Vasectomy Consent Form

Patient Information

Vasectomy Patient Information Handout


Vasectomy ring clamp (2)

Vasectomy dissector (1)

Mosquito forceps, curved (2 pair)

Mosquito forceps, straight (1 pair)

Iris scissors, straight (1 pair)

Needle driver (1 pair)

Nitrile exam gloves (1 pair)

Sterile gloves (3 pair per provider)

Sterile medium drape (3)

Suture: 4-0 vicryl (2)

Sterile towels (5 towels)

Cautery pen (1)

ChloraPrep 26 ml stick (1)

Foam tape (1 new roll)

Sterile 4x4 gauze (20)

1% lidocaine without epinephrine (1 vial with minimum 20mL remaining)

10 ml syringe (2)

18 gauge 1.5 inch needle (2)

27 gauge 1.5 inch needle (2)

15 Blade disposable scalpel (1)

Exam-room sheet (1 sheet)

Chux pads (2)

Formalin cups (2 cups)

Pre-Procedure Preparation

Room Preparation

Remove any unnecessary items from the room (stool, vitals machine)

Clean the room: wipe down all surfaces and wait the appropriate amount of contact time.  Vacuum the floor.

Ensure the room temperature is set to 70 degrees Fahrenheit.

Turn on the surgical light.

Prepare a surgical tray in sterile fashion:

Suture material, cautery pen, ChloraPrep stick, 10 cc syringes, 18 and 27 gauge needles (1 each)

Have all other equipment available on top of a chux pad, on top of the equipment drawers.

Patient Preparation

Check the patient in, and bring them to an exam room to review and sign the consent form.  Once they have had a chance to ask any questions, bring them into the procedure room.

Make sure a chux pad is on the procedure table.  Have the patient remove pants and underwear, and cover themselves with the sheet.  

Have the patient apply foam tape to penis securing it against the abdomen.

Once provider enters, ensure TIMEOUT occurs.

Put on non-sterile gloves.  Once provider starts, assist by elevating the scrotum while the provider sterilizes the skin with ChloraPrep.  Provider will then place blue towels under and around the region, and finally cover the entire area with a a medium sterile drape to create a sterile field.

Procedure Note


Pre-procedure counseling completed, including risk discussion of bleeding, infection, need for repeat procedure, chronic pain, failure of sterilization.  Timeout completed and documented on paper chart.

An examination of the genitals is normal; both testes normal without tenderness, masses, hydroceles, varicoceles, erythema or swelling.

Shaft normal, meatus normal without discharge. No inguinal hernia noted. No inguinal lymphadenopathy. Anatomic landmarks were confirmed

Under sterile conditions, a 1-2 cm wheal was made at the desired incision site with 1% lidocaine without epinephrine, administered to provide local skin anesthesia. The needle was then advanced through the wheal parallel and adjacent to the _left vas and toward the external inguinal ring. After gentle aspiration to ensure the needle is not in a blood vessel, _ cc of 1% Lidocaine without epinephrine was injected into the external spermatic fascia.

The vas was maneuvered to the desired location, and vas clamp was applied to isolated vas.  The soft tissue was then bluntly dissected with a fine cured hemostat. The left vas was elevated and exposed.  The vas was hemi-transected.  Thermal cautery applied to a 1 cm length inside the lumen of the prosthetic end of the cut vas until blanching occurred.  The vas was then completely transected and facial interposition achieved with a metal clip over the prostatic end and the testicular end. The area was inspected thoroughly and good hemostasis was noted before the vas was reduced back into the scrotum. The procedure was repeated on the right vas. The estimated blood loss was <2 cc.  Petroleum jelly applied over areas of dissection to provide barrier protection.  The patient tolerated the procedure well.

Patient instructed to return 8-12 weeks post procedure for semen analysis, after minimum of 25 ejaculations.  Patient agreed and voiced understanding that sterility not confirmed until lab evaluation shows no sperm.