High level ligation of the internal spermatic vein is the main modality for the treatment of varicocele, including open surgery and laparoscopic surgery. In recent years, transumbilical single-port laparoscopic technique (embryonic natural orifice transluminal endoscopic surgery, E-NOTES) is becoming a new choice for the surgical treatment of this disease because of its advantages such as less trauma, faster recovery and better cosmetic effect. We modified E-NOTES surgery and treated 14 patients with varicocele using transumbilical dual-channel laparoscopic technique from March to July 2010 with satisfactory results. The results are reported as follows. 1. Clinical data All 14 cases in this group were inpatients of our hospital. Their ages ranged from 10 to 35 years old, with an average of 22 years old; among them, 4 cases were aged 10-16 years old and 10 cases were aged 19-35 years old. There were 8 cases on the left side (3 cases in pediatric patients), 2 cases on the right side, and 4 cases on both sides (1 case in pediatric patients). The duration of the disease was 2 months to 3 years. Eight cases were seen for scrotal swelling and discomfort, five cases were seen for post-marital infertility, and one case was seen for varicocele (bilateral) found on physical examination. There were 5 cases of degree II and 9 cases of degree III. All patients underwent preoperative color Doppler ultrasonography, and the diameter of the internal spermatic vein was >2.0 mm, and the Valsalva test showed blood reflux. 4 pediatric patients had a 15-20% decrease in testicular volume on the affected side compared to the opposite side. 10 adult patients underwent semen analysis. 2. Equipment and instruments All patients were treated with plain laparoscopes and their instruments: 5mm Trocar (Stryker USA), 5mm 30° laparoscope (Stryker USA); 5mm non-invasive separating forceps (Stryker USA), 5mm knot pusher (Stryker USA); 5mm ultrasonic knife (Ethicon USA). 3.Surgical method General anesthesia. Head low and feet high 15° supine position. A 5-mm incision was made at the left and right lateral margins of the umbilicus, and the skin was incised (without incising the subcutaneous and rectus abdominis sheaths), and a 5-mm Trocar was inserted with a 5-mm 30° laparoscope and operating instruments, respectively. The posterior peritoneum was incised about 2-3 cm above the internal ring opening to reveal and free the spermatic vein, and the spermatic vein was ligated in two passes with a No. 7 silk thread using a knot tied outside the body and pushed into the cavity for tightening, without disconnecting the vessels. In case of bilateral lesions, the opposite side was treated in the same way. The incision was closed with continuous intracutaneous sutures with 5-0 Vicryl thread. 4. Statistical analysis The semen analysis indexes of 10 adult patients before and after surgery were expressed by median, and the statistical analysis was processed by SPSS14.0 software package, and the statistical method was paired sample t-test, and P < 0.05 was considered statistically significant difference. 5. Results All 14 surgeries in this group were successfully completed. There were no significant intraoperative or postoperative complications. No painkillers were needed after surgery, and there was no pneumatization or edema in the scrotum. The patients' scrotal swelling and discomfort were relieved or disappeared, and the varicose spermatic vein masses were reduced or disappeared; the change of testicular volume was not obvious in 4 children; no testicular atrophy on the affected side was found in 10 adult patients, and the results of semen analysis were significantly better than before surgery. The umbilical incision healed well and was obscured by the surrounding folds, and the scar was not obvious. 6. Discussion Varicocele can lead to male infertility. About 40% of adult men with primary infertility and 80% of those with secondary infertility suffer from varicocele. Clinically, they are common in young adults and mostly occur on the left side. However, the incidence of pediatric varicocele has been found to be as high as 8.5% to 19.8% in recent years, and the incidence of bilateral varicocele can reach more than 40% of the disease. Surgery is the most effective and reliable method to treat varicocele and can restore fertility in most patients. All 10 adult patients in our group showed improvement in semen quality after surgery. Since varicocele is a progressive disease, early surgical treatment is also recommended for pediatric patients. In our group of 4 pediatric patients, the postoperative follow-up testicular volume changes were not significant, which was considered to be related to the short follow-up period. Conventional laparoscopic techniques for high level ligation of the internal spermatic vein are mostly three-hole or two-hole methods and require the use of a 10-mm laparoscope. For patients with unilateral lesions, it has been suggested that the trauma is not significantly different from that of conventional open surgery. In recent years, the emergence of laparoendoscopic single-site surgery (LESS) has provided a new idea for minimally invasive treatment of varicocele. Among them, E-NOTES utilizes the umbilical "natural lumen" to perform the surgery, which can obtain the result of no scar on the abdominal wall. We have improved on E-NOTES by performing transumbilical dual-channel laparoscopic high level ligation of the internal spermatic veins, which has the following advantages: first, two 5-mm-long incisions are made at the umbilical rim to place the trocar, which is less traumatic and more cosmetically effective than the E-NOTES procedure, in which 3-4 cm of the umbilical rim is incised to place the special port, especially to reduce the psychological impact of the surgery and the surgical scar on the pediatric population. Second, the distance between the laparoscope and the operating instruments is farther, which effectively reduces the collision between the operating instruments and the laparoscope and improves the efficiency of the operation; Third, the umbilical margin incision does not cut through the subcutaneous and rectus abdominis sheaths, and two 5mm Trocar are placed directly, which effectively avoids air leakage and reduces the increased cost of the operation due to the purchase of special Port; Fourth, the use of silk ligation of the spermatic cord internal vein, which reduces the increased surgical cost due to the use of vascular ligature lock, and also avoids the poor ligation caused by the use of titanium clips, which leads to postoperative recurrence. Of course, there is some difficulty in tying the knot through a single operating channel. To overcome this difficulty, we used the method of ligating the spermatic veins by tying the knot outside the body and pushing it into the lumen for tightening, and the operation time was not prolonged after proficiency, and the shortest unilateral operation time was only 10 min in the late cases of this group. Despite the small number of cases in this group and the short follow-up time, the minimal trauma, faster recovery, good cosmetic results and the absence of perioperative complications fully demonstrated the advantages of transumbilical dual-channel laparoscopic spermatic The safety and feasibility of transumbilical dual-channel laparoscopic high level ligation of the internal spermatic vein, especially for pediatric and bilateral patients, are well demonstrated. In addition, this procedure requires no special equipment, has a short learning curve, and can be used as an "introductory" procedure to E-NOTES technology.