SISS TECHNIQUE of VASECTOMY
VASOLIGATION for SPACING THE CHILDREN
MODIFIED STEINACHE II OPERATION for STERILIZATION &
REJUVENATION SURGERY for STERILE MAN
Various operations performed on the Epididymis and Vas Deferens Include the Vasectomy operation. In this a short length of the Vas Deferens is excised in the scrotum to procure sterility. Mere division Of Vas has been followed by a natural re-union with canalization in human beings and in animal experiments to render this impossible a short segment is resected. In various other conditions like trauma, Vascular-derangements, inflamation and new growths, as much of the Vas is removed with the testicle or epididymis as the primary Lesion demands.
The operation of Vasectomy is being performed by scrotal or inguino-scrotal incision on either side, after infiltration with local anesthesia. Vas Deferens is brought under the skin, is exposed, freed, delivered and then cleared of its coverings to avoid inclusion of the spermatic artery and other structures and grasped with artery forceps. A short segment of about two to two and half centimeter is excised. The cut ends of the Vas Deferens are ligated and droped back. The wound is closed by about two to three stitches on each side.
The author reported SISS Technique for Vasectomy in 1958. As the name suggests, with the technique the operation will need only a single incision in the midline on scrotum and one stitch to close the wound, removable the next day, for bilateral vasectomy. The advantage of this technique is that the procedure is much more simplified and made painless and it offers much better chance of repair of the Vas deferens if and when need arises (through lateral incisions in the undisturbed area) and there are no complications or fears of failures as the Vas is manipulated to the center thus avoiding injury to other structures of the Spermatic Cord.
To make the Sterilization stay temporary for spacing the children, the author suggested Vasoligation, which is followed by natural continuity and canalization, in 1960. The clinical trials in the last few years have come out with very satisfactory and encouraging results.
Division and Ligation of the Vas Deferens is performed as a part of the operation of the epididymectomy, orchidectomy and seminal-vesiculectomy, but it is sometimes carried out independently with the object of checking the spread of infection, i.e. for preventing epididymo-orchitis where deep-seated infection exists.
VESICULOGRAPHY was first described by Belfield (1913). This is now employed mainly for radiography of the seminal vesicle.
For Vesiculography the Vas is delivered through an incision in the scrotum, which is cleared of its coverings so that a neat incision into its lumen, preferably in long axis is made. About 5 c.c. of lipiodol is introduced through a blunted hypodermic needle and radiographs taken.
Repair of the Vas Deferens or VASORRAPEY as it is called, is re-constructive operation performed after a purposeful vasectomy or when the Vas may be accidentally divided in the course of an operation (in the inguino-scrotal region) or if Vas has been torn in an accident.
Various techniques used for Vasorraphy have essentially the same principal, thorough exposure, exact opposition and anastomosis over an internal splint, which may be removable and is transfixed on the wall of the scrotum or a non-removable splint of catgut or silkworm gut. Functional continuity of the Vas can be successfully restored by this operation.
Anastomosis of the Vas Deferens to the rete-testis was performed FOR STERILITY resulting from an epididymitis which had caused permanent obstruction to the escape of spermatozoa from the testicle, only when the Vas is patent at its urethral end and that spermatogenesis is active in the testicle.
Injecting methylene blue in the lumen of the Vas and observing its escape from the urethra can confirm the patency of the Vas. Spermatogenesis active or otherwise can be seen by testicular biopsy. The anastomosis is rendered more simple if combined with a partial epididymectomy. The Vas is divided opposite the globus minor and spilt for half an inch and the open end is then laid upon the rete-testis, which is sacrificed. Interrupted fine catgut sutures are passed between edge of the split-vas and the tunica albuginea of the testicle. The anastomosis is reinforced by scrotal connective tissue.
The operation of EPILIDYNO-VASOTOMY was introduced by Martin in 1902 in which the Vas is anastomosed to the head of epididymis (globus major) where there is fibrosis at the lower end of the epididymis and is the obstructing element. The technique of the operation bears a close resemblance to the description given above. Phadke (1953) described the same operation by the name of Vaso-epididmostomy.
The operation of EPIDIDIMECTOMY is practiced commonly in the tubercular disease. Occasionally, it is required in cystic disease and sometime performed in conjunction with vaso-testicular anastomosis. Depending upon the nature of the disease for which it is performed the same is approached either through a scrotal or inguinal incision.
Ligation of the Vas effrentia - The Steinache II Operation. It was described and practiced by Steinache for rejuvenation. Neihans practiced it for prostatic conditions. Sand (1923), Benjamin (1922), Tietje (1921) practiced it in the Continent and America for rejuvenation. Mathew (1947) in India practiced for rejuvenation and reported that very good results followed.
The operation is performed under local anesthesia. An incision about two inches over the cord in the scrotum opens the tunica vaginalis. The testicle is delivered and a needle threaded with silk, transfixes the base of the digital fossa. The stitch is carried round and falls into the gutter between the head of the epididymis and the upper pole of the testicle and is tightly tied. This includes all the ducts. If no gutter exists a shallow incision is made, allowing the ligature to fall into place without puckering or causing undue tension in the tunica albuginea of the testicle or epididymis.
Author has modified the technique. He ligates where the globus minor meets the Vas Deferens (Modified Steinache II). The results are much better with this author’s modified technique.
The operation aroused enough controversy in the past and it does so even today. And so a peep into the history of the subject will not be out of place.
