Surgical repair remains the most popular form of treatment for varicocele and is usually achieved by open varicocelectomy (retroperitoneal high ligation, inguinal and sub-inguinal ligation). This out of necessity requires a long incision in the groin and the division of muscle fibres. An attractive alternative is laparoscopic varicocelectomy.
Laparoscopic varicocelectomy has the advantage of the surgeon being able to isolate the internal spermatic veins proximally at their point of drainage into the left renal vein. At this level there are only one or two large veins present, hence there are fewer veins to be ligated and divided. In addition, the testicular artery at this level has not yet branched and is often distinctly separate from the internal spermatic veins.
The persistence/recurrence rate following laparoscopic varicocelectomy lies between 6-15%. Failure is usually due to perseveration of the periarterial plexus of fine veins (venae comitantes) that run along with the artery. These veins communicate with larger internal spermatic veins. If left intact they may with time dilate and lead to a recurrence. Another less common cause of failure is the presence of parallel inguinal or retroperitoneal collaterals which can leave the testicle and bypass the ligated retroperitoneal veins rejoining the internal spermatic vein proximal to the site of ligation.
The operating time is in the order of 30-45 mins. Complications have been reported in the literature at a rate of about 8% and have included air embolism, inadvertent arterial division, hydrocele development (fluid around the testicle), bowel injury injury and peritonitis.
Laparoscopic varicocelectomy should only be performed by experienced laparoscopic surgeons
Conventional open varicocelectomy is associated with a wide range in surgical outcomes. Complications are reported in up to a third of patients and include hydroceles, inadvertent arterial ligation and testicular atrophy, injury to the vas deferens, epididymitis, hematoma and wound infection. The recurrence/persistence rate of varicocele is significantly higher at 10-45% than with the laparoscopic approach.