Salpingostomy and Salpingectomy
- Author: Molina B Dayal, MD, MPH; Chief Editor: Michel E Rivlin, MD more...
Salpingectomy is the surgical removal of a fallopian tube. Salpingectomy is different from salpingostomy (also called neosalpingostomy). Salpingostomy is the creation of an opening into the fallopian tube, but the tube itself is not removed in this procedure.
The term fimbrioplasty is often used instead of salpingostomy (ie, simply opening the fallopian tube) because salpingostomy does not address the important role of the fimbriae. Reconstruction that preserves the delicate fimbriae is important for fertility outcomes. The purpose of fimbrioplasty is to open the obstructed fallopian tube and salvage enough function of the fimbriae to allow successful entrapment and transportation of the oocyte.
In vitro fertilization (IVF) is often used to treat infertility caused by tubal disease. IVF is the only treatment available for severely damaged, inoperable fallopian tubes and for situations in which tubal disease is concurrent with another fertility factor. However, reconstructive tubal surgery, such as salpingostomy and salpingectomy, should be considered in select individuals.
Distal tubal obstruction is found to be the culprit of tubal disease in the majority of cases. Various techniques of treating or bypassing tubal disease include either open or laparoscopic surgery, namely salpingectomy or salpingostomy, or assisted reproductive techniques. Fimbrioplasty is performed for patients who have patent fallopian tubes, whereas salpingostomy is performed with occluded tubes. Many times, patients have pelvic adhesions and phimosis of the fimbriated end of the fallopian tube.
Surgical treatment should be considered for all women with hydrosalpinges prior to IVF treatment. In cases of sonographically apparent hydrosalpinges, a salpingectomy, rather than a salpingostomy, is the preferred route of treatment. Some couples, however, may prefer a salpingostomy, which offers some potential of a spontaneous pregnancy.
For many infertile couples, a several-month postoperative trial at spontaneously conceiving is undesirable and unwise. Therefore, patient selection for surgical treatment of infertility must be individualized and carefully considered.
The role of reconstructive tubal surgery in a woman of advanced maternal age is limited. Given the low monthly chance of pregnancy following surgery in the setting of an already reduced fecundability in a woman of advanced maternal age, IVF is the better treatment option. In contrast, reconstructive surgery for a young woman with minimal tubal disease is a reasonable option.
In general, patients who fail to conceive after primary tubal reconstructive surgery have severely limited success with repeat surgical procedures. In these cases, assisted reproductive techniques are strongly indicated.
In a retrospective study of 434 infertile women who underwent laparoscopic salpingostomy, Audebert et al found evidence that the procedure should not be utilized in certain patients, based on factors such as tubal or adhesion stage and chlamydial serology. The investigators, who measured outcomes in terms of intrauterine pregnancy, delivery, and ectopic pregnancy rates (as achieved without IVF), reported poor-prognosis patterns in association with the following :
Tubal stage 3 or 4
Previous ectopic pregnancy
Severe adhesion stage
Positive chlamydial serology test
The cause of tubal disease must be taken into consideration when determining the prognosis for successful surgery. Successful surgical outcomes depend on whether tubal disease is due to intrinsic (from ascending infection or salpingitis isthmica nodosa) or extrinsic (previous pelvic surgery, endometriosis) causes. The location, type, and degree of tubal injury impact the chance of surgical success. The presence of tubal rugae on HSG, the absence of or presence of small hydrosalpinges (< 15 mm in diameter), the absence of significant pelvic adhesions, and the presence of fimbriae during laparoscopy are all associated with good prognosis following tubal reconstructive surgery.
In a study of 186 women who underwent IVF, 24 women underwent salpingectomy after one or two failed IVF cycles. Salpingectomy implied a significant increase in birth rate. Within the subgroup of patients with ultrasound-visible hydrosalpinges, the birth rate was even higher. Implantation rate was significantly higher in patients who had undergone salpingectomy (27.2% versus 20.2%); in the subgroup of patients with ultrasound-visible hydrosalpinges, the difference was even larger (30.3% versus 17.1%).[4, 5]
For patients with mild distal tubal disease, long-term live-birth rates after surgical treatment are in the range of 39-59% (approximately 5% per month probability of pregnancy) with an associated ectopic pregnancy rate of 4-10%. The outcome for patients with severe distal tubal disease is significantly worse, with an overall pregnancy rate of less than 15%, which equates to a monthly fecundability rate of 1-2%.
Results of fimbrioplasty are difficult to distinguish from other tubal corrective surgeries because this procedure tends to be included as a method of salpingostomy. In one series of 40 patients who underwent microsurgical fimbrioplasty, 63% of patients had intrauterine pregnancies and 5% had ectopic pregnancies after 2 years of follow-up. Other series have reported an ectopic pregnancy rate ranging between 5% and 12.9% after 18 months of follow-up.[8, 9] In most cases, approximately half of patients never conceived in the interval of time studied. No randomized controlled trials for fimbrioplasty versus other methods of tubal reconstructive surgery have been done.
