Step II
Administer Anesthesia
At this point, you have obtained informed consent, positioned the patient, and created the sterile field. You will now administer anesthetic agents.
Note
The information below includes directions for both right- and left-hand dominant operators. Specific directions for left-handed operators are described for the steps on this page only. If you are left-hand dominant, simply use the opposite hand, reverse positioning of fingers, and stand on the opposite side of the patient where indicated in subsequent procedural steps pages.
1. Draw up anesthesia.
2a. For right hand-dominant operators: Isolate the right vas deferens in your left hand, using the three-finger technique.
a. Stand on the patient's right side.
b. Using your left hand, place your thumb and index finger on top of the scrotum, and your middle finger below the scrotum.
i. Your thumb should be located more distal (near the testicle) and your index finger is located more proximal, with the middle finger located between them.
c. With these three fingers, palpate and isolate the vas, using upward pressure from the middle finger and downward pressure from the index finger and thumb.
d. For reference, the vas has the size and consistency of a piece of cooked spaghetti.
In this image: Left hand grasping right vas deferens, using the three-finger technique. Note positioning of thumb, index finger, and middle finger. Also note that this operator is right-hand dominant.
2b. For left-hand dominant operators: Isolate the right vas deferens in your right hand, using the three finger technique.
a. Stand on the patient's left side.
b. Using your right hand, reach across to the right hemi-scrotum, and place your thumb and index finger on top of the scrotum, and your middle finger below the scrotum.
i. Your index finger should be located more distal (near the testicle) and your thumb is located more proximal, with the middle finger located between them.
c. With these three fingers, palpate and isolate the vas, using upward pressure from the middle finger and downward pressure from the index finger and thumb.
d. For reference, the vas has the size and consistency of a piece of cooked spaghetti.
3. With the vas isolated, sweep it towards the median raphe.
4. Inject 1cc of anesthesia into the skin of the scrotum overlying the isolated vas at the median raphe, creating a small skin wheal.
In this image: Administration of anesthetic to skin at median raphe. Note that this physician prefers to administer anesthetic prior to creating the sterile field, an acceptable alternative. Also note that this operator is right-hand dominant.
5. Administer 2cc - 4cc of anesthetic to the vas deferens.
a. Direct the needle down toward the vas, into the vas sheath (but not into the vas itself).
i. The needle should be angled in a cephalad (proximal) fashion.
ii. Continue to advance the needle parallel to the vas, in the sheath, to the full length of the needle.
b. The patient may feel a dull ache that radiates to the ipsilateral groin or lower abdomen. This is normal, and confirms that the needle is positioned correctly.
c. Note that you are administering the anesthetic proximal to where you will actually operate on the vas in subsequent steps. The anesthetic agents cause anesthesia both proximal and distal to where they are administered in the vas, thus ensuring adequate anesthesia in the operative field.
In this image: Injection of anesthetic to right vas deferens. Note that needle is inserted cephalad and parallel to the vas deferens. Also note that the needle is not yet inserted to its full length. This operator is right-hand dominant.
6a. For right-hand dominant operators: Repeat the steps on the left vas deferens.
a. You can isolate the left vas while still standing on the patient's right side, again using your left hand.
b. Reach across the abdomen and grasp the vas with the three finger technique.
i. Now, your index finger will be distal (near the testicle), your thumb proximal, and the middle finger between them.
c. Sweep the vas toward the anesthetized median raphe, and administer anesthetic to the vas.
In this image: Administer anesthesia to left vas deferens. Note positioning of fingers while isolating the left vas using the three finger technique. This operator is right-hand dominant.
6b. For left-hand dominant operators: Repeat the steps on the left vas deferens.
a. You can isolate the left vas while still standing on the patient's left side, again using your right hand.
b. Place your fingers on the left hemi-scroutm and grasp the vas with the three finger technique.
i. Now, your thumb will be distal (near the testicle), your index finger proximal, and the middle finger between them.
c. Sweep the vas toward the anesthetized median raphe, and administer anesthetic to the vas. You have now administered anesthetic to the bilateral vas deferens. The next step is isolation of the vas in the ringed clamp.
Note
Some physicians prefer to administer anesthesia to the bilateral vas deferens at this step, while others prefer to administer only to the right side at this step. They will operate on the right vas deferens, then administer anesthetic to the left vas prior to operating on it.