title: Microsurgical subinguinal varicocelectomy in children, adolescents, and adults: surgical anatomy and anatomically justified technique.
abstract: Microsurgical varicocelectomy has become the gold standard in adults  because of low recurrence and postoperative hydrocele rates; it is  increasingly applied in children and adolescents. This review aims to provide  the surgeon with the necessary surgical anatomy of the spermatic cord and with  a step-by-step, anatomically justified description of technique, toward  clearer comprehension and improved application. The anatomic compartments of  the spermatic cord are delineated by the external and internal spermatic  fasciae. Venous drainage of testis-epididymis is accomplished by the internal  spermatic, deferential, and external spermatic (cremasteric) veins. All 3  anastomose at the caudal pole of testis, and then via gubernacular veins with  the posterior scrotal veins. Another anastomosis exists between a cremasteric  branch and anterior scrotal veins, which gives the external pudendal vein.  Subinguinal approach offers access to varicose spermatic veins and  collaterals. Use of surgical microscope offers identification of small veins,  preservation of arteries, lymphatics, and nerves, and appreciation of  spermatic cord fasciae, which permits the development of two surgical planes.  In the surgical plane of internal spermatic vessels, internal spermatic veins  are ligated, whereas the testicular artery and innervation, as well as  lymphatics, are preserved. In the plane of cremasteric vessels and vas,  cremasteric veins are ligated, whereas the cremasteric artery, vas deferens  and its vasculature, lymphatics, and the genital branch of genitofemoral nerve  are preserved. Delivery of the testis to ligate gubernacular veins is at the  discretion of the surgeon. Finally, venous return is effected by deferential  and scrotal veins, or, when gubernacular veins are ligated, by deferential  veins only.
authors.affiliation: Centers for Surgical Anatomy and Technique, Emory University School of Medicine, Atlanta, GA 30322, USA. pmirilas@gmail.com
authors.forename: Petros
authors.initials: P
authors.lastname: Mirilas
authors.forename: Anastasia
authors.initials: A
authors.lastname: Mentessidou
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D004822:Epididymis / Q000033:anatomy & histology / Q000098:blood supply / Q000294:innervation / Q000601:surgery*; D006801:Humans; D008297:Male; D008866:Microsurgery / Q000379:methods*; D013085:Spermatic Cord / Q000098:blood supply / Q000294:innervation / Q000601:surgery*; D013737:Testis / Q000033:anatomy & histology / Q000098:blood supply / Q000294:innervation / Q000601:surgery*; D016896:Treatment Outcome; D013521:Urologic Surgical Procedures, Male / Q000379:methods*; D014646:Varicocele / Q000601:surgery*; D014649:Vas Deferens / Q000033:anatomy & histology / Q000098:blood supply / Q000294:innervation / Q000601:surgery*; D055815:Young Adult