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Laparoscopic Tubal Ligation Technique

  • Author: Jessica L Versage, MD; Chief Editor: Christine Isaacs, MD  more...
Updated: Jan 26, 2015

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.[39]

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

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

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.

Falope ring

This nonthermal method was introduced by Yoon and colleagues in 1975.[40] 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.

Spring clip

The spring clip was introduced in 1974.[41] 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.[42]

Filshie clip

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.

Contributor Information and Disclosures

Jessica L Versage, MD Resident Physician, Department of Obstetrics and Gynecology, Mountain Area Health Education Center

Jessica L Versage, MD is a member of the following medical societies: Association of Reproductive Health Professionals

Disclosure: Nothing to disclose.


Arthur T Ollendorff, MD Director of Medical Education, Department of Obstetrics/Gynecology, Mountain Area Health Education Center; Clinical Professor, Department of Obstetrics/Gynecology, University of North Carolina School of Medicine

Arthur T Ollendorff, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, North Carolina Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Christine Isaacs, MD Associate Professor, Department of Obstetrics and Gynecology, Division Head, General Obstetrics and Gynecology, Medical Director of Midwifery Services, Virginia Commonwealth University School of Medicine

Christine Isaacs, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists

Disclosure: Nothing to disclose.



The authors thank everyone at the U.S. Collaborative Review of Sterilization.

  1. Centers for Disease Control and Prevention. National Survey of Family Growth. Available at Accessed: October 12, 2011.

  2. Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol. 1996 Apr. 174(4):1161-8; discussion 1168-70. [Medline].

  3. Sokal D, Gates D, Amatya R, Dominik R. Two randomized controlled trials comparing the tubal ring and filshie clip for tubal sterilization. Fertil Steril. 2000 Sep. 74(3):525-33. [Medline].

  4. Dominik R, Gates D, Sokal D, Cordero M, Lasso de la Vega J, Remes Ruiz A. Two randomized controlled trials comparing the Hulka and Filshie Clips for tubal sterilization. Contraception. 2000 Oct. 62(4):169-75. [Medline].

  5. Peterson HB, Xia Z, Wilcox LS, Tylor LR, Trussell J. Pregnancy after tubal sterilization with bipolar electrocoagulation. U.S. Collaborative Review of Sterilization Working Group. Obstet Gynecol. 1999 Aug. 94(2):163-7. [Medline].

  6. Soderstrom RM, Levy BS, Engel T. Reducing bipolar sterilization failures. Obstet Gynecol. 1989 Jul. 74(1):60-3. [Medline].

  7. Grimes DA. Update on Female Sterilization. The Contraception Report. 1997. 7(13):

  8. Kovacs GT, Krins AJ. Female sterilisations with Filshie clips: what is the risk failure? A retrospective survey of 30,000 applications. J Fam Plann Reprod Health Care. 2002 Jan. 28(1):34-5. [Medline].

  9. Robinson DC, Stewart SK, Reitan RE, Gist RS, Jones GN. Laparoscopic pomeroy tubal ligation: a comparison with tubal cauterization in a teaching hospital. J Reprod Med. 2004 Sep. 49(9):717-20. [Medline].

  10. Murray JE, Hibbert ML, Heth SR, Letterie GS. A technique for laparoscopic pomeroy tubal ligation with endoloop sutures. Obstet Gynecol. 1992 Dec. 80(6):1053-5. [Medline].

  11. Pollack A,. ACOG practice bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 46, September 2003. (Replaces technical bulletin number 222, April 1996). Obstet Gynecol. 2003 Sep. 102(3):647-58. [Medline].

  12. Peterson HB. Sterilization. Obstet Gynecol. 2008 Jan. 111(1):189-203. [Medline].

  13. Rock JA, Jones HW III. TeLinde’s operative gynecology. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2008.

  14. Jamieson DJ, Hillis SD, Duerr A, Marchbanks PA, Costello C, Peterson HB. Complications of interval laparoscopic tubal sterilization: findings from the United States Collaborative Review of Sterilization. Obstet Gynecol. 2000 Dec. 96(6):997-1002. [Medline].

  15. Ryder RM, Vaughan MC. Laparoscopic tubal sterilization. Methods, effectiveness, and sequelae. Obstet Gynecol Clin North Am. 1999 Mar. 26(1):83-97. [Medline].

