Laparoscopic Tubal Ligation

Laparoscopic tubal ligation is a surgical sterilization procedure in which a woman's fallopian tubes are either clamped and blocked or severed and sealed. Both methods prevent eggs from being fertilized. Tubal ligation is a permanent method of sterilization.

About 20% of women choose tubal ligation as their contraceptive method, making it the second most common form of female contraception in the United States.[1] The use of tubal ligation increases with parity: 59% of women who have had 3 children undergo sterilization versus 13% after 1 child. Of women who decide not to have more children, 44% choose sterilization over reversible contraceptive methods.[2]

The number of tubal ligation procedures performed in the United States has recently declined somewhat. This decline is thought to be attributable to the introduction of more options for long-acting reversible contraception, an aging baby-boomer population, and access-to-care issues.

Tubal ligation can be performed in the peripartum period or at any time remote from pregnancy (referred to as interval sterilization). Approximately half of female sterilizations are interval sterilizations, and the other half are performed at the time of cesarean delivery or immediately postpartum. Most interval sterilizations are performed laparoscopically.

Laparoscopic tubal ligation has many advantages that explain its use as the interval procedure of choice. It offers the opportunity to explore pelvic and abdominal anatomy, especially if the patient has complaints such as pelvic pain. The procedure is an outpatient surgery with a rapid recovery, allowing patients to return quickly to work or home. All laparoscopic methods are immediately effective. Laparoscopic tubal ligation is attractive to surgeons because many gynecologists are well trained in laparoscopic techniques and it involves a short operating time.

Disadvantages of laparoscopic tubal ligation include the need for anesthesia and cost of laparoscopic equipment. The procedure is usually performed under general anesthesia, which has its own risks. There is inherent risk with any surgery in which the peritoneal cavity is entered, including the rare risks of bowel injury, hemorrhage, transfusion, and, with some sterilization methods, thermal injury. All sterilization methods have risks of failure and regret.

Indications

Indications for laparoscopic tubal ligation include the following:

• Desire for permanent sterilization

• Completed childbearing

Contraindications

Contraindications to laparoscopic tubal ligation include the following:

• Any contraindication to laparoscopic surgery (see Gynecologic Laparoscopy)

• Concern that patient's decision for sterilization was not fully voluntary or that patient does not fully understand the intended permanence of the procedure

• Other condition requiring a hysterectomy or bilateral oophorectomy (eg, gynecologic malignancy)

• Concurrent desired pregnancy

Laparoscopic sterilization is a very effective permanent contraceptive procedure. The US Collaborative Review of Sterilization published data on 10,685 women monitored for 8-14 years. This study showed 143 sterilization failures with a resulting pregnancy. With all methods considered (unipolar, bipolar, Falope ring, spring clip, peripartum Pomeroy), there was a 5-year cumulative life-table probability of failure of 13 per 1,000 procedures and a 10-year cumulative life-table probability of failure of 18.5 per 1,000 procedures. The risk of failure continued and accumulated over time.[3]

In the US Collaborative Review of Sterilization study, bipolar cauterization had a 10-year cumulative life-table probability of failure of 24.8 per 1,000 procedures, Falope ring was 17.7 per 1,000 procedures, and the spring clip was 36.5 per 1,000 procedures. These were all performed laparoscopically.[3]

The probability of failure was directly affected by age: The younger the age at the time of sterilization, the higher the failure rate. When bipolar cauterization and Falope ring procedures were considered, women younger than 28 years at the time of their procedure had a statistically significant increase in failure compared to women 34 years or older. All methods, except for the spring clip, had failure rates equivocal to an intrauterine device.[3]

An internationally performed clinical trial followed women for 1 year after randomized placement of the Filshie clip or Falope ring. In the laparoscopic procedure group, there was a 1 year life-table pregnancy probability of 2.5 per 1,000 procedures for both the Falope ring and Filshie clip.[4] Another randomized trial followed Filshie clip and spring clip patients for 1 year to examine failure rates. The 1-year cumulative life-table pregnancy probability was 1.9 per 1,000 procedures in the Filshie group and 9.5 per 1,000 procedures in the spring clip group.[5]

The US Collaborative Review of Sterilization data included 2,267 women who underwent bipolar electrocautery as their sterilization method. Patients with 3 or more burn sites had a failure rate of 6.3 per 1,000 procedures. Patients with 2 or less burn sites had a failure rate of 12.9 per 1,000. These data demonstrated lower failure rates with increased physician experience and more burn sites.[6] Soon after the US Collaborative Review of Sterilization study was published, another study established the exact amount of electrical energy needed to cause complete desiccation and hopefully decrease failure rates further.[7]

Family Health International conducted 11 studies looking at failure and complication rates with Filshie clips. At 24 months, 0.7 failures occurred per 100 procedures.[8] Another retrospective review of 30,000 patients found 73 failures, or a failure rate of 2-3/1,000 patients.[9] Long-term failure rates are unknown at this time.

