1. EAES Presenter Disclosure Slide
Brij B. Agarwal
Nothing To Disclose

2. Consultant Endoscopic Surgeon
Totally extraperitoneal bilateral varicocoelectomy- anatomical study of collateral veins of left and right varicocoele & their surgical accessibility
Dr. Brij B. Agarwal
Consultant Endoscopic Surgeon
Sir Ganga Ram Hospital
India

3. Varicocele Surgery
Most common surgery for correctable male infertility
Subinguinal microvascular approach is gold standard
Laparoscopic varicocelectomy abandoned
Retroperitoneal approach desirable
Agarwal BB et al, Int J Surg, 2009
ASRM Report, Fertil Steril 2006
Sweeney DD et al. Nat Clin Pract. Urol 2007
Agarwal BB et al, EAES 2009

4. Principles in Varicocele Surgery
Retroperitoneal approach (Paloma’s)
Inguinal / subinguinal
Agarwal BB et al, Int J Surg, 2009
Beutner S et al. Surg Endosc 2007
collaterals
Agarwal BB et al, EAES 2009

5. Pitfalls of Laparoscopic Varicocelectomy
Insult to peritoneal cavity and its contents
Insult from use of energy source
High rate of recurrence
Agarwal BB et al, Int J Surg, 2009
Vallancien G et al. J. Urol 2002
Agarwal BB et al Surg Endosc 2007
Agarwal BB et al, 2007 Surg Endosc.
Agarwal BB et al, EAES 2009

6. Methods Prospective experience.
Infertile couple, Socio-biologically normal female partners, Subnormal semen parameters with clinical varicocele.
> 27 months follow up
No energy sources used / single dose chemoprophylaxis.
“Fast track Module” for surgery /ABCDE- 2 days.
Only Paracetamol used for pain
Agarwal BB et al, EAES 2009

7. Our Technique
Extraperitoneal approach as in TEP inguinal hernia surgery
Preservation of testicular artery
Dissection of collaterals from
High retroperitoneum to
Subinguinal
No use of energy sources
Agarwal BB et al, EAES 2009

8. Watch the video at: endosurgeon.org

9. Results 40 varicocelectomies in 20 patients No technical difficulty
No bleeding
No handicap felt in not using energy sources
Agarwal BB et al, EAES 2009

10. Results Follow up >12 months No recurrence No chronic groin pain
No testicular atrophy
Significant improvement in fertility parameters
Hydroceles in 35%
Resolved on conservative treatment
Agarwal BB et al, EAES 2009

11. Results Collateral were commoner on Left side
Collateral from Left Right
Inferior epigastric vein
Vein to vas
Inguinal canal vessels
Pelvic veins
Subinguinal vessels
Agarwal BB et al, EAES 2009

12. Collateral Veins A - Vas deferns, B -Vein from vein to vas
C -Parallel veins pulled out from inguinal canal
D -Vein from inferior epigastric vein
Agarwal BB et al, EAES 2009

13. Conclusion EVE is an ideal procedure for varicocele in our experience.
It provides access from high reteroperitoneum to sub-inguinal level collaterals
Collateral venous circulation is multilevel on left side
Collaterals are more extensive on left side
Agarwal BB et al, EAES 2009

14. Questions or Comments? Thankyou for your kind attention.
Watch the video at: endosurgeon.org
Thank you Pooja, Krishna Adit & Nayan