Step IV
Expose the Vas
At this point, you have the right vas deferens isolated in the ringed clamp. You will now create the opening in the scrotal skin, identify the vas deferens, and strip away the surrounding fascia and blood vessels to expose the bare vas deferens.
1. Create an opening in the scrotal skin at the anesthetized median raphe.
a. Note: this is the "no scalpel" part of the procedure. In the traditional technique, a scalpel is used to create the skin opening and gain access to the vas.
b. While still holding the ringed clamp (containing the isolated vas deferens) in your left hand, pick up the dissecting forceps in your right hand.
c. Open the tips of the instrument, and using only one tip, puncture through the skin just beyond the ringed clamp.
In this image: Puncture skin to create opening. Note that only one blade of the dissecting forceps tip is used.
d. Advance the tip a few millimeters down toward the vas deferens, then remove the forceps from the puncture site.
e. Close the tip of the dissecting forceps, then place the tip into the puncture site.
f. Spread the instrument tips about 1cm to create an opening in the skin.
In this image: Spread dissecting forceps tips to widen skin opening.
2. Begin to strip away peri-vas fascia.
a. Identify the vas deferens and its surrounding fascia through the skin opening.
i. Fascia is white and dull appearing, with small blood vessels visible.
b. Puncture the fascia with a single tip of the dissecting forceps, inserting the tip several millimeters into the fascial layer, parallel to the vas deferens, then withdraw the tip.
In this image: Puncture fascia with 1 tip of dissecting forceps.
c. Close the dissecting forceps tip, and insert into the punctured fascia.
d. Spread the tips to gently peel away the fascia from the vas deferens.
In this image: Spread the tips of the dissecting forceps to strip away fascia from the vas.
e. Repeat this step a few times to peel away as much fascia as you can at this time.
f. Note: You will not be able to strip all the fascia away during this step.
3. Reapply the ringed forceps to the vas and its remaining fascia.
a. Grasp the vas with another instrument, such as a toothed forceps, so it is not inadvertently lost when the ringed clamp is removed and reapplied. This method is demonstrated in the picture below.
In this image: Grasping the vas deferens with a toothed forceps before removing and reapplying the ringed clamp.
b. An alternative method for this step of reapplying the ringed clamp to the vas involves the use of the dissecting forceps, and is pictured below.
i. Using the tip of the dissecting forceps, pierce the peri-vasal fascia just inferior to the vas.
ii. Gently elevate the vas with the dissecting forceps and ensure that you have adequate control so that the vas is not inadvertently lost when you remove the ringed clamp.
iii. Remove and reapply the ringed clamp.
In this image: Using the dissecting forceps to elevate and control the vas deferens so that the ringed clamp can be reapplied.
c. After the ringed clamp has been reapplied, elevate the vas through the skin opening.
4. Continue to strip away the remaining fascia from the vas.
a. There are several techniques that can be used to remove the remaining fascia and vessels; your attending physician will demonstrate his or her preferred method.
i. One common method involves inserting the closed tips of the dissecting forceps through the fascia, just inferior to the vas.
