Laparoscopic Tubal Ligation Technique
- Author: Jessica L Versage, MD; Chief Editor: Christine Isaacs, MD more...
Introduction of the Laparoscope
Place the patient in the dorsal lithotomy position. Follow safe positioning techniques to decrease the risk of nerve injury. If the patient did not void immediately prior to the procedure, drain the bladder with a urinary catheter.
Insert a uterine manipulator of choice. A sponge stick in the posterior vaginal fornix may suffice.
There are multiple options for the surgeon to obtain laparoscopic access to the peritoneal cavity (Veress needle, direct trocar entry, open laparoscopic technique). Regardless of method chosen, injection of 2 mL of 0.5% bupivacaine at the trocar insertion sites can decrease postoperative pain.
Place the laparoscope into the trocar and confirm correct placement in the peritoneal cavity by surveying the anatomy. First, view directly below the trocar site to confirm there is no injury to the omentum or small bowel. Next, view the uterus, ovaries, and fallopian tubes by pushing the uterine manipulator cranially and anteriorly. Inspect the posterior cul-de-sac, the uterosacral ligaments, and the ovarian beds. Next, visualize the appendix, liver, and gallbladder and document normal or abnormal findings.
Follow the fallopian tubes from the uterine cornu to the fimbriae on each side. Identify the round ligament. It is imperative that the fallopian tube is successfully identified.
If using a 10-mm single port operating laparoscope, no additional trocars need to be placed. Otherwise, identify a preferred location for the additional trocar. Suprapubic sites are generally preferred. Identify anatomical landmarks to avoid the bladder and inferior epigastric arteries.
Placement of a total of 5 mL of 0.25% plain bupivacaine topically over both fallopian tubes can decrease postoperative pain. Start at the uterine cornu on each side and move distally toward the fimbriae.
All laparoscopic sterilization techniques avoid the proximal 2 cm of the fallopian tube near the uterus. It is theorized that the proximal 1-2 cm of the fallopian tube is a reservoir for uterine fluid from uterine contractions. Too much direct pressure on this segment may increase the risk of tuboperitoneal fistula formation. The presence of a fistula increases the risk of pregnancy.
Tubal Ligation Technique
Tubal ligation technique varies with the chosen method, as described below.
Unipolar electrocautery was the first method of laparoscopic tubal ligation. Unfortunately, most serious morbidity and mortality of laparoscopic tubal surgical was associated with this procedure (mostly related to the associated thermal injuries, especially bowel injuries). This technique is no longer recommended and has been replaced by bipolar cauterization.
Bipolar electrocautery is one of the older techniques; it has been in use since the early 1970s. Bipolar electrocautery allows for one paddle to act as an energy conductor and the other paddle to be the return for the electrical energy, which causes desiccation in the targeted tissue by removing all the fluid and electrolytes.
The electric current applicator device may be used through a 10-mm operating laparoscope or an additional accessory trocar site. Grasp the fallopian tube so that the entire tube is encompassed by the paddles and gently lift it away from all surrounding structures to avoid accidental thermal damage.
Start in the distal isthmic portion of the tube. Use a cutting waveform with a power output at least 25 W against a 100-V load. This has been shown to cause complete desiccation. Activate the current and continue until there is a complete lack of flow according to the resistance monitor. The resistance meter is very important because visual inspection of the tissue is not reliable in determining if the entire tube has been desiccated. This should be repeated for a total of 3 burns over an area of 3 cm. Do not desiccate closer than 2 cm from the uterine cornu. There is a 1.5- to 3-cm zone of thermal injury with this procedure.
This nonthermal method was introduced by Yoon and colleagues in 1975. The technique uses a 3.6-mm silicone band, with an inner diameter of 1 mm, to cause ischemia and necrosis of approximately 2 cm of the isthmic portion of the fallopian tube. There is barium sulfate in the ring to make it visible on radiography.
Correct placement is important because it takes a few days for full necrosis to occur, and early slippage of the ring may lead to failure. The applicator device used to apply the Falope ring can be used through the 10-mm operating laparoscope or an accessory 7-mm trocar.
Immediately prior to placing the instrument in the port, stretch the band over the ends of the applicator barrel around the smaller sheath, ensuring the ring is not defective. Next, introduce the applicator device into the abdomen and open up the grasping prongs so they are outside of the sheath.
Place one of the prongs on either side beneath the isthmic portion of the fallopian tube so it is in the mesosalpinx, about 3 cm away from the uterine cornu. Gently pull the prongs into the applicator and ensure that they close around the tube as they are being pulled into the sheath; approximately 1.5–2.5 cm of the tube will be pulled in.
It is useful to push the applicator toward the tube at the same time to ensure that there is not too much tension on the fallopian tube. The larger sheath will push the Falope ring over the loop of the tube grasped by the prongs; the ring will then constrict back to its original size.