  16. Yoon IB, Wheeless CR Jr, King TM. A preliminary report on a new laparoscopic sterilization approach: the silicone rubber band technique. Am J Obstet Gynecol. 1974 Sep. 120(1):132-6. [Medline].

  17. Huggins GR, Sondheimer SJ. Complications of female sterilization: immediate and delayed. Fertil Steril. 1984 Mar. 41(3):337-55. [Medline].

  18. Lawrie TA, Nardin JM, Kulier R, Boulvain M. Techniques for the interruption of tubal patency for female sterilisation. Cochrane Database Syst Rev. 2011. (2):CD003034. [Medline].

  19. Peterson HB, DeStefano F, Rubin GL, Greenspan JR, Lee NC, Ory HW. Deaths attributable to tubal sterilization in the United States, 1977 to 1981. Am J Obstet Gynecol. 1983 May 15. 146(2):131-6. [Medline].

  20. Escobedo LG, Peterson HB, Grubb GS, Franks AL. Case-fatality rates for tubal sterilization in U.S. hospitals, 1979 to 1980. Am J Obstet Gynecol. 1989 Jan. 160(1):147-50. [Medline].

  21. Minilaparotomy or laparoscopy for sterilization: a multicenter, multinational randomized study. World Health Organization, Task Force on Female Sterilization, Special Programme of Research, Development and Research Training in Human Reproduction. Am J Obstet Gynecol. 1982 Jul 15. 143(6):645-52. [Medline].

  22. Lok IH, Lo KW, Ng JS, Tsui MH, Yip SK. Spontaneous expulsion of a Filshie clip through the anterior abdominal wall. Gynecol Obstet Invest. 2003. 55(3):183-5. [Medline].

  23. Palanivelu LM, B-Lynch C. Spontaneous urethral extrusion of a Filshie clip. J Obstet Gynaecol. 2007 Oct. 27(7):742. [Medline].

  24. Kale A, Chong YS. Spontaneous vaginal expulsion of a Filshie clip. Ann Acad Med Singapore. 2008 May. 37(5):438-9. [Medline].

  25. Dua RS, Dworkin MJ. Extruded Filshie clip presenting as an ischiorectal abscess. Ann R Coll Surg Engl. 2007 Nov. 89(8):808-9. [Medline].

  26. Bharathan R, Hanson M. Filshie clip torsion presenting as acute abdomen. J Obstet Gynaecol. 2010. 30(8):879-80. [Medline].

  27. Hillis SD, Marchbanks PA, Tylor LR, Peterson HB. Poststerilization regret: findings from the United States Collaborative Review of Sterilization. Obstet Gynecol. 1999 Jun. 93(6):889-95. [Medline].

  28. Curtis KM, Mohllajee AP, Peterson HB. Regret following female sterilization at a young age: a systematic review. Contraception. 2006 Feb. 73(2):205-10. [Medline].

  29. Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. The risk of ectopic pregnancy after tubal sterilization. U.S. Collaborative Review of Sterilization Working Group. N Engl J Med. 1997 Mar 13. 336(11):762-7. [Medline].

  30. Peterson HB, Jeng G, Folger SG, Hillis SA, Marchbanks PA, Wilcox LS. The risk of menstrual abnormalities after tubal sterilization. U.S. Collaborative Review of Sterilization Working Group. N Engl J Med. 2000 Dec 7. 343(23):1681-7. [Medline].

  31. Rulin MC, Davidson AR, Philliber SG, Graves WL, Cushman LF. Long-term effect of tubal sterilization on menstrual indices and pelvic pain. Obstet Gynecol. 1993 Jul. 82(1):118-21. [Medline].

  32. Thranov I, Hertz JB, Kjer JJ, Andresen A, Micic S, Nielsen J. Hormonal and menstrual changes after laparoscopic sterilization by Falope-rings or Filshie-clips. Fertil Steril. 1992 Apr. 57(4):751-5. [Medline].

  33. Rivera R, Gaitan JR, Ruiz R, Hurley DP, Arenas M, Flores C. Menstrual patterns and progesterone circulating levels following different procedures of tubal occlusion. Contraception. 1989 Aug. 40(2):157-69. [Medline].

