Patient Education & Consent

Careful counseling is essential. The surgeon must be comfortable that the patient is not being pressured to have the procedure, understands the intended permanence of the procedure, and understands the chance of regret.

Document that the patient has verbalized her understanding of the permanence of the procedure, risk of regret, risk of failure, and, in the rare event pregnancy occurs, the risk of ectopic pregnancy, which is as high as 50%. Also document that the patient has declined other forms of birth control, especially long-acting reversible contraception methods with similar failure rates.

Equipment

Equipment for laparoscopic tubal ligation includes the following:

Ambulatory or inpatient surgical center
Anesthesia personnel and equipment
Laparoscopic equipment, including CO₂ gas and monitor, viewing screens, camera, and light source
Laparoscope (10-mm operating or 5-mm diagnostic)
Trocar for the umbilicus (5 mm or 10 mm)
Additional trocars for accessory ports (5 mm or 7-8 mm)
Appropriate instruments for technique (eg, bipolar cautery, Falope ring applicator, spring clip applicator, Filshie clip applicator, Endoloops, endoscopic scissors)
Laparoscopic graspers or a blunt probe
Uterine manipulator per physician preference
Fascial and skin closure devices (suture or Dermabond)

Bipolar electrocautery or the Pomeroy technique can be used if a patient is not comfortable with a permanent object in her body. Pomeroy is a preferred technique if tissue is needed for pathologic analysis.

With bipolar electrocautery, the paddles heat when current is applied. Burn injuries can occur if the hot paddles contact other tissue. Always keep the paddles in the middle of the field of vision and away from any bodily structures. Remove the paddles from the abdominal cavity as soon as they are no longer needed.

It is difficult to apply the Falope ring correctly if the tube in thickened, edematous, or involved in significant adhesions. Consider using another technique in this situation. When applying the ring, slow movements are key to a successful procedure. Additionally, if the sheath is slowly pushed toward the fallopian tube while the prongs are pulled into the sheath, it will decrease tension and the risk of fallopian tube injury.

It is difficult to apply the spring clip correctly if the tube is thickened, edematous, or involved in significant adhesions. Consider using another technique in this situation. Use of a second port to allow straightening of the tube may optimize clip placement.

Practice partially closing the Filshie clip externally so that it is not accidentally closed while placing it in the abdomen.

Anesthesia

General anesthesia is the most commonly used anesthesia in the United States for laparoscopic sterilization.^[39]While mortality is an extremely rare complication of laparoscopic sterilization, most of the deaths noted in older studies were attributable to anesthetic complications.^[20]More recent studies have not seen this correlation, as no deaths were reported.^{[15, 22]}

Positioning

The dorsal lithotomy position allows for the placement of a uterine manipulator for better visualization and ease of the procedure.

During initial Veress needle/trocar placement, it is important for the patient to be flat to decrease the likelihood of major vessel injury. After insufflation, the patient should be placed in Trendelenburg position for better intraoperative visualization.

Technique

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