pushed down at a 90° angle over the skin to trap the width of the vas between the ring forceps and the underlying surgeon’s finger. The ring clamp is then closed and locked in place.

  • If excess scrotal skin is palpated around the vas, it can gently be "milked" out by releasing the lock on the ring forceps 1-2 mm at a time without dropping the vas. Care should be taken to assure that the ring forceps are applied at a direct perpendicular angle and that an equal amount of vas can be palpated exiting both sides of the ring.

    Perpendicular application of the ring forceps. Perpendicular application of the ring forceps.
  • Following confirmation of securing the vas, the handles are then lowered and the fingers of the nondominant hand reapplied, using the index finger to stretch the scrotal skin over the arch of the entrapped vas.

  • The dissecting forceps are then opened with the surgeon’s dominant hand; the innermost blade should be used to pierce the scrotal skin directly over the vas.

  • The tine is then directed to a 45° angle to a depth of approximately 3-4 mm, preferably into the center of the vas lumen.

  • The single tine is then withdrawn and the dissecting tines are closed and placed back in the original puncture hole. Then the dissecting tines are forcibly opened to spread the outer scrotal skin and fascial layers down to and exposing the bare vas. Several openings and closings of the dissecting forceps are helpful to ensure all covering layers are stretched, free, and penetrated. Frequently, optimal exposure can be confirmed by a light grayish discoloration of the vas (compared to the surrounding fascial tissue). The stretching should also be approximately twice the width of the vas to allow for extricating of the vas once the ring forceps are released.

    Insertion of sharp dissecting forceps. Insertion of sharp dissecting forceps.
  • After outward exposure of the vas, the outermost tine of the dissecting forceps is used to spear or secure the vas. The handles are then rotated 180°. As the rotation occurs, the ring clamp is gently released by the opposite hand, and the dissecting forceps are raised vertically to pull the vas free of the surrounding fascia and out of the scrotum.

    Rotation and extrication of vas. Rotation and extrication of vas.
  • The ring clamp can then be used to secure the exposed vas outside the scrotum.

  • While holding the ring clamp in the vertical position, a blunt cotton-tipped applicator can be used to separate out and push down surrounding fascia from the loop of exposed vas.

  • The sharp forceps can then be used to penetrate the tissue between the loop of vas and spread it downward to reveal a clean loop. Care must be taken not to stretch or rupture the very small but powerful blood vessels that surround the body of the vas. Light electric cautery can be used to seal any ruptured vessels at this time.

    Stripping of fascia to expose loop of vas. Stripping of fascia to expose loop of vas.
  • Numerous methods of occlusion of the vas can be instituted at this point in the procedure.

    • This author’s technique involves hemi-transecting the vas, threading an electric cautery needle 1 cm into the loop on the prostatic end of the vas, and slowly withdrawing it while applying current. A full-thickness burn injury is not optimal, as this can cause future necrosis and subsequent sloughing of the tip of the cut vas, which can result once again in a patent vas lumen. A progressive burn of the inner lumen of the vas is preferred, leaving the outer vas layer intact.

      Intraluminal cautery. Intraluminal cautery.
    • Multiple studies have shown cautery to be a superior method of vas occlusion that results in a lower failure rate compared to simple suture or clip ligation; [8] however, medical consultations for hematoma or infection were more frequent in the cautery group. The clinical significance of this finding should be balanced against the much higher effectiveness. [9]

  • After cautery, the prostatic vas is then completely transected and allowed to retract.

  • The Allison forceps are then used to pull the fascia over the end of the prostatic vas. The fascia is then secured with a single medium steel handle clip. Fascial interpositioning between the cut vas ends further reduces recannulization rates and sterilization failures. [10]

    Fascial interpositioning with hemoclip. Fascial interpositioning with hemoclip.
  • This author prefers the open end vasectomy, in which the testicular end is not cauterized but is simply allowed to retract into the scrotum once bleeding is controlled. The theoretic benefit in this technique is that the open end method has fewer symptoms of epididymal congestion and low instance of sperm granuloma. The sterilization efficacy rate has proven to be very similar to that of vasectomy techniques in which both ends of the vas are occluded. [11]

  • Following confirmation of which testicle is attached, the vas ends are both released back into the scrotum. The second vas is then brought into position under the original puncture hole, again using the 3-finger technique. In the author’s experience, only a single puncture hole has been required well over 99% of the time, as the vasa are very freely moveable within the scrotum. The single puncture hole cuts down on the trauma to the scrotum considerably by stretching rather than cutting the skin, obviating the need for closing sutures.

  • After the second vas is positioned and secured with the ring forceps under the puncture hole, the procedure described above is carried out on the second vas.

  • After the second vas is released back into the scrotum, the small puncture hole usually contracts to only several millimeters and does not require suturing, stapling, or other closure. Antibiotic ointment is typically applied, as well as fluffed gauze for padding under an athletic supporter.


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