OT notes · Urology

Varicocelectomy (inguinal / subinguinal / microsurgical)

Usual anaesthesia
Local infiltration with IV sedation if only the cord is delivered; spinal or light general if the testis is delivered
Position
Supine, slight reverse Trendelenburg
Setting
elective

Operative note template for open varicocelectomy by the inguinal, subinguinal or retroperitoneal route, with a filled example for a left inguinal varicocelectomy with magnification in an infertile man.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • hydrocele after surgery
  • injury to the testicular artery and shrinkage of the testis
  • varicocele may persist or come back
  • injury to the vas deferens
  • dull ache in the testis for some weeks
  • scrotal haematoma or wound infection
  • numbness in the groin from nerve injury (inguinal route)
  • semen may not improve and pregnancy is not assured

Pre-operative details for this operation

  1. SideLeftRightBilateral
  2. Clinical grade (standing)Grade I (palpable only with Valsalva)Grade II (palpable without Valsalva)Grade III (visible)
  3. Collapses on lying downYesNo: retroperitoneum imaged (USG / CT), result
  4. IndicationInfertility with abnormal semen analysisTesticular hypotrophyPain with no other causeAzoospermiaLow testosteronefor infertility: duration, semen analysis values, female partner evaluated
  5. Testicular volume, both sidesorchidometer or USG, ml
  6. Scrotal colour Dopplervein diameter, reflux on Valsalva (if done)
  7. Previous inguinal or varicocele surgery / solitary testisthese change the choice of approach

Anaesthesia and position

  1. AnaesthesiaLocal (1% lignocaine + 0.25% bupivacaine) with IV sedationSpinalGeneral
  2. PositionSupine, slight reverse Trendelenburg
  3. MagnificationOperating microscope (magnification)Loupes (magnification)None
  4. Micro-Doppler probeUsedNot available

Operative findings

  1. Number of internal spermatic veins ligatedcount them; also note largest diameter
  2. Testicular arteryidentified by pulsation / Doppler; number of branches; preserved
  3. Lymphaticsidentified and preserved (number)
  4. Vas deferens and vasal vesselsSeen and preservedDilated vasal veins ligated (> 2.5 mm)
  5. External spermatic / cremasteric / gubernacular veinsnumber ligated
  6. Testis and hydrocele (if testis delivered)size, consistency, hydrocele present or not

Procedure (steps)

  1. ApproachSubinguinal (fascia intact)Inguinal (external oblique opened)Retroperitoneal (high)reason for choice
  2. Skin incisionsite and length in cm (external ring marked by invaginating scrotum)
  3. Camper's and Scarpa's fascia dividedsuperficial epigastric vessels retracted or ligated
  4. External oblique aponeurosis opened (inguinal)along fibres from external ring; ilioinguinal nerve identified and protected
  5. Cord delivered and slungBabcock clamp, Penrose drain around cord; nerves kept out of the sling
  6. Testis deliveredYes: external spermatic and gubernacular veins ligatedNo
  7. Spermatic fasciae openedexternal and internal spermatic fascia; cremasteric fibres opened along their length
  8. Artery identifiedpulsation, papaverine irrigation, micro-Doppler; vessel loop
  9. Veins ligated and dividedmethod: 4-0 silk ties / clips / bipolar for tiny veins; vasal veins spared
  10. Cord checked for remaining veinscord run over finger; reverse Trendelenburg to fill missed veins
  11. Local anaesthetic to corddrug and strength (e.g. 0.25% bupivacaine)
  12. Hydrocele (if present)NoneRepaired, method

Closure, drains and dressing

  1. Spermatic fasciae.g. 2 to 3 interrupted 5-0 polyglactin 910
  2. External oblique aponeurosis (if opened)continuous absorbable, size; ilioinguinal nerve not caught
  3. Scarpa's fasciainterrupted absorbable
  4. SkinSubcuticular 4-0 absorbableInterrupted
  5. DrainNoneScrotal Penrose (if hydrocele excised)
  6. Scrotal supportApplied

Specimens and implants

  1. SpecimenNoneHydrocele sac for HPETesticular biopsy (separate consent)
  2. ImplantsNoneLigating clips: number and size

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Scrotal supportscrotal support with fluffed gauze
  2. Watch for scrotal swellinginform if the scrotum swells or bruises rapidly (haematoma)
  3. Analgesiadrug, dose and frequency as on the drug chart
  4. Dischargeusually on the day of surgery
  5. Activitylimit for 2 to 4 days after subinguinal and 7 to 10 days after inguinal or retroperitoneal surgery
  6. Wound reviewdate; absorbable subcuticular needs no removal
  7. Semen analysisat 3 to 4 months if done for infertility
  8. Follow-up examinationfor hydrocele, testis size and recurrence

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. A.M., 29 years, married 3 years with primary infertility. Left grade III varicocele that collapses on lying down. Two semen analyses show oligoasthenozoospermia. Wife evaluated by gynaecology, no female factor found.

Case details

Date: 20/05/2026. Elective left inguinal varicocelectomy. OT 1.

In OT 08:30. Spinal given 08:40. Skin incision 08:55. Closure completed 10:05.