Limited information is available about failure rates with the laparoscopic Pomeroy method, probably because of its infrequent use as a sterilization technique. One study looking at this method in a teaching institution found 1 failure in the 99 procedures performed.[10] Another small study followed 28 woman undergoing laparoscopic Pomeroy and found no failures at 18 months.[11] More data is needed to determine failure rates with this method.

Several prospective observational studies have noted a reduction in ovarian cancer risk after a sterilization procedure. Furthermore, no relationship between breast cancer and sterilization has been found.[12] While pelvic inflammatory disease and tubo-ovarian abscesses occur in sterilized patients, fewer sterilized patients require hospitalization. This is possibly from the physical blockage of organisms from the lower genital tract.[13]

A French nationwide cohort study by Bouillon et al that included 105,357 women reported that risks of medical outcomes were not significantly increased with hysteroscopic sterilization compared with laparoscopic sterilization. Hysteroscopic sterilization was associated with higher risk of gynecological complications over 1 year and over 3 years compared to laparoscopic sterilization in women undergoing first sterilization.[14]

Immediate complications

Immediate complications of laparoscopic tubal ligation include the following:

• Incorrect anatomical site of sterilization

• Bowel, bladder, or blood vessel injury or perforation

• Conversion to laparotomy

• Electrocautery complications

• Transection of the fallopian tube

• Uterine perforation or cervical laceration

• Mortality

It is important to identify the fallopian tube and document this in the dictation. Performing procedures on the round ligament will result in a procedure failure. Taking a picture after the procedure will help document correct surgical site in the event of a failure.

Laparoscopic surgery has certain inherent associated complications, including bowel, bladder, or blood vessel injury or perforation by the trocar, scalpel, or Veress needle. These complications are very rare but can be life threatening.[15]

Conversion to laparotomy occurs upon unexpected injury or technical difficulty. Conversion may be caused by abnormal anatomical findings, such as extensive adhesions, distorted pelvic anatomy, or pelvic masses. A patient's comorbidities, such as obesity or previous abdominal surgery, can increase this risk. The US Collaborative Review of Sterilization found that conversion to laparotomy was the most common complication with laparoscopic tubal ligation. It occurred in 0.9% of laparoscopic sterilization procedures because of difficulty with the fallopian tube, failed pneumoperitoneum or entry, incidental disease, or laparoscopic complication.[16]

Thermal injury is associated with any procedure that involves electrocautery. Most thermal injuries from the sterilization procedure itself occur with unipolar cauterization sterilization. Bipolar cauterization is safer as a sterilization technique because the electric current is localized to the tissue in the paddles. However, unsuspected or accidental injuries can occur by unintentional contact of the paddles to other tissue. In the US Collaborative Review of Sterilization, the one thermal injury that occurred with laparoscopic tubal ligation was associated with cauterization during a Falope ring procedure.[16] These injuries typically present with acute abdomen, peritoneal signs, fever, or sepsis about 5-7 days after the procedure.[15, 17]

Transection of the tube occurred in 1%-5% of Falope ring cases in the original trials.[18] In a series of 846 Falope ring sterilizations, 3.1% had bleeding complications, but only 2 of these cases required laparotomy.[19] The US Collaborative Review of Sterilization found a 0.79% complication rate associated with this technique, which is much lower than previously found. However, all fallopian tube transections occurred in Falope ring procedures.[16]

It is possible that the complication rate with Falope ring procedures is decreasing owing to increasing surgeon experience. If a fallopian tube laceration occurs, it can be addressed by cauterizing the fallopian tube or placing a ring over each transected end. There is differing information about the possibility of increased postoperative pain with this procedure compared to others. A Cochrane review reported more pain in the Falope ring group than in the bipolar cauterization group.[20]

Placement of the uterine manipulator can result in uterine perforation or cervical laceration. Uterine perforation can be assessed laparoscopically and usually requires no intervention, as the bleeding typically stops on its own. If uterine bleeding is seen, it can be addressed by pressure and time, cauterization, or suture ligation. The cervix should be inspected upon removal of the uterine manipulator. Cervical bleeding can be addressed with pressure, silver nitrate, Monsel solution, or suture if heavy bleeding is seen.

