V1593: Robotic-assisted laparoscopic mobilization of the vas deferens for correction of obstructive azoospermia induced by mesh herniorrhaphy
VideoIntroduction and Objectives
Mesh used during bilateral inguinal hernia repair is associated with iatrogenic obstructive azoospermia. The obstruction occurs at the internal inguinal ring, making vasovasostomy challenging. We present the first description of robotic-assisted laparoscopic mobilization of the retroperitoneal vas deferens to facilitate microsurgical vasovasostomy.
This patient with iatrogenic obstructive azoospermia underwent bilateral open inguinal exploration, microsurgical vasotomies, and vasograms which confirmed bilateral obstruction at the level of the internal inguinal ring. Over 50 million sperm with 40% motility were cryopreserved from the bilateral vasotomy sites. The vasa were then transected as proximally as possible, where they entered the mesh plugs. After inserting laparoscopic ports, the robotic mobilization began by incising the peritoneum overlying the vas deferens. Careful attention was paid to manipulating only the tissue adjacent to the vas deferens, so as not to devascularize or cause crush injury to the vas deferens itself. The abdominal vas was dissected as distally a possible, where it became entrapped in the mesh (see image). It was then dissected proximally to the ampulla of the vas. The bedside assistant then passed a clamp through floor of the inguinal canal. The vas deferens was handed to the assistant’s clamp, and the abdominal vas was pulled into the inguinal incision field. The abdominal vas deferens was now in the inguinal canal with plentiful length, enabling an easier, tension free microsurgical multilayer vasovasostomy.
The patient’s total sperm count improved to 95 million with 12% motility 2 months post-operatively.
Robotic assisted laparoscopic retroperitoneal dissection of the vas deferens facilitates mobilization of the vas deferens while preserving vasal blood supply. The increased vasal length obtained, compared to our prior experience with open and pure laparoscopic dissection, allows for an easier, tension free inguinal vasovasostomy.