A varicocele is an abnormal dilatation and tortuosity of the veins of the pampiniform plexus within the spermatic cord. It is one of the most common surgically correctable causes of male infertility, affecting nearly 15% of the general male population and up to 40% of men presenting with primary infertility. Varicoceles are more common on the left side due to the anatomical drainage of the left testicular vein into the left renal vein, which creates higher venous pressure.

The preferred treatment for symptomatic or infertility-associated varicocele is surgical ligation of the dilated veins while preserving the testicular artery and lymphatics. Among the various surgical techniques available, laparoscopic varicocelectomy has emerged as a minimally invasive and effective approach, providing excellent visualization, fewer complications, and quicker recovery.

Understanding Varicocele

Pathophysiology:
Varicocele results from incompetent or absent venous valves in the internal spermatic vein, leading to retrograde blood flow and venous hypertension. This causes increased scrotal temperature, hypoxia, and oxidative stress, all of which impair spermatogenesis.

Clinical features:

Dull aching scrotal pain or heaviness, often worsening with prolonged standing

Visible or palpable “bag of worms” appearance in the scrotum

Testicular atrophy, especially in adolescents

Infertility due to abnormal sperm count, motility, or morphology

Diagnosis:

Physical examination is the gold standard. Varicoceles are graded I to III based on palpability and visibility.

Doppler ultrasonography confirms reflux and vein dilatation.

Semen analysis helps assess the impact on fertility.

Indications for Surgery

Not all varicoceles require surgery. Laparoscopic varicocelectomy is indicated when:

Infertility with abnormal semen parameters

Symptomatic varicocele causing persistent pain or discomfort

Testicular atrophy in adolescents

Bilateral varicocele requiring treatment

Why Laparoscopic Varicocelectomy?

Traditional methods include open retroperitoneal (Palomo), inguinal (Ivanissevich), or microsurgical subinguinal approaches. However, laparoscopic surgery provides distinct advantages:

Magnified view of the spermatic cord structures ensures precise dissection.

Minimally invasive with small incisions and less postoperative pain.

Bilateral varicocele correction possible through the same port placement.

Short hospital stay and faster return to normal activities.

Low recurrence rates when performed with proper technique.

Surgical Technique
Patient Preparation

General anesthesia is administered.

The patient is placed in the supine position with slight Trendelenburg tilt.

A urinary catheter may be inserted for bladder decompression.

Port Placement

A 10 mm umbilical port is inserted for the laparoscope.

Two additional 5 mm working ports are placed in the lower abdomen, usually at the lateral borders of the rectus muscle.

Identification of Spermatic Vessels

The peritoneum over the internal spermatic vessels is incised.

The dilated internal spermatic veins are exposed and carefully dissected.

The testicular artery and lymphatic channels are identified and preserved to avoid testicular atrophy and hydrocele.

Ligation of Veins

The dilated veins are clipped or coagulated using bipolar cautery or vessel-sealing devices.

Multiple veins are ligated to reduce recurrence risk.

Closure

The peritoneum is closed to prevent adhesions.

Ports are removed, and incisions are closed with absorbable sutures.

Postoperative Care

Pain Management: Mild analgesics are usually sufficient.

Hospital Stay: Most patients are discharged within 24 hours.

Activity: Light activities are resumed in 2–3 days; strenuous exercise is avoided for 2–3 weeks.

Follow-up: Patients are reviewed for wound healing and later for semen analysis to assess improvement in fertility.

Outcomes and Success Rates

Laparoscopic varicocelectomy provides excellent results with minimal morbidity.

Pregnancy rates: Improve significantly within 6–12 months after surgery.

Semen quality: Marked improvement in sperm count, motility, and morphology.

Complication rates: Low, with rare occurrences of hydrocele (due to lymphatic injury) or recurrence.

Bilateral correction: Easily performed in the same sitting, an advantage over open techniques.

Challenges and Limitations

Requires general anesthesia and advanced laparoscopic skills.

Slightly higher cost compared to open techniques.

Risk of arterial injury if meticulous dissection is not done.

Recurrence, though rare, can occur if smaller collateral veins are missed.

Despite these, laparoscopic varicocelectomy remains one of the most effective options, especially in centers with experienced laparoscopic surgeons.

Conclusion

Laparoscopic varicocelectomy is a safe, effective, and minimally invasive treatment for varicocele, particularly beneficial for men struggling with infertility or chronic scrotal discomfort. By offering magnified visualization, precise vessel ligation, and quicker recovery, it has become a preferred surgical technique worldwide.

At advanced institutions such as World Laparoscopy Hospital, under the guidance of skilled surgeons like Dr. R. K. Mishra, laparoscopic varicocelectomy is performed with high success rates, restoring fertility potential and improving quality of life for affected men.