When working as a team of diversely trained staff, understanding of instrument techniques and functions may differ amongst members. Alignment of training and knowledge in the surgical clinic is crucial to the benefit of patient care and the efficacy of a procedure. During a recent conference attended by various healthcare professionals, doctors and surgeons, a chat amongst specialised vasectomy specialists revealed a particular detail applauded yet unintentionally overlooked by many, regarding the function of Vasectomy ring forceps used in ‘No-scalpel vasectomy’ (NSV).

The complex and intricate procedure of NSV can be performed in various ways, depending on the surgeon and their training. However, a basic requirement of vasectomy includes two central modes of action: delivery and exposure (Labrecque et al, 2004). Both delivery and exposure entail the contribution of model instruments to overcome complications leading to bleeding or crushing of the delicate vas deferens anatomy. Consequently, BlueKit Medical’s single-use vasectomy ring forceps offer an ideal tool for “locating and isolating” the vas deferens with precision (Kumar et al, 2001).

King’s Birthday Vasectomy Festival (Nirapathpongporn, Huber and Krieger, 1990).

On December 5th, 1987, in Bangkok, China, a King’s Birthday Vasectomy Festival was held comparing two vasectomy techniques, performed by experienced vasectomists. The NSV and standard incisional technique were separated into 8 different operating rooms, where on a first come, first serve basis, men underwent the different methods of vasectomy. The results revealed a higher average of procedures performed per day and a significantly lower risk of complication when using the NSV method, compared to the standard incisional method – proving NSV as an alternative method with fewer complications and increased patient acceptability. The results of the study were also consistent with other authors holding similar comparisons with around 81% of any bleeding complications and 90% of any infection complications experienced with the standard method, suggesting higher risks associated with invasive dissection (Nirapathpongporn, Huber and Krieger, 1990). Whilst both techniques are successful methods, consideration of methods that can improve patient outcome by reducing risks, is essential to medical care.

What makes them ideal?

With a 1-2% risk of complications reported in vasectomies (Stormont and Deibert 2023), BlueKit’s ring forceps aim to reduce this percentage even further by offering embedded functions that provide precision and security during the procedure. The specialised instrument features a conforming shape to grasp the vas deferens within its 4mm diameter ring-shaped tip, allowing fixation and isolation of the vas from within the spermatic cord. This effectively removes complications such as cutting or slipping off the vas, commonly experienced with the use of sutures (Stormont and Deibert, 2023). By guaranteeing the vas to be fixed in the optimal position, the instrument facilitates dissection required to achieve occlusion, whilst reducing the risk of excessive movements that may affect the neurovascular supply to the testis (Koslov and Andersson, 2013).

The most enticing feature of the ring forceps includes the incorporation of Dr. Li’s ‘cantilever action’, achieved by the cantilever arms and 3-point ratchet construction. The effectively engineered instrument precludes complications involved in pinching of the deferential arteries surrounding the vas, or compression of the autonomic postganglionic nerve fibres, innervating the vas deferens (Koslov and Andersson, 2013). The embedment of the 3-point ratchet primarily achieves this technique by forming a self-retaining clamp that can allow users to differ pressure levels when grasping the vas, whilst still isolating and fixating with security.

A normal pair of ring forceps close to exert high pressure around the tip, increasing in tightness with each lock of the ratchet. BlueKit Medical’s vasectomy ring forceps’ third ratchet, using Dr. Li’s cantilever action, conversely offer outward opening of the cantilever arms, creating a small gap at the tip to alleviate pressure exerted on the vas deferens.

Instructions for Use

While the NSV procedure is minimally invasive and therefore does not carry a high risk of bleeding, the potential for errors still persists. Understanding how to utilise the ring forceps is important to minimise such risk. Below highlights, in generalised steps, the importance of BlueKit Medical’s specialised ring forceps to perform No-scalpel Vasectomy (EngenderHealth, 2003):

This is a generalised form of instructions to further highlight the importance of this instrument along with the inherent cantilever action. The instrument should only be used by vasectomy surgeons trained in minimally invasive vasectomy techniques. Incorrect use may cause damage to skin.

  • Position placement of ring forceps with palm of hand facing up, for better control;
  • Contact vas deferens at a 90-degrees angle;
  • Open ring forceps over the vas on the scrotum skin, stretching the skin to avoid enclosing excess skin within the ring and thereby not encircling the vas;
  • Apply upward and downwards pressure of forceps to capture the vas within the ring - this step contributes the most complications in stabilising the vas. Fixation of the vas, incorporating the layer of skin, requires a technique that can keep the vas stabilised whilst relieving pressure to avoid scrotal skin damage, allowing full encirclement of the vas. This technique is called the ‘Cantilever Action’.

 

 

 

The Cantilever Action

Developed by Dr Li Shunqiang in China, the NSV technique was engineered to surpass the conventional incisional scalpel technique that exhibited higher rates of adverse events (Cook et al, 2014). BlueKit Medical’s design image of the vasectomy ring forceps in Figure 1 depicts the inclusion of Dr Li Shunqianq’s cantilever action: A) represents lock at first ratchet, creating tightly shut ring hold around the vas, whilst B) represents lock at third ratchet, where cantilever arms create approx. 0.3-0.45mm gap at ring-tip, removing pressure on the vas and surrounding internal and external structures.

Figure 1: BlueKit Medical's Vasectomy Ring Forceps Ratchet Mechanism Design:

 

The detail at the third ratchet lock seems to be missed by practitioners, which is crucial to avoid damage to the structures held within the ring, typically exerted by non-cantilevered forceps. Ultimately, this mechanism assists surgeons to operate safely with minimal complications for their patients.

Other Benefits

Studies indicate that employing the minimally invasive technique results in fewer complications such as bleeding, haematoma formation, infection and long-term pain (Cook et al, 2014). A large contributing factor to these low rates of complications is the combination of optimal training of specialised instruments facilitating the NSV technique and a thorough understanding of their functionality (Johnson and Sandlow, 2017) (Engender, 2003).

A review of clinical trials examining changes in the vas anatomy and contractility response provides substantial evidence for the importance of security and precision during a vasectomy. While one trial indicated that acute ischemia reduces the contractility of the ipsilateral vas deferens, another demonstrated a reduced response from formation of varicose veins within the scrotum (Koslove and Anderrson, 2013). Collectively, these studies underscore the influence of clinical interventions on the functionality of the vas, thereby emphasising the heedful handling of the vas through optimal instruments and training.

Over 75% of vasectomies are performed by urologists in the United States of America with nearly 500,000 procedures conducted annually (Johnson and Sandlow, 2017). The minimally invasive operative technique with inherent reduced complications and a high success rate, when paired with an optimal method of vasal occlusion, can enhance patient satisfaction, supporting the growing demand of contraception and the use of vasectomy as the first method of choice.

Conclusion

Overall, isolation of the vas deferens is achieved with the correct use of the extracutaneous ring forceps. The ring-shaped tip and cantilever action allows for simple control of pressure during the procedure, facilitating grasping of the vas through the skin and fixation of the vas during isolation. To minimise complications during and after surgery, training of the NSV should emphasise understanding of the ‘cantilever action’. Dr. Li Shunqiang further advocates promoting high-quality training of NSV through informative and educational programmes. Therefore, BlueKit Medical aims to contribute to refining vasectomy procedures by promoting the Vasectomy Ring Forceps with ‘Cantilever action’.

With special thanks to Dr. Melanie Atkinson for your advice and support.

REFERENCES

Nirapathpongporn, A., Huber. D.H., and Krieger, J. N. (1990) 'No-scalpal vasectomy at the King's Birthday Vasectomy Festival' The Lancet, 335 pp.894-895. (Accessed 16th July 2024)

EngenderHealth (2003) ‘No-Scalpel Vasectomy- An illustrated Guide for surgeons Third Edition.’ (online). Available at: https://www.vasdoc.org/wp-content/uploads/2020/09/No-Scalpel-Vasectomy-An-Illustrated-Guide-for-Surgeons.pdf (Accessed 20 May 2024)

Johnson, D. and Sandlow, J. I (2017) ‘Vasectomy: tips and tricks’, Translational Andrology and Urology. 6 (4) pp704-709. Available at : https://doi.org/10.21037%2Ftau.2017.07.08

Koslov, D.S. and Andersson, K. E. (2013). ‘Physiological and pharmacological aspects of the vas deferens—an update’. Frontiers in Pharmacology, 4(101). Available at: https://doi.org/10.3389%2Ffphar.2013.00101

Labrecque, M., Dufresne, C., Barone, M.A. and St-Hilaire, K. (2004) ‘Vasectomy surgical techniques: a systematic review.’ BMC Medicine, 2(1). Available at: https://doi.org/10.1186/1741-7015-2-21

Kumar, Kaza, Singh, Singhal and Kumaran (2001) ‘An evaluation of the no-scalpel vasectomy technique’, BJU International 83(3), p. 283-284. Available at: https://doi.org/10.1046/j.1464-410x.1999.00934.x

Resnik, M., Bencina, M., Levicnik, E., Rawat, N., Iglic, A. and Junkar, I. (2020) ‘Strategies for Improving Antimicrobial Properties of Stainless Steel’, materials. 13(13) 2944. Available at: https://doi.org/10.3390%2Fma13132944

Stormont, G. and Deibert, C.M. (2023) Vasectomy. (online). Available at: https://www.ncbi.nlm.nih.gov/books/NBK549904/ (Accessed 8 June 2014).

Cook. L.A, Pun, A., Gallo, M.F., Lopez, L.M. and Van Vliet, H.A. (2014). ‘Scalpel versus no-scalpel incision for vasectomy’. Cochrane Database of Systematic Reviews. Available at: https://doi.org/10.1002%2F14651858.CD004112.pub4