Placement of the surgical clip for the epididymal obstruction
Vazoepydidymostomy by Tubule Intussuseption
Sixteen to twenty-one days after the induction of obstruction via a midline skin incision reproductive organs are delivered and examined [6, 7]. When the reproductive organs are exposed, the cauda and corpus of the epididymis are dissected and mobilized. The epididymis can be transected above the level of obstruction (Fig. 5.2) for end-to-end anastomosis or a 2-mm buttonhole opening is made in the epididymal tunic in the dilated cauda epididymis for end-to-side anastomosis. An avascular and clearly visible area should be selected. The vas deferens is then secured to the epididymal tunic next to the selected tubule using two interrupted sutures (Fig. 5.3).
The transection of the epididymis above the level of obstruction
Suturing of the vas deferens to the epididymal tunic next to the selected tubule
End-To-End Technique 
Following transection of the epididymis above the level of obstruction, closure is performed in a two-layer fashion. Three to four evenly spaced 10-0 sutures are used for the mucosal approximation (Fig. 5.4). The outer layer is approximated with 10 to 14 9-0 or 10-0 sutures (Fig. 5.5).
The view of the mucosal approximation
The view of the outer layer approximation
Following a buttonhole opening in the epididymal tunic a dilated epididymal tubule is selected and exposed by dissecting it free from the epididymal tunic.
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Two Double-Armed Suture Transverse Intussusception Vasoepididymostomy 
With a setup as described above two double armed 10-0 sutures are placed perpendicular to the select epididymal tubule and it is opened with microscissors transversely between the two needles (Fig. 5.6). To prevent fluid leakage and tubule collapse the needles are not pulled through the epididymal tubule until the tubular opening is made. The needles were passed through the vasal lumen in inside-out fashion, exiting at four points, and tie sequentially, resulting in intussusception of the epididymal tubule into the vasal lumen (Fig. 5.7). Six to eight 9-0 or 10-0 sutures are used to close outer layer (Fig. 5.8).
Placement of the sutures perpendicular to the select epididymal tubule and planning of the opening hole (two double-armed suture transverse intussusception vasoepididymostomy technique)
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