E P I D I D Y M E C T O M Y : AN A L T E R N A T I V E T E C H N I Q U E 13

EPIDIDYMECTOMY : AN ALTERNATIVE TECHNIQUE

BY ASHTON MILLER, F.R.C.S. SURGICAL REGISTRAR, WESTMINSTER HOSPITAL (ALL SAINTS) UROLOGICAL CENTRE.

REMOVAL of an epididymis was first described by Bardenheuer in 1887 in a case with tuberculous infection. As performed by Wildbolz, Zuckerkandl, Marion, Hugh Young, and Thomson-Walker, it consisted of high ligation of the vas through an oblique inguinal incision, the extraction of the cord and testis from the scrotum via the inguinal canal, and the excision of the distal part of the vas and epididymis by dissection from above downwards. With this technique, it is usually difficult to be certain of avoiding damage to the spermatic vessels and there has been a tendency to seek an alternative and safer method.

Heinatz (1934) described an original method by which the epididymis was dis- sected free after opening the tunica vaginalis through a scrota1 incision, and he used a neat manaeuvre to ensure that the spermatic vessels were separated from the vas and kept out of danger. A small incision was made through the tunica albuginea on the medial side of the testis adjacent to the body of the epididymis, a director was inserted and pushed up the cord, and all the layers superficial to it were divided with the scalpel. The director lies within the internal spermatic fascia and the vas and spermatic vessels are preserved deep to it. In the early tuberculous epididymis this method is sound, but if advanced caseation is present there is an obvious disadvantage in opening the tunica albuginea so close to an infected area.

Surraco (1937) has modified the technique so as to avoid this trouble by approaching from the lateral aspect and inserting his director into the sinus of the epididymis and on up the cord in exactly the same tissue plane ; then, however, he cuts through the body of the epididymis between ligatures, and it is felt that this raises a similar objection in that infected tissue may be laid open.

An attempt was made, therefore, to devise a technique by which these disadvantages could be avoided, but in which the approach and maneuvre of Heinatz could be utilized. The operation described below has been evolved, has proved satisfactory in practice, and is now employed by us as a routine.

SURGICAL ANATOMY The Tunica Vaginalis.-Within the dartos, the testis lies covered by three layers

of fascia, the external spermatic, cremasteric, and internal spermatic, each of which is in the form of a pear-shaped bag extending downwards from the tubular neck which surrounds the cord in the region of the external abdominal ring, the three necks lying one within another. Inside the internal spermatic fascia lie the cord and the tunica vaginalis surrounding testis and epididymis. The body of the epididymis lies on the posterolateral aspect of the testis with the head projecting over the upper pole slightly down on to the anterior surface, and the tail reaching to the lower pole (Figs. 4, s>: The visceral tunica vaginalis is reflected from the testis on to the epididymis, which it partly ensheathes : in the region of the head it passes on up the cord for a distance of 2-3 cm. before turning downwards, while from the tail it is reflected directly as the parietal layer (Fig. 6). On the lateral side of the testis there is a pocket formed by an invagination of the tunica as it passes from the testis on to the body of

I4 T H E B R I T I S H J O U R N A L O F U R O L O G Y

the epididymis, called the sinus of the epididymis, which extends upwards deep to the epididymis, so that its limit may be in contact with the tunica on the medial side.

It follows, therefore, that an instrument passed into this pocket and on up the cord will pass through the tunica forming the fundus of the sinus into the space within the internal spermatic fascia containing the neurovascular bundle and the vas.

F ~ G . J.-Posterior aspect of FIG. 5.-Anterior aspect right testis. right testis.

of FIG. 6.-Lateral aspect of right tunica vaginalis (opened).

The Spermatic Cord.-The relationships of the contents of the cord in the scrotum are important, but are not well described. The structures divide themselves into anterior and posterior groups, the former consisting of spermatic artery and veins,

Funicular

Vas

Artery to vas

. Spermatic artery. Veins

Plane of cleavage sought by scissors

FIG. 'I.-Cross-section through right cord in upper part of scrotum.

nerves, and processus vaginalis, and the latter of vas deferens with its artery and veins

At a lower level tI-g vessels of these two groups supply separate regions, the anterior passing to the hilum of the testis and the posterior to the distal parts of the vas and epididymis (Fig. 8).

Arteries of the Cord.-These are three in number, the spermatic artery, the artery to the vas, and the funicular artery. The spermatic artery is a branch of the aorta which passes down within the cord to cross the inner aspect of the epididymis and so to enter the hilum of the testis, giving off lateral and medial branches to the

(Fig. 7).

E P I D I D Y M E C T O M Y : A N A L T E R N A T I V E T E C H N I Q U E 15

tunica albuginea as it does so. At a variable point just above the upper border of the head of the epididymis it gives off two epididymal branches, an anterior one (occasionally absent) to the head, and a posterior one which passes backwards and downwards along the inner aspect of the epididymis to anastomose with the artery to the vas at the lower pole (Fk. 9).

FIG. E.-Cross-section through body of epididymis and hilum of right testis.

The artery to the vas, a branch of the inferior vesical artery, passes along the length of the vas to the tail of the epididymis, up which it ascends to anastomose with the posterior branch of the spermatic artery ; it gives some branches to the lower pole of the testis.

The funicular artery is a small branch of the deep epigastric vessel and supplies only the fascia1 coverings of the cord.

OPERATIVE TECHNIQUE A transverse incision 2 in. long is made

through the scrota1 skin and dartos of the affected side. If a discharging sinus is present, this is included in the incision and the track dissected out. The three spermatic fasciae are divided in the line of the incision, thus displaying the tunica vaginalis, which is opened sufficiently to allow the testis to be evaginated from it. The fasciae are not separated from the tunica, which is turned inside out ; skin and dartos, however, are separ- ated from the external spermatic fascia so as to allow the cord and its coverings above the tunica to be brought into view outside the. wound. With the testis lying on its medial side a pair of straight Mavo scissors are mshed into the

Branch t o .upper pole of epidi- dvmis

Branch to lower pole of epidi- dpmis

FIG. 9.-Diagram of arterial supply of right testis and epididymis seen from behind.

.., sinus of the' epididymis and on up the cord until the points present at a level. above the upper limit of the tunica (Fig. 10). The fasciae overlying the separated scissor points are divided with a scalpel, and the edges retracted ; the spermatic artery can then be seen beneath the scissor blades, and the two branches to the epididymis isolated, ligated, and divided. Keeping the scissors in position, the tail of the epididymis

16 T H E B R I T I S H J O U R N A L O F U R O L O G Y

is picked up and dissected free from the testis, then the head, after cutting the vasa recta ; the body is already separated by the scissors. Those portions of the tunica and overlying fasciae attached to the epididymis are then separated from the remainder as far up as the original incision on to the scissors points, bleeding vessels (branches of the

FIG. 10.-Scissors passed up cord within internal spermatic fascia.

FIG. ll.-Removal of epididymis. with attached portions of fascix, leaving spermatic artery intact.

funicular artery) being picked up with homostats as they are cut. The sole remaining attachment is the vas itself, which is followed as far as possible up the cord before being divided (Fig. 11). A running suture then closes the spermatic fasciae, and the skin and dartos are closed with a small drain.

REFERENCES HEINATZ (1934), Z . Chir., 61, 1729. SURRACO (1937), 3. Urol. med. chir., 44, 311. WILDBOLZ, H. (1924), Handbtich der UrologiZ. ZUCKERKANDL, 0. (1921), Med. Klinik, 5, 124.

Berlin.