**6. Laparoscopy**

Sanchez De Badajoz et al. reported the first laparoscopic varix ligation in 1988 [36, 37].

In 1991, Aaberg reported the first experiences of Palomo performed by laparoscopy with the use of clips [38]. In 1992, Hagood et al. and Donovan et al. [39, 40] reported laparoscopic varicocelectomies with sparing of the spermatic artery. They reported that a laparoscopic camera provided a good level of magnification of the vascular structures. The arteries could readily be visualized after a papaverine drip, and the internal spermatic veins were identified and clipped without difficulty. Donovan reported a mean operating time of 101/153 minutes. As of the early 1990s, laparoscopic surgery has increasingly been utilized by pediatric surgeons [41, 42].

The principle of laparoscopic varicocele ligation is based on the following steps: peritoneal approach; opening a small window on the posterior peritoneum at a distance of 1–2 cm from the inner inguinal ring; isolation of the vessels and their ligation or sealing "en bloc"; or exclusion of the artery and the lymphatics. The procedure is facilitated by the magnifying effect of the laparoscopic lens, which allows for excellent visualization of the structures of the vascular bundle. To achieve

**Figure 1.** *Laparoscopic clips varicocelectomy.*

*Controversies in the Laparoscopic Treatment of Varicocele in the Pediatric Population DOI: http://dx.doi.org/10.5772/intechopen.106793*

**Figure 2.** *Laparoscopic LigaSure™ vessel-sealing varicocelectomy.*

better visualization of the lymphatics, recent findings have shown that intra-dartos/ intra-testicular injection of isosulfan blue is significantly better than the previously described intra-dartos injection, thereby allowing identification of lymphatic vessels in 100% of the cases in our series [43–46].

With time lymphatic/artery sparing technique has taken over from Palomo while still maintaining the same laparoscopic approach. Laparoscopic varicocele ligation can also be performed by SILS. The ligature of the vessels can be achieved by using a simple absorbable thread, by clips (absorbable or not absorbable), or by LigaSure™ [47–50].

A further improvement in terms of success and prevention of complications in laparoscopy of varicocele appears to be the high ligation of the venous plexus above the linea terminalis. This aspect is highly innovative and should be pursued (**Figures 1**–**4**) [51].
