I have recently been looking after a patient who had some very unfortunate complications following a vasectomy.
This is usually a straightforward procedure done under local anaesthetic with a very high success rate and a very low complication rate. There are essentially two ways of carrying out a vasectomy, one being the traditional incision technique and the other being the no scalpel technique ( or Li technique) which is a minimally invasive procedure using only specially adapted sharp forceps to puncture the skin and other special forceps to deliver the vas through a 5mm puncture in the skin; essentially the vasectomy is done by feel rather than by vision through a one and a half to two centimetre cut.
The no scalpel technique is nearly always done via small puncture in the middle of the scrotum, whereas often the traditional technique uses two cuts which then to be stitched up. The no scalpel technique is not a new technique. It has been around for over 30 years. About 70% of vasectomies in the UK and probably more in North America are now carried out using the no scalpel technique. I certainly haven’t used any other option for over 30 years, What’s unusual is that there’s very good evidence that the no scalpel technique is quicker, has a lower risk of pain during the procedure, a quicker return to normal activity and a lower risk of bleeding and chronic pain. Where national bodies recommend a technique, they recommend the no-scalpel technique. The no-scalpel technique requires a few specialized instruments, but these are now available in disposable form, which are not expensive.
My patient, who ended up losing a testicle after a nasty infected hematoma, asked me why people are allowed to do the older technique. I found this difficult to answer. The reason I think surgeons and GPs do not carry out a no-scalpel technique is because they’ve not been trained in it and indeed there are some small tricks which make it easy but can be quite difficult to get the knack of, In my book, that’s not a reason for not offering the technique.
When assessing whether the complications which arose after my patient’s disastrous operation were negligent, I had to tell him that I did not think there was negligence, as all operations on the testicle have a theoretical chance of a testicle being lost and it would not be clear that there was prima facie technical negligence in the way the operation was carried out.
I do, however, feel that there’s a problem with consent here. I think most reasonable patients, they’re told that they’re being operated on using a technique which has been shown to be inferior in many ways to the newer technique would decide not to go ahead with the procedure, but would seek a surgeon who would offer a no scalpel technique Consent doesn’t just include explaining to the patient what you do as a surgeon but it also means you should make the patient fully aware of what alternatives there are.