Varicocelectomy

Varicocelectomy ligates the refluxing internal spermatic (gonadal) veins so that warm, retrograde corporeal blood no longer reaches the testis, improving testicular function. The gonadal veins (running scrotum-to-retroperitoneum) are most prone to reflux and are the ligation target; the vasal (deferential) veins are spared — they do not reflux and become the main venous outflow after repair. Varicocele is the commonest surgically-correctable cause of male infertility, and microsurgical (subinguinal or inguinal) repair is the gold standard — best clinical response and fewest complications. Selection and the infertility work-up are covered in the Male Infertility topic; this page is the operative reference.

Indications and Grading

• Palpate the cord with the patient standing (erect). Repair a palpable varicocele in a man who is infertile with abnormal semen parameters, has testicular hypotrophy, or has pain without another cause. Do not repair a non-palpable (imaging-only) varicocele.
• Repair raises pregnancy rates versus no treatment but defers ART by ≥ 6 months.
• Emerging/relative indications: azoospermia (a 30–40% chance of developing ejaculated sperm after ligation — though the evidence to repair before ART in non-obstructive azoospermia is not definitive) and low testosterone (a 50–100 ng/dL improvement after repair).

Grade	Clinical finding
I	Palpable only during/after Valsalva
II	Palpable on routine exam without Valsalva
III	Visible and palpable

A subclinical (ultrasound-only) varicocele = veins > 3 mm with flow reversal on Valsalva — not an indication for repair.

Choosing the Approach

Four approaches ligate the veins at different levels; the meta-analysis-favoured microsurgical (subinguinal/inguinal) techniques give the best clinical response with the fewest complications.

Approach	Level	Artery	Lymphatics	Notes
Microscopic subinguinal	Below the external ring	Spared	Spared	No muscle cut, but the most veins to ligate; lymphatic-sparing minimises hydrocele
Microscopic inguinal	Internal ring (through external oblique)	Spared	Spared	Easier dissection; ~2–3 venous branches
Retroperitoneal (Palomo)	High, at the pedicle	Often ligated	Bulk-ligated	Pediatric/slender adults; higher hydrocele
Laparoscopic	High (retroperitoneal level)	Spared or bulk	Variable	Best for bilateral cases; misses perforating veins → recurrence

Microsurgical Varicocelectomy (Subinguinal / Inguinal)

Preserve the gonadal artery (a Doppler probe helps — remember ≥ 25% of men have more than one artery) and the lymphatics (vein-sized clear vessels) to minimise atrophy and hydrocele.

Subinguinal

1. Position/incision — supine with slight reverse Trendelenburg to distend the veins; a 2–3 cm transverse incision over the external ring along a Langer line, down to Scarpa's fascia; deliver the subinguinal cord.
2. Isolate the cord — grasp with a Babcock, sweep off the cremaster, encircle with a 1-inch Penrose drain, and clip perforating cremasteric/external-spermatic veins. A tongue depressor in the Penrose gives a platform.
3. Open and inspect — incise the external spermatic fascia under loupes or the operating microscope (6–10×); find the pulsating gonadal artery and the vas "packet" (its perivasal veins are spared).
4. Ligate the veins — dissect and ligate the internal spermatic veins with 4-0 or 2-0 silk (largest first; division optional), ligate the veins investing the artery, and preserve the lymphatics. Have an awake patient Valsalva to reveal missed veins, and ligate in a line perpendicular to the cord to avoid redundant ties.
5. Close — a 0.25% bupivacaine cord block, then Scarpa's fascia and a 4-0 subcuticular skin closure.

Inguinal

Manages the veins at the internal ring: incise the external oblique aponeurosis along its fibres from the external toward the internal ring (avoid the ilioinguinal nerve), encircle the cord with a Penrose, and microsurgically ligate the usual 2–3 branches of the internal spermatic vein plus any cremasteric veins draining to the pudendal vein at the external ring. Reverse-Trendelenburg the patient to distend remaining veins, then close the external oblique with 4-0 absorbable suture (protecting the nerve).

Retroperitoneal and Laparoscopic Approaches

• Retroperitoneal (Palomo / high ligation) — the entire spermatic pedicle, including the gonadal artery, is ligated high (adequate distal collateral makes arterial ligation rarely harmful); favoured in children and slender adults. All three abdominal-wall muscle layers are breached, and because lymphatics are bulk-ligated, hydrocele is more common. Enter the retroperitoneum 3–5 cm above and medial to the inguinal ligament and bulk-ligate the veins proximal to their union with the vas; dilute papaverine can make the artery pulsate if artery-sparing is attempted.
• Laparoscopic — best for bilateral cases; requires general anaesthesia and peritoneal entry (vascular/visceral-injury risk). Because it is a high ligation, perforating external-spermatic veins are missed and can cause recurrence. Identify the gonadal artery early (before manipulation causes spasm), and control the veins with Endoclips (two proximal, two distal) or a bulk clip of the cord excluding the vas.

Postoperative Care and Complications

• Discharge the same day; limit activity 2–4 days after subinguinal repair and 7–10 days for the other approaches. If done for infertility, recheck semen at 3–4 months; the mean time to natural conception is 7–8 months.
• Complications: testicular atrophy (arterial injury — least likely with the high retroperitoneal/laparoscopic approaches, given rich collateral); hydrocele (lymphatic obstruction); a self-limited dull testicular ache for weeks (up to 6 months if perivasal veins were also ligated); recurrence/persistence (a missed vein or anomalous drainage); and vas injury (repair immediately).