whereas varicocele before puberty is rare , the prevalence of this disease in adolescence is equivalent to that in the general male population : 12.4 to 16.2% , with an average of 15% .
in addition , the incidence of varicocele in male patients investigated for infertility is approximately 40% .
varicocele can negatively and progressively affect the testicular growth , histology and function resulting in progressive decline in fertility .
fifty percent to 60% of men who have had their varicocele treated show improvement in semen quality . in the last few years
the present study compares the laparoscopic and conventional open methods for high ligation of varicocele .
sixty - five consecutive patients who were referred to the urology department ( group i ) had open varicocelectomy by palomo 's technique .
one hundred and twenty - eight patients ( group ii ) , referred to the general and pediatric surgery departments , had laparoscopic varicocelectomy .
the ages of the patients in group i ranged between 8 and 42 years , with an average of 24.4 years .
those in group ii were between 8 and 39 years , with an average of 21.3 years .
the majority of school age patients were asymptomatic , and the disease was discovered during routine medical check - up . while testicular pain and/or swelling were the main complaint among patients between 15 and 25 years of age , subfertility was the major presentation among those above 25 years of age .
the diagnosis of varicocele was established mainly by clinical examination with the patient in upright position .
the disease was graded according to the criteria published by lion et al . in the majority of cases ,
nine patients in group i ( 13.8% ) and 21 patients in group ii ( 16.4% ) had recurrent disease .
sixty - two patients in group i ( 95.4% ) and 109 patients in group ii ( 85.2% ) had left - sided disease .
bilateral varicocele was present in 3 patients in group i ( 4.6% ) and in 19 patients in group ii ( 14.8% ) ( table 1 ) .
doppler ultrasound scan was done in all cases to confirm the diagnosis and to evaluate the testicular size pre- and postoperatively . for patients with subfertility ,
seminal analysis was done at least twice preoperatively , and then checked every 6 months for 18 to 24 months postoperatively .
the examination included sperm count , the percentage of sperm motility each hour for four hours , and the presence of abnormal forms .
results of semen analysis were evaluated according to the criteria of the world health organization laboratory manual .
all patients in group i had high ligation of the dilated testicular veins by the technique described by palomo in 1969 .
laparoscopic varicocelectomy was performed with the patient in the supine or trendelenburg position ( 20 - 30 degrees head down ) .
a urinary catheter was routinely inserted after the induction of anesthesia to evacuate the bladder .
a veress needle for the creation of pneumoperitoneum was introduced into the abdomen through a supra - umbilical transverse skin incision .
carbon dioxide insufflation was maintained through the veress needle at a rate of 1 - 2 liters per minute , and the intra - abdominal pressure was kept between 11 - 14 mm hg , depending on the patient 's age . after the withdrawal of the veress needle , a 5-mm trocar was inserted through the umbilical incision , connected to the carbon dioxide insufflator , and a 0 or 30 degree laparoscope was introduced into the peritoneal cavity . in all cases ,
the abdominal and pelvic viscera were examined in addition to the spermatic vessels and internal inguinal rings on both sides . for unilateral varicoceles , the working ports consisted of two 5-mm trocars introduced via a stab in the ipsilateral iliac fossa and in the contralateral iliac fossa in the midclavicular lines .
the operator was standing on the contralateral side of the operating table using the working ports , while the assistant surgeon was standing on the ipsilateral side and controlling the laparoscope .
after identifying the spermatic vessels , the overlying peritoneum was caught with a blunt grasper in the ipsilateral port . using a blunt endo - scissors in the contralateral port , a t - shaped incision was made parallel to and lateral to the spermatic vessels .
the vascular bundle was then carefully grasped and dissected approximately 3 - 5 cm from the parietal peritoneum and underlying structures using a blunt endo - scissors or a diathermy hook .
the testicular artery was not always searched for ; this was relatively more difficult in the pediatric age group .
the testicular veins were clipped approximately 3 - 5 cm above the internal inguinal ring and then divided between the clips . at the conclusion of the procedure ,
in group ii , other procedures were concomitantly performed , including right orchidopexy in 14 patients ( 11% ) , repair of right inguinal hernia on 5 patients ( 4% ) and removal of a chronically inflamed appendix in one child ( 0.8% ) . in group
i , the average operative time was 38.5 minutes for unilateral cases and 69.5 minutes for bilateral cases . for laparoscopic varicocelectomy ,
the overall average of the operative time for the unilateral cases was 58.3 minutes and 74.2 minutes for bilateral cases .
the average operative time for the first 20 operations was 69.8 minutes for unilateral operations and 92.5 minutes for bilateral cases . with increasing familiarity with the technique , the timings were gradually reduced in the remaining cases to 42.3 and 71.8 minutes , respectively ( table 2 ) .
while no collateral veins were reported at operation in group i , retropubic collateral channels were identified in 8 patients ( 6.3% ) , and lateral collaterals were found in 22 patients ( 17% ) during laparoscopic varicocelectomy .
all the collateral veins were interrupted laparoscopically using either clipping or diathermy coagulation , according to their sizes .
the testicular artery was detected in 49 patients ( 75.4% ) in group i and in 120 patients ( 93.8% ) in group ii .
three patients ( 2.3% ) had pneumoscrotum , which has spontaneously resolved within 24 - 48 hours . the postoperative hospital stay for patients in group i was 2 - 8 days , with a mean of 3.5 days . in group
ii , the postoperative hospital stay was shorter , 1 to 3 days , with a mean of 1.3 days .
one patient in each group developed wound infection that responded to systemic antibiotics . almost all wound complications in group ii occurred at the site of the umbilical port .
scrotal edema occurred in 11 patients in group i ( 17% ) compared to only 3 patients in group ii ( 2.3% ) .
postoperative wound pain was subjectively evaluated among patients above the age of 12 years , and its intensity was estimated on the basis of the number of narcotic injections administered during the first 24 hours after surgery . while all patients in group i required one or more narcotic injections , 87% of those in group ii did not require any narcotic injection ( table 3 ) .
five children ( 3.9% ) in group ii had mild postoperative shoulder pain , which was gradually resolved in 24 hours .
patients who had open surgery returned to their normal activities after 7 - 14 days , with a mean of 8.9 days compared to 3 - 7 days for those who had laparoscopic varicocelectomy , with a mean of 4.5 days .
ipsilateral hydrocele developed in three patients in each group ( 4.6% and 2.3% respectively ) .
seven patients in group i ( 10.8% ) and five patients in group ii ( 3.9% ) had recurrence of the disease within 6 to 18 months postoperatively .
no testicular atrophy was reported in any case in the study , regardless of whether the testicular artery was clipped or not . this was based on the postoperative seminal parameters and the measurement of testicular size .
seminal analysis was done for 21 patients in group i and 45 patients in group ii . according to the results of the preoperative semen analyses
, the postoperative seminal parameters were classified into :  improved ,   no change ,  or 
improvement of seminal parameters after varicocele ligation was observed in 43% of cases in group i and in 51% of cases in group ii ( table 4 ) .
varicocele has generally been attributed to the absence or incompetence of valves in the internal spermatic veins . however , with the help of spermatic venography , bypassing collateral channels have been found in about 20% of patients with varicocele despite competent venous valves . in the present study ,
the sole indication for surgery in the present study was the presence of varicocele , even when asymptomatic .
this was based on the concept that early correction of varicocele will alter not only the progressive decline in fertility but will also prevent future infertility in younger male patients . the relatively higher rate of reversal of the seminal parameters ( 51% vs 43% ) and the fewer incidences of recurrent varicocele ( 3.9% vs 10.8% ) after laparoscopic varicocelectomy can be attributed to better visualization and access provided by the laparoscopic approach .
the mean operative time of laparoscopic varicocelectomy reported in the present series was similar to that reported by donovan and winfield and tan et al .
technical failures and problems with the laparoscopic instruments constituted the major causes of prolonged operative time for laparoscopic varicocelectomy .
furthermore , adhesions of the bowel to the parietal peritoneum of the groin were found in 19 out of 21 patients with recurrent varicocele after open surgical varicocelectomy .
neither obesity nor the presence of bilateral or recurrent disease was a problem for performing varicocelectomy via laparoscopy .
although laparoscopic varicocelectomy has been performed by many surgeons on a day - surgery basis , the mean hospital stay after laparoscopic varicocelectomy in our study was relatively longer than was anticipated .
almost all our patients prefer to remain in the hospital and do not wish to resume activities until complete pain relief .
additional factors that contributed to prolonged hospital stay were postoperative wound complications and the performance of additional operative procedures , particularly inguinal hernia repair .
the hospital stay after laparoscopic varicocelectomy was not affected by whether the disease was unilateral or bilateral .
similar to other studies , we did not find any significant difference between testicular artery ligation and preservation during varicocelectomy .
laparoscopic varicocelectomy is a minimally invasive procedure that is easy to perform with simple instruments .
not only can the bilateral varicocele be easily dealt with through the same ports , but other procedures , such as hernia repair and orchidopexy , can also be simultaneously performed .
the clear visualization and magnification it provides facilitate control of the affected vessels and enable detection of abnormal collateral channels , one of the major reasons for postoperative recurrence .
compared to the open technique , laparoscopic varicocelectomy has minimal postoperative morbidity , shorter convalescence and a faster return to normal activities .
therefore , we recommend that the laparoscopic technique for varicocele ligation replace the conventional open method .
 the purpose of this study is to determine the relative advantages of laparoscopic varicocelectomy compared to the conventional open high ligation of palomo . 
 we studied 193 patients who presented with varicocele . while 65 patients were treated by open high ligation of the testicular veins , 128 patients had laparoscopic varicocelectomy . 
 in addition to varicocele ligation , 14 patients ( 11% ) had laparoscopy - assisted right orchidopexy , and 5 patients ( 4% ) had laparoscopic repair of concomitant right inguinal hernia . 
 the mean hospital stay was 3.5 days and 1.3 days , respectively , and the recurrence rates were 10.8% and 3.9% , respectively . 
 return to normal activity was significantly earlier in group ii ( mean 4.5 days ) compared to group i ( mean 8.9 days ) . 
 there was no incidence of testicular atrophy in any case in the study , regardless of whether the testicular artery was ligated or preserved during surgery . 
 we conclude that laparoscopic varicocelectomy is safe , effective and minimally invasive . 
 in addition to its better cosmetic results and advantage in case of bilateral disease , it allows excellent exposure and control of the affected vessels . 
 furthermore , the shorter hospital stay and the earlier return to normal activities are very important advantages in recommending this technique as an efficient alternative to the open surgical method . 
INTRODUCTION
PATIENTS AND METHODS
SURGICAL TECHNIQUE
RESULTS
DISCUSSION
CONCLUSIONS