  34. Gentile GP, Helbig DW, Zacur H, Park T, Lee YJ, Westhoff CL. Hormone levels before and after tubal sterilization. Contraception. 2006 May. 73(5):507-11. [Medline].

  35. Hillis SD, Marchbanks PA, Tylor LR, Peterson HB. Higher hysterectomy risk for sterilized than nonsterilized women: findings from the U.S. Collaborative Review of Sterilization. The U.S. Collaborative Review of Sterilization Working Group. Obstet Gynecol. 1998 Feb. 91(2):241-6. [Medline].

  36. Hillis SD, Marchbanks PA, Tylor LR, Peterson HB. Tubal sterilization and long-term risk of hysterectomy: findings from the United States collaborative review of sterilization. The U.S. Collaborative Review of Sterilization Working Group. Obstet Gynecol. 1997 Apr. 89(4):609-14. [Medline].

  37. Costello C, Hillis SD, Marchbanks PA, Jamieson DJ, Peterson HB,. The effect of interval tubal sterilization on sexual interest and pleasure. Obstet Gynecol. 2002 Sep. 100(3):511-7. [Medline].

  38. MacKay AP, Kieke BA Jr, Koonin LM, Beattie K. Tubal sterilization in the United States, 1994-1996. Fam Plann Perspect. 2001 Jul-Aug. 33(4):161-5. [Medline].

  39. Brennan MC, Ogburn T, Hernandez CJ, Qualls C. Effect of topical bupivacaine on postoperative pain after laparoscopic tubal sterilization with Filshie clips. Am J Obstet Gynecol. 2004 May. 190(5):1411-3. [Medline].

  40. Yoon I, King TM. The laparoscopic falope ring technique. Adv Plan Parent. 1975. 10(3):154-9. [Medline].

  41. Mercer JP, Hulka JF, Fishburne JI, Kumarasamy T, Omran KF. Spring clip tubal sterilization. Obstet Gynecol. 1974 Sep. 44(3):449-54. [Medline].

  42. Harrison MS, DiNapoli MN, Westhoff CL. Reducing postoperative pain after tubal ligation with rings or clips: a systematic review and meta-analysis. Obstet Gynecol. 2014 Jul. 124(1):68-75. [Medline].

  43. Boring CC, Rochat RW, Becerra J. Sterilization regret among Puerto Rican women. Fertil Steril. 1988 Jun. 49(6):973-81. [Medline].

  44. Chan LM, Westhoff CL. Tubal sterilization trends in the United States. Fertil Steril. 2010 Jun. 94(1):1-6. [Medline].

  45. Filshie GM, Casey D, Pogmore JR, Dutton AG, Symonds EM, Peake AB. The titanium/silicone rubber clip for female sterilization. Br J Obstet Gynaecol. 1981 Jun. 88(6):655-62. [Medline].

  46. Ke RW, Portera SG, Bagous W, Lincoln SR. A randomized, double-blinded trial of preemptive analgesia in laparoscopy. Obstet Gynecol. 1998 Dec. 92(6):972-5. [Medline].

  47. Mosher WD, Jones J. Use of contraception in the United States: 1982-2008. Vital Health Stat 23. 2010 Aug. (29):1-44. [Medline].

  48. Oliphant SS, Jones KA, Wang L, Bunker CH, Lowder JL. Trends over time with commonly performed obstetric and gynecologic inpatient procedures. Obstet Gynecol. 2010 Oct. 116(4):926-31. [Medline].

  49. Palter SF, Al-Rejjal R, Berky C. The Endosquid, a new device for laparoscopic Pomeroy tubal ligation. J Am Assoc Gynecol Laparosc. 2001 Aug. 8(3):433-7. [Medline].

  50. Pollack A. ACOG practice bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 46, September 2003. (Replaces technical bulletin number 222, April 1996). Obstet Gynecol. 2003 Sep. 102(3):647-58. [Medline].

  51. Shavell VI, Abdallah ME, Shade GH Jr, Diamond MP, Berman JM. Trends in sterilization since the introduction of Essure hysteroscopic sterilization. J Minim Invasive Gynecol. 2009 Jan-Feb. 16(1):22-7. [Medline].

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