It is important to perform this last step slowly and not to place too much traction on the fallopian tube. Otherwise, the band can come off completely, encompass only the serosal portion of the tube, cause laceration of the fallopian tube and subsequent bleeding, or cause a complete transection of the tube. If a complete transaction occurs, separate rings may be placed around both ends of the tube, or cauterization may be used.
The spring clip was introduced in 1974. It consists of two Lexan plastic-toothed jaws. The applicator device can be inserted through a 10-mm operating laparoscope or an accessory trocar. It is technically easier using separate trocars on either side because the clip must be placed exactly perpendicular to the tube. A uterine manipulator is extremely helpful in visualizing and straightening the fallopian tube.
The clip should be loaded into the applicator and then introduced into the abdomen in a partially closed position. The spring clip is carefully placed perpendicular to the isthmic portion of the fallopian tube, about 2 cm from the uterus. The lower edge of the clip should be visualized in the mesosalpinx.
The clip may be partially closed to investigate placement. If the placement is incorrect, the clip may be reopened and moved. Once in the correct location, close the hand applicator completely so the clip closes completely and is locked in place. If the clip is incorrectly placed, it cannot be removed, and another clip should be placed.
A literature review by Harrison et al of randomized, double-blind, placebo-controlled studies indicated that the administration of local anesthetic during laparoscopic ring or clip tubal ligation can significantly reduce postoperative pain for up to 8 hours.
The Filshie clip method was approved in 1996 by the US Food and Drug Administration. It involves applying a titanium clip with silicone rubber lining around the fallopian tube. The Filshie clip works by exerting continued pressure on the fallopian tube, causing avascularization for the 3- to 5-mm area it encompasses. The silicone continues this pressure even after necrosis starts and the fallopian tube decreases in size. Fibrosis then occurs, and the clip is peritonealized.
The applicator may be placed though a 10-mm operating laparoscope or a 7- or 8-mm accessory trocar. The Filshie clip applicator is loaded externally with the clip open. To fit it through the port, the clip must be closed partially by compressing the applicator handle halfway; care must be taken to not close the clip completely. Once the end of the applicator is in the abdomen, pressure on the handle should be released so the clip opens.
The uterine manipulator should be used to improve visualization and accuracy by straightening the fallopian tube. The clip should be placed perpendicular to the isthmic portion of the tube, about 2 cm from the uterine cornu, so that it completely encompasses the tube and the lower edge of the jaw can be seen in the mesosalpinx. Tension should be avoided on the fallopian tube during this process.
The clip should then be partially closed by pressing the handle halfway to ensure that it is correctly placed. The clip may be gently twisted to ensure that the tube is completely encompassed. If the clip is incorrectly placed, pressure should be removed from the handle and the clip moved. Care should be taken to not injure the fallopian tube by tearing it when removing the clip.
If the clip is placed correctly, slowly compress the handle completely until blanching is seen in the fallopian tube and the jaws of the clip are clearly seen in the mesosalpinx. Release the clip by relaxing on the handle and carefully pull it away from the fallopian tube.
Pomeroy procedure (partial salpingectomy)
The Pomeroy procedure began being performed with the laparoscope in the late 1990s. It is also referred to as a partial salpingectomy.
A 10-mm operating laparoscope with an accessory trocar port or a 5-mm laparoscope with two lateral 5-mm ports is needed. Two laparoscopic slip knots may be used for this procedure.
When using the Endoloop, insert it through a lateral port. Then, place the loop of suture over the isthmic portion of the fallopian tube. Laparoscopic graspers are then used to gently bring a loop of the fallopian tube through the Endoloop. Make sure a minimum of 1 cm of fallopian tube is brought through. The extraabdominal plastic end of the Endoloop is cracked, and the suture is pulled to tighten the knot. The plastic sheath is then removed.
The other laparoscopic slip knot is a plain-gut Roeder knot. This is introduced through a lateral port and placed over the isthmic portion of the fallopian tube. A grasper is used to pull a loop of the fallopian tube through the knot, and the knot is then tightened down.
For both techniques, laparoscopic scissors are used to cut the suture. The looped portion of the fallopian tube is excised with the laparoscopic scissors. At minimum, a 1-cm segment should be removed to decrease the failure rate. The excised tubal segments may be sent to pathology.
Finishing the Procedure
Perform the procedure on the contralateral tube.
Decrease the intraperitoneal pressure to 5 mm Hg to ensure hemostasis along the fallopian tubes. Remove all the lateral and suprapubic ports under direct supervision. Any bleeding should be addressed and stopped.
Remove the umbilical port.
For trocar sites of 10 mm or more, reapproximate the fascia using a method of the surgeon's choice.
The skin incisions can be closed with Dermabond or an absorbable monofilament suture (4-0).
Remove the uterine manipulator and inspect for any cervical lacerations or bleeding.
Remove the Foley catheter, if placed.
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