The major determinants of outcome from neosalpingostomy are the degree of pre-existing tubal damage and the extent and type of periadnexal adhesions. In cases of mild tubal damage, the reported live birth rates are 40-60%. Live birth rates are reported to be < 20% in cases where severely damaged tubes exist.
Reconstructive surgery should not be performed until a complete infertility evaluation of the couple has been made.
The gold standard for evaluating the patency of tubes is diagnostic laparoscopy. However, given the invasive nature of a laparoscopy, a hysterosalpingogram (HSG) often serves a useful initial procedure for evaluating the fallopian tubes.
Compared to laparoscopy, the HSG has moderate sensitivity (ability to detect patency when the tubes are open) but relatively high specificity. In other words, when an HSG suggests that both tubes are proximally occluded, there is a small likelihood that the tubes really are open. However, if the HSG demonstrates patency, there is little chance that the tubes are blocked. The diagnosis of distal tubal occlusion is generally accurate but proximal tubal occlusion may be the result of uterine contractions or catheter placement as opposed to true pathologic obstruction. A recent review estimated the sensitivity and specificity of HSG in detecting any tubal pathology to be 53% and 87%, respectively. For bilateral tubal disease, the sensitivity and specificity were noted to be 46% and 95%, respectively.
Contemporary laparoscopy equipment consists of an imaging system comprised of a telescope (laparoscope) and video camera system, an abdominal insufflation system, and specialized surgical instruments. Laparoscopes range in size from 1.8 mm to 12 mm in diameter with lenses available in varying viewing angles. Most gynecologic surgeons prefer the 0-degree lens, as it provides a panoramic view of the pelvis. Angled lenses help in evaluating the anterior abdominal wall or operating around masses. Similar to hysteroscopes, operative laparoscopes are equipped with a central channel that allows laser, electrosurgical, or mechanical instruments to be introduced into the abdomen. The abdominopelvic cavity is illuminated with a light source inserted through the laparoscope with a fiberoptic cable.
Insufflation systems expand the abdominopelvic cavity with gas to optimize visualization. Insufflation may be achieved with a Veress needle or a Hassan trocar, filtered tubing, an insufflator, and gas tanks. Insufflation tubing with a 0.3-µm filter is recommended to prevent intraperitoneal contamination with bacteria, microparticles, and debris from the insufflator and gas tank.
A Veress needle, direct trocar insertion, and open laparoscopy are used to create a pneumoperitoneum. Most gynecologic surgeons use carbon dioxide because it is rapidly absorbed by blood. Because carbon dioxide causes pain upon conversion to carbonic acid, some surgeons prefer using nitrous oxide or helium. Other surgeons use heated or hydrated gas to avoid hypothermia during laparoscopy.
Trocars and sleeves are important to puncture the abdominal wall for placement of the laparoscope and surgical instruments. Trocar sleeves range from 2 to 15 mm in diameter and are available as reusable, disposable, and reposable systems. Uterine manipulators or cannula modify the position of the uterus to improve visualization of and access to pelvic structures. The use of uterine cannulas is contraindicated in the event that a patient has no uterus, has anatomic distortions that prevent visualization of the cervix, is a prepubescent female, or has a suspected intrauterine pregnancy. A sponge stick or examining hand may be positioned in the vagina in the absence of the uterus or if pregnant.
Grasping forceps are used to manipulate tissue and come in a variety of types with different specializations. There are broad, flat forceps and finer forceps used to handle more delicate tissue. Toothed forceps apply traction on tissue such as ovarian cysts or leiomyomas that need to be removed. Forceps with pointed ends are used for tissue dissection and surgical plane development. A disposable Babcock-type atraumatic grasper with a ratcheted scissors handle is useful in handling adnexal structures.
Many devices have been created to facilitate laparoscopic suturing and stapling. Laparoscopic suturing uses stock suture, which is usually 36-48 inches in length. Needle drivers are used to drive needles through tissue, and knots may be tied outside the laparoscopic port (extracorporeal knot) or within the body (intracorporeal knot). The prettied loop is the simplest laparoscopic ligature to tie. The Roeder loop can also be applied using standard suture. To simplify laparoscopic suturing, the endoswitch instrument is used, which uses a preloaded needle and passes suture through tissue up to 2-cm thick by closing a handle and a toggle switch.
Special instruments have been designed to achieve hemostasis while preventing thermal damage. Endoscopic vascular clips and the harmonic scalpel, for example, are safe to use near vital structures. The harmonic scalpel uses vibration at the rate of 55,000 cycles per second as an energy source to break hydrogen bonds in tissue, resulting in cutting or coagulation of vessels. Monopolar and bipolar electrosurgical instruments can also be used to obtain hemostasis.
Suction and irrigation are essential for all types of laparoscopic surgery. Irrigation is important to remove debris, visualize a bleeding source, and to dissect and create tissue planes (hydrodissection). Many types of suction instruments have been designed that are adequate for removal of irrigation fluid, or intraperitoneal air and smoke. A large-bore device is best for removal of blood clots when brisk bleeding is encountered and also for passing laser fiber.
