Mirilas Petros, Mentessidou Anastasia
Centers for Surgical Anatomy and Technique, Emory University School of Medicine, Atlanta, GA 30322, USA.
J Androl. 2012 May-Jun;33(3):338-49. doi: 10.2164/jandrol.111.013052. Epub 2011 Aug 11.
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.
显微外科精索静脉结扎术因其复发率和术后鞘膜积液发生率低，已成为成人精索静脉曲张治疗的金标准；该术式在儿童和青少年中的应用也日益增多。本综述旨在为外科医生提供精索必要的手术解剖结构，并对手术技术进行逐步的、基于解剖学的描述，以促进更清晰的理解和更好的应用。精索的解剖间隙由精索外筋膜和精索内筋膜界定。睾丸 - 附睾的静脉引流通过精索内静脉、输精管静脉和精索外（提睾肌）静脉完成。这三条静脉在睾丸尾极处吻合，然后经 gubernacular 静脉与阴囊后静脉相连。提睾肌分支与阴囊前静脉之间还存在另一吻合支，形成阴部外静脉。腹股沟下途径可显露曲张的精索静脉及其属支。使用手术显微镜有助于识别小静脉，保留动脉、淋巴管和神经，并清晰辨认精索筋膜，从而可形成两个手术平面。在精索内血管平面，结扎精索内静脉，保留睾丸动脉、神经及淋巴管。在提睾肌血管和输精管平面，结扎提睾肌静脉，保留提睾肌动脉、输精管及其血管、淋巴管和生殖股神经的生殖支。是否将睾丸提出以结扎 gubernacular 静脉由外科医生自行决定。最后，静脉回流通过输精管静脉和阴囊静脉实现，若结扎 gubernacular 静脉，则仅通过输精管静脉回流。