Deaths associated with tubal ligation are very rare.[21, 22] Most of the deaths result from hypoventilation and cardiopulmonary arrest during the administration of general anesthesia.[1] Many studies include all types of sterilization procedures and do not look exclusively at laparoscopic procedures. The US Collaborative Review of Sterilization, which included 9,475 patients, and a randomized study conducted by the World Health Organization showed no deaths attributable to laparoscopic tubal sterilization.[16, 23]

Delayed complications

Delayed complications of laparoscopic tubal ligation include the following:

• Failure

• Filshie clip complications

• Regret

• Ectopic pregnancy

• Menstrual changes

• Hysterectomy

• Sexual function

Laparoscopic sterilization is a very effective permanent contraceptive procedure. Failure rates are described in more detail in Outcomes.

There have been case reports of migration and spontaneous extrusion of the Filshie clip from various locations, including the vagina, urethra, and the abdominal wall.[24, 25, 26] Furthermore, case reports have reported Filshie clips involved in abscesses.[27] There is a case report of torsion involving a Filshie clip.[28] These complications are rare because the clip is peritonealized over after fibrosis of the tube occurs.[15]

Regretting the decision for sterilization is a common complication of sterilization. However, most women do not regret their decision.[12] The US Collaborative Review of Sterilization looked at 11,232 women in a prospective cohort study over 14 years, in which 12.7% of the sterilized woman experienced regret. Regret occurred in 20.3% of women who were younger than 30 years at the time of sterilization compared to 5.9% among women older than 30 years. Regret was the same for peripartum and interval sterilizations. The most common reasons for regret were the desire for more children or a divorce or remarriage.[29]

Another review showed that women aged 30 years or younger were twice as likely to express regret, up to 8 times more likely to request information about reversal procedures, and 8 times more likely to undergo these procedures.[30] Therefore, it is imperative to have thorough presterilization counseling discussion with all women, as well as to focus on the high risk of regret in young women. Some studies show that women who experience regret report feeling they had not received enough counseling regarding the risks and alternatives.[12]

The different surgical techniques also have different likelihoods of successful surgical reversal. Bipolar cautery causes damage to a large area of the fallopian tube and is difficult to reverse. The Filshie clip and spring clip affect a small width of the fallopian tube and have minimal lateral damage. The Falope ring has a relatively higher rate of successful reanastomosis compared to bipolar cautery, but not as high as the Filshie clip. Pregnancy was successful in 72% of cases for Falope ring and 90% for Filshie clip after successful reanastomosis.[17]

All of the tubal techniques depend on complete occlusion of the fallopian tube to be successful. Most failures in a properly performed procedure involve tuboperitoneal fistula formation. This is thought to be the mechanism for a large proportion of poststerilization pregnancies being ectopic in nature. The absolute risk is very low at 7.3 per 1,000 procedures, but it should be a top concern if a patient has a positive pregnancy test after a sterilization procedure.[13]

The US Collaborative Review of Sterilization found a 32.9% ectopic rate among failed tubal ligations. The ectopic risk increased the longer time from surgery. About 20% of ectopic pregnancies occurred in the first 3 years, and 61% occurred 4-10 years after sterilization. Patients younger than 30 years at the time of sterilization had twice the ectopic rate as women aged 30 years or older at the time of sterilization. This is possibly because of their greater fecundity.[31]

The risk of ectopic pregnancy was highest among the bipolar coagulation group (65% of pregnancies were ectopic), Falope ring group (29%), and spring clip group (15%). The high bipolar cauterization ectopic rate is thought to result from inadequate cauterization. These cases were done prior to the routine use of a power meter to monitor tissue desiccation. The Filshie clip was not included in this study.[31]

Many studies have investigated posttubal sterilization syndrome or posttubal ligation syndrome. There is no consensus definition of this syndrