Laparoscopic mobilization of the retroperitoneal vas deferens for microscopic inguinal vasovasostomy.

The management of obstructive azoospermia arising from previous inguinal hernia repair represents an uncommon dilemma. Mobilization of an adequate length of abdominal vas to provide a tension-free anastamosis for inguinal vasovasostomy is technically difficult. We report a novel laparoscopic approach to mobilization of the inguinal vas. CASE REPORT A 41-year-old male with a history of combined vasectomy and right polypropylene mesh hernia repair was referred for vasectomy reversal. At the time of the right inguinal hernia repair right inguinal vasectomy and left scrotal vasectomy were performed. At exploration standard 2-layer microscopic vasovasostomy was performed on the left side. On the right sid ea2c m inguinal incision was made at the level of the external ring. The right vas deferens was identified just inferior and medial to the area of the hernia repair and was incised approximately 0.5 cm from the area of the hernia site. Fluid from the testicular aspect of the vas revealed motile sperm. Laparoscopic mobilization of the abdominal aspect of the right vas deferens was initiated with a 12 mm port placed at the umbilicus, the abdomen was insufflated, a 10 mm laparoscope was placed and 2, 12 mm ports were placed in the lower midline and the lateral right lower quadrant. The right vas deferens and testicular vessels were seen coursing into the hernia repair site (fig. 1). The peritoneum overlying the right vas deferens was dissected free, and the vas deferens was mobilized with its blood supply off the pelvic side wall down to the polypropylene mesh. A tunnel was created bluntly for the vas to exit through the transversalis fascia and out through the external inguinal ring. The vas deferens was then transected as it entered the polyprolyene mesh plug and pulled medial to the medial umbilical ligament. A right angle clampwas then p laced inguinally through the transversalis fascia tunnel. The clamp was visualized laparoscopically, and the vas was then transferred to the right angle clamp and pulled through the external ring (fig. 2). Approximately 5 cm vas was mobilized using this technique (55 minutes). A 2-layer inguinal microscopic vasovasostomy was performed. Postoperatively sperm concentration increased from 15 million per ml (1 month) to 42 million per ml (6 months), with increased motility from 1% (1 month) to 30% (6 months). A healthy child was born at 1.5 years postoperatively. Since combined scrotal and inguinal vasovasostomy was performed, success of the inguinal reconstruction cannot be clearly determined. DISCUSSION The success rate for inguinal vasal repair following herniorrhaphy is poorer than that in standard vasectomy reversal cases where scrotal vasovasostomy may be performed, and is likely related to the technical difficulty associated with microsurgical anastomosis in the inguinal canal or other factors related to iatrogenic vasal injury.1, 2 Buch and Woods reported that 5.83 cm additional length can be gained from retroperitoneal dissection of the vas and redirection through the external ring.3 Inguinal and retroperitoneal approaches in patients with inguinal vasal obstruction may require a large incision and extensive dissection, and result in subsequent increased morbidity especially associated with polypropylene mesh. Laparoscopic vasal mobilization theoretically maintains the efficacy of the hernia repair, mini