1. Preparation: Before the procedure, the patient should completely shave the scrotum on the anterior and lateral sides. There is no need to shave the pubic area. Cleanse the skin with an antiseptic solution before draping the patient’s genitals so that only the scrotum is exposed (Figure 43-2).

2. Isolation of the vas: The most technically challenging portion of a vasectomy is the isolation of the vas. When performing the lateral approach, grasp the vas by pushing the thumb posteriorly at the midline of the scrotum, then isolate the vas laterally with the finger. Push the vas tubule between the index and third fingers with the thumb, and bring the vas to the surface with a lateral rotation movement. When repositioning the vas more laterally and anteriorly, always keep the thumb and middle finger compressed behind the vas to prevent it from slipping back and out of your grasp (Figure 43-3A). If performing a single midline incision, the hand position is different. The index and third fingers lift the vas to the midline moving lateral to medial, while the thumb holds the vas in position during the clamping process after anesthesia is given (Figure 43-3B). When secured, do not relax your grip until the anesthesia and the vas clamp are applied.