- Incision and exposure
- Transverse inguinal incision made 2 cm above and parallel to the inguinal ligament
- Incise through subcutaneous tissue and Scarpa’s fascia
- Open external oblique aponeurosis in line with fibres
- Retract spermatic cord with a Penrose drain or cord dissector
- Identification and dissection
- Isolate the spermatic cord structures
- Identify and preserve the vas deferens and testicular artery
- Identify dilated pampiniform plexus veins
- Carefully dissect veins away from artery and vas using sharp dissection or vessel loops
- Ligation of veins
- Ligate and divide all visible dilated veins
- Usually 3–6 veins, including cremasteric and external spermatic veins
- Clips or silk ties can be used
- Avoid lymphatic injury to reduce risk of hydrocele
- Closure
- Return cord to inguinal canal
- Close external oblique aponeurosis with absorbable sutures
- Close subcutaneous tissue and skin in layers