Tissue morcellators are used to reduce large masses into smaller fragments to assist with tissue removal. Manual and automatic morcellators can be used. Automatic morcellators are more effective and time-efficient in removing large amounts of tissue but are more expensive than manual morcellators. To facilitate tissue removal, tissue dilators are used for stretching a 10-mm port to a 20-mm port. Furthermore, a corkscrew device can be screwed into leiomyomas to remove them through a colpotomy incision or through a mini-laparotomy incision.
The patient is placed in a supine or dorsal lithotomy position with the patient's legs placed in Allen stirrups. The knees should be deflexed to avoid stretching of the femoral nerve.
The buttocks should be a few centimeters beyond the edge of the table to allow uterine manipulation. A bladder catheter is inserted to prevent bladder distension, thereby decreasing the risk of bladder perforation and facilitating visualization of pelvic structures.
Tubal surgery uses the basic principles of microsurgery. Microsurgery entails surgery under magnification, thus minimizing peritoneal trauma and/or tissue damage; the goal of this technique is to limit or even prevent the formation of postoperative adhesions.
Tissue damage can be minimized in the following manner:
Delicately handling tissues
Limiting the use of electrical/laser energy
Irrigating the peritoneal cavity with heparinized lactated Ringer's solution, thus providing constant moisture to the serosa and preventing tissue desiccation
Limiting foreign body exposure
Ensuring scrupulous hemostasis
Limiting lateral tissue damage
Completely removing injured tissue
Carefully dissecting proper tissue plane cleavage
Exactly reapproximating tissue planes
Using magnification with fine microsurgical instruments and suture material to ensure the above principles are adhered to
Thoroughly irrigating the peritoneal cavity with complete removal of foreign body, blood, and/or debris
Salpingostomy is the creation of a new opening in a tube with an occluded distal hydrosalpinx. The new stoma (opening) can be located at the terminal end of the tube or at the ampullary or isthmic portions of the tube. Ampullary and isthmic neosalpingostomies, however, have little clinical applicability because the likelihood of pregnancy with limited tubal length is extremely low.
It is important that all pelvic and periadnexal adhesions are lysed prior to undertaking an attempt of neosalpingostomy. This method ensures that the new opening will be placed at an appropriate location, at the most distal portion of the tube. Once the salpingo-ovariolysis is completed and the tube is completely free, the tube is distended with transcervical chromopertubation. An avascular area is identified at the distal-most aspect of the fallopian tube and a cruciate area is cauterized and then incised using microelectrode/microsurgical scissors. The central avascular point is then entered with the incision being extended in a cruciate fashion.
In this manner, the new opening forms a new fimbria-ovary relationship. Bleeding is controlled with careful desiccation using a microelectrode. Once a reasonable sized stoma is attained, the flaps created in the process are secured by desiccating their serosal surface, which allows them to fold back upon themselves.
Although the surgeon should be as conservative as possible, the patient may be better served with a single well-functioning fallopian tube than with 2 defective tubes, which elicits an increased risk for ectopic pregnancy or recurrence of pelvic adhesions. If the fallopian tubes are beyond repair, bilateral salpingectomy is recommended in preparation for IVF.
A salpingectomy can be performed as either an open or laparoscopic procedure. Endoscopic staplers, endocoagulation, bipolar cautery, and endoscopic ligatures can be used as methods of performing a laparoscopic salpingectomy. One simple laparoscopic method includes cauterization of the tubo-ovarian ligament first with bipolar cautery, followed by sharp transection of the tube with scissors. The mesosalpinx is also cauterized and transected in a similar manner, staying as close as possible to the length of the tube so as to not impact the vascular supply. The proximal tube is then cauterized and transected, leaving approximately 1 cm of nondiseased interstitial tube, if possible. The specimen is then removed with an endoscopic bag through a 12-mm port.
Note the images below.
Fimbrioplasty is reconstruction of the tubal fimbriae or infundibulum where fimbrial agglutination or partial distal tubal occlusion exists. The technique of fimbrioplasty is the same regardless of whether the procedure is performed via an open incision or a laparoscopic approach.
A small opening is usually present at the distal end of the tube, which can be easily visualized with transcervical chromopertubation. If the opening is covered by fibrous tissue, this tissue must be excised to gain access to the fimbriae. Agglutination can be corrected by inserting either mosquito forceps or alligator forceps, with its jaws closed followed by opening its jaws and withdrawing the forceps multiple times (see the image below). The direction in which the jaws are opened should be varied in order to optimize the de-agglutination. Bleeding is usually minimized with a gentle technique.
In some instances, the ampullary portion of the tube distends with minimal efflux of dye solution. In this situation, it is necessary to longitudinally incise the tube along its antimesosalpinx border to the fimbriated end. The incision is made electrosurgically with a microelectrode or mechanically with microsurgical scissors. The edges of the 2 flaps can be folded back with electrosurgery by desiccating the serosal margins of the flaps, causing them to fold backward, away from the fimbriae.
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