Experimental Vasectomy dates from eighteen hundred and thirty. As a surgical procedure, it came into use in the latter part of the nineteenth century, as an alternative to castration, when then used to be the treatment for senile enlargement of prostate. This was, however, too severe a measure with very little benefit.
The clinical application of this operation was gradually extended for eugenic purposes. Later, the operation was used for prevention of ascending and descending infections in the genito-urinary tuberculosis and also to prevent the spread of infection from the prostatic-bed after prostatectomy, this is in practice even now. The operation was then employed as a remedy for premature senility and sexual debility. Of late, Vasectomy is being done in normal healthy persons for procuring sterility.
Experimental work and histological studies were mainly concerned with the study of the effects of Vasectomy on the germinal epithelium of the seminiferous tubules. Earliest recorded experimental work in the literature is by Sir Austley Cooper (1830). Thereafter, numerous other workers carried out experimental and histological studies. Gosselin (1947), Brissaud (1880), Griffiths (1894), Simmonds (1921), Bouin and Ancel (1903), Shattock and Seligman (1904), Wallace (1904), Kuntze (1921), Steinache (1921), Tiedje (1921), Wheelon (1921), Sand (1921), Benjamin (1922), Moore and Quick (1924), Oslund (1924) and many more carried out similar studies. The results and observation could be described under three heads: (A) those who found that there was no change in the germinal epithelium but due to the block in the Vas the spermatozoa were being collected in the epididymis and in the stump of Vas, which increased in size; (B) others noticed that there was inactivity and degeneration of the germinal epithelium in the seminiferous tubules; (C) the third led by Steinache were of the opinion and observed that degeneration of the germinal epithelium was followed by proliferation of the interstitial tissue (leydig cells).
In the last few years two such studies were carried out here in India - one by the author in 1954 and another by R. C. Singh in 1958. The author’s study included histological studies in the sterilized animals and clinical studies in operated sterilized men. The histological studies were qualitative in nature. Singh carried out a quantitative study of spermatogenesis after Vasectomy. It is worth noting that none of the studies carried out earlier, since the inception of this subject, were quantative in nature. For accuracy and to observe earliest changes in the seminiferous tubules, of the nature of degeneration or regeneration, the quantitative study was superior.
From the experimental study of the author, it was observed that there is degeneration of the seminiferous tubules, which either is incomplete or temporary in nature, and there was a marked proliferation of the interstitial tissue, following Vasectomy. During the clinical follow up it was observed that improvement in the physical and sexual faculties was reported by most of the operated cases. The clinical improvement in the physical and sexual faculties and the experimentally observed proliferation of the interstitial tissue - to correlate the above two facts a study of the 17 ketesteroids before and after Vasectomy is imperative, and was suggested.
Singh at the end of the experimental work concluded - (a) that there was dilation and distention of the epididymis and the short stub of Vas Deferens, up to a period of 75 days, after which no further distinction takes place. This initial increase was due to the accumulation of the debris of the spermatozoa; (b) size and weight of the testes also showed a progressive increase up to a period of 75 days followed by a decrease up to 120 days due to degenerative changes in the tubules; (c) he further observed that an actual degeneration in the tubules sets in 75 days after Vasectomy. Hyperplasia of the interstitial cell is observed at the same time and the same is very much marked after 120 days; (d) he further observed that animals gained weight after Vasectomy, which becomes marked during the latter stages. He ascribed it to the proliferation of the interstitial cells, which in turn promote the secretion of the testosterone - the sex hormone in men, and facilitate the protein metabolism and nitrogen retention.
Recently, as was suggested earlier by the author himself and encouraged by the results of the modified Steinache II operation, a study has been undertaken for hormonal valuation before and after Vasectomy. The 17 ketesteroids are produced not only by the testes but by suprarenal also. To have an exact assessment of the hormonal activity of the testes, the 17 ket. from the suprarenals is suppressed by administration of Dexamethason (8 mg/day) for three days prior to collection of the twenty-four hours urine for estimating the 17 ketesteroid. The results of the studies so far show that there is an increase in the 17 ketosteroids. Hormones after 20 to 24 weeks of Vasectomy, and more so, when the modified Steinache II technique was employed in the age group above forty.
17 ketesteroids output determination have been made by various workers in the normal healthy subject and in various diseased conditions. Das Gupta and Singh (1956), Friedmann (1954), Nathanson (1951), Oesting and Webster (1938), Patwardhan, Panse & Khanolkar (1957), Pincus (1948), Sanjivi, Friedmann & Thiruvengadan (1952), Ram Chandra, Venkatachalam and Gopalan (1956), Tampan, Ramaswamy (1955) and Zimmermann (1935) having carried out this work at length.
A study of the excretion of 17 ketosteroids. in normal subject was also carried out by Sachdeva and Rawat. They observed that in normal healthy Indian males (between the age of 16 to 40) the values on an average were 11.55; these were bit higher in non-vegetarians than vegetarians. Friedmann-who’s observations were similar to that of Sachdeva and Rawat had pointed that the 17 ketosteroids. output in adult Indian was sufficiently lower than those in the healthy Europeans. Thus, this work, which is no more new, and the values of which can be relied upon, can be made use of, to co-relate the experimentally observed interstitial-tissue hyperplasia following Vasectomy in the experimental animals and the clinically observed improvement in the physical and sexual faculties following modified Steinache II operation.
VASECTOMY to procure sterility in normal healthy subjects is being widely practiced. The study of this subject is. Therefore imperative.
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