Wednesday, April 04, 2007

The Artful Vasectomy

I enjoy doing vasectomies. A well done vasectomy is a beautiful thing: a work of art. Doing a vasectomy well requires a well planned and well orchestrated sequence of events that starts from the moment the man contacts the office until he returns for his follow-up care. Remember, he is nervous and really does not want the procedure. Therefore, I give him every opportunity to contact the office and schedule the vasectomy. The consultation must be low stress and the patient must develop an impression that the procedure is “no big deal” and that you are supremely confident in your ability to perform it and perform it artistically. A well performed vasectomy is painless—truly painless—and quick and easy. The well performed vasectomy is a joy to do. It is your job to convey this to the patient.

Vas day:

Only you and the patient should be in the room. Men don’t like crowds for their vasectomies. Even the presence of one medical assistant in the room will make some men nervous, and a nervous patient translates into a more challenging case. My Dad—a retired periodontist—used to give his patients a glass of Harvey’s Bristol Cream before the procedure. Old school—and wonderful.

For a right handed person, the left vas is approached from the patient’s left and the right vas from the patient’s right.

The best way to immobilize the vas, the most secure way, is to gently pinch it between your thumb and index finger. By this way, only the vas and small amount of perivasal tissue sits in that space and within this space, it is very easy to numb the vas and engage it in the vas clamp.

I use The No Needle Technique that allows for absolutely pain-free delivery of the local to the site without distortion of the anatomy. But if you do not, here is how to inject the local. After injecting the perivasal space with lidocaine, gently message down the bubble of local anesthetic. This serves several functions. It restores distorted anatomy to normal anatomy. It guarantees that the local hits the intended target, the vas and it gives a few extra seconds the lidocaine to take effect.

Never, ever, ever start the vas until the patient is 100% numb. It is at this time in the procedure, the beginning, that the patient is the most nervous, and unnecessarily inflicting pain on him will adversely impact his confidence in you and make your case that much more difficult. It is a wonderful when your patient asks you if you’ve started as you are finishing.

Gently lean the vas clamp over your thumb after you have successfully engaged the vas. This will deliver the vas, and nothing else, directly into optimal position.

Incise the sheath of the vas directly above the vas, then gently user the sharp spreader to free the vas. Now the vas will essentially “jump” into the field.

The rest is easy. Cut, cut, burn, dunk. That is it.

Next time I’ll tell you how I do facial interposition.

The IU.