Surgeon: Dr A. (2nd-year resident, Urology). Assistant: Dr B. Consultant: Dr C., scrubbed.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: palpable left varicocele, grade III, with abnormal semen analysis and couple infertility.

Semen analysis (two samples, 4 weeks apart): count 9 and 11 million/ml, progressive motility 22% and 25%.

Testicular volume by orchidometer: right 18 ml, left 15 ml. Scrotal Doppler: left pampiniform vein 3.8 mm with reflux on Valsalva. No previous groin surgery.

Consent: general, procedure-specific and anaesthesia consent in Hindi. Explained hydrocele, artery injury and testicular shrinkage, recurrence, and that pregnancy is not assured.

Left side marked. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 08:35.

Anaesthesia and position

Spinal anaesthesia. Supine with slight reverse Trendelenburg. Parts painted with povidone-iodine from umbilicus to mid-thigh including scrotum and draped.

Magnification: loupes 3.5x. Micro-Doppler not available.

Procedure

External ring marked by invaginating the scrotum. 3 cm oblique incision from the external ring along the line of the inguinal canal.

Camper's and Scarpa's fascia divided with cautery. Superficial epigastric vein clamped, divided and ligated.

External oblique aponeurosis opened along its fibres from the external ring. Ilioinguinal nerve identified and kept out of the way.

Cord lifted with a Babcock clamp and slung with a Penrose drain. Testis not delivered.

Cremasteric fibres and internal spermatic fascia opened. Vas deferens with its vessels swept aside and kept out of the dissection.

Findings: 4 dilated internal spermatic veins, largest about 4 mm. Testicular artery seen pulsating after papaverine irrigation, single trunk, looped and preserved. Three lymphatics seen and preserved. One cremasteric vein at the external ring.

Each of the 4 internal spermatic veins and the cremasteric vein doubly ligated with 4-0 silk and divided.

Table tilted further head up. Cord run over the finger and floor of the canal checked: one more small vein found and ligated. Artery still pulsating at the end.

Proximal cord infiltrated with 5 ml of 0.25% bupivacaine.

Closure

Penrose removed, cord returned to its bed. External oblique aponeurosis closed with continuous 3-0 polyglactin 910 (Vicryl), ilioinguinal nerve not caught.

Scarpa's fascia closed with interrupted 3-0 Vicryl. Skin closed with subcuticular 4-0 poliglecaprone 25 (Monocryl). No drain.

Scrotal support applied with fluffed gauze.

Specimens and implants

No specimen. No clips or implants.

End of procedure

Estimated blood loss 20 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse. WHO sign out done.

No intra-operative complications. Vas deferens intact.

Shifted to post-operative ward in stable condition. Pulse 76/min, BP 122/76 mmHg.

Post-op orders

Pulse and BP 4-hourly. Check scrotum for swelling at each round.

Oral fluids after 4 hours, normal diet in the evening.

Analgesia as on drug chart.

Discharge on POD 1 if comfortable. Scrotal support for 1 week.

Avoid heavy work for 7 to 10 days.

Wound check in OPD on day 7. Semen analysis at 3 months.

Signature

Dr A., JR-2, Urology. Reg. no. ________. 20/05/2026, 10:20.

Must document for this operation

  • The approach used (subinguinal, inguinal or retroperitoneal) and whether magnification was used. Recurrence and hydrocele rates differ by approach, and a surgeon operating on a recurrence needs to know where the first ligation was done.
  • How the testicular artery was identified, and that it was preserved. If the testis shrinks later, the note is the only record of whether the artery was seen and kept.
  • Number of veins ligated and the check for missed veins. A missed vein is a common cause of recurrence, so the count helps judge a later recurrence.
  • That the vas deferens and vasal veins were seen and spared. The vasal veins drain the testis after ligation, and vas injury matters to a man being treated for infertility.
  • Lymphatics preserved. Lymphatic ligation causes post-operative hydrocele, which is the most common complication.
  • The pre-op semen analysis and testicular volume. These are the baseline against which the 3 to 4 month result is judged.

Common mistakes in these notes

  • Writing 'varicocele ligated' with no approach, vein count or artery status.
  • Not recording the side, or recording it only on the consent form.
  • Leaving out whether the testis was delivered.
  • Not writing the follow-up semen analysis date in the post-op plan.
  • No mention of the ilioinguinal nerve when the external oblique was opened.

Indian practice and paperwork

  • NABH expects the operative note to be written before the patient is moved out of recovery, and the post-op care to follow a written plan. This applies to day-care cases too. (NABH 5th ed., COP.14(e) and (f))
  • Consent must explain the procedure, risks, benefits, alternatives (for example radiological embolisation) and who will operate, in a language the patient understands. (NABH 5th ed., PRE.4(c))

Sources

  • Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2026, Ch 108, Varicocele ligation (Turek PJ), pp. 869-874.
  • Keane TE, Graham SD Jr, eds. Glenn's Urologic Surgery. 8th ed. Wolters Kluwer; 2016, Ch 53, Microsurgical varicocelectomy (Goldstein M), e-book PDF pp. 818-829.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV adult (3 g if 120 kg or more), started within 60 min before incision. Table 2, urologic, clean without entry into urinary tract: cefazolin. www.ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.pdf

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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