Scrotal varicoceles are similar in nature to varicose veins of the lower extremity. They are caused by abnormal dilatation and tortuosity of the veins due to valvular dysfunction within the pampiniform plexus. The prevalence is 15–20 % but may be as high as 40 % in the subgroup of infertile men. Over 90 % of varicoceles occur on the left side [1]. The peak age for varicocele presentation is in adolescence, during the time of rapid testicular growth [2]. In addition to an undesirable appearance, often causing distress, it may be the cause of scrotal pain in up to 10 % of patients [3]. More importantly, several studies show that varicoceles may lead to abnormal semen parameters and testicular growth [4]. Surgical correction of the varicocele has been shown to improve semen parameters and inspire catch-up growth of the affected testicle [5–7].

Because approximately 90 % of males with a varicocele appear fertile and men with abnormal semen parameters have achieved pregnancy and resolution of a varicocele, there has been considerable debate regarding if and when surgical correction should occur. This debate is compounded by many pediatric studies that do not include data on semen parameters.

Usually, patients describe the gradual onset of a scrotal lump, commonly described as a “bag of worms.” On examination, the volume of the testes should be similar. Studies have demonstrated that the affected side may have a smaller volume or even be atrophic [8]. Varicoceles are graded on a scale of severity, designated I, II, or III. Grade I implies a small varicocele, palpable during Valsalva. Grade II implies a medium-sized varicocele, palpable at rest. A grade III varicocele is large and visualized at rest. Isolated right-sided varicoceles are rare and should be investigated further for causes of extrinsic compression or mass effect. Varicoceles also should decrease in size in a supine position versus standing. There is debate over the necessity of testicular ultrasound in the initial workup.

Several studies demonstrated a benefit in adolescent varicocelectomy, whereas others advocate watchful waiting [9]. A recent Cochrane review on the subject could not identify a significant benefit to early repair [10]. Thus far, optimal timing for surgery has not been established, and there are limited data suggesting that postponement of surgery affects outcomes. Initial treatment with nonsteroidal anti-inflammatory medications and scrotal support is recommended for patients who have mild discomfort. At this point, the accepted treatment indications in adolescents include pain, discomfort, and a testicular size discrepancy greater than 15–20 % on more than one occasion, although these often are debated [11].

There are several approaches to performing a varicocelectomy, including open inguinal, microscopic inguinal, laparoscopic, and open high (Palomo) ligation, and sclerotherapy. This chapter focuses on the laparoscopic Palomo technique. The goal of this procedure is to take advantage of the good collateral blood flow to the testes and to target the internal spermatic vessels before their descent into the deep inguinal ring.

The patient is asked to void before proceeding to the operative suite to avoid intraoperative catheterization and to keep the bladder out of the surgical field. The patient is placed under general anaesthesia, then prepared and draped in the supine position. An incision is made in or around the umbilicus along a natural skin line. We prefer to use an open Hasson technique and dissect down to the peritoneum using opposing hemostats to present each layer. Once the peritoneum is entered, a 5-mm port is placed in the abdomen and pneumoperitoneal pressure is kept between 10 and 15 mmHg. The lens is placed into the abdomen, and the abdomen is evaluated thoroughly for possible bowel or vessel injury, as well as to assess the anatomy of both inguinal canals (Figs. 33.1, 33.2, 33.3, 33.4, 33.5 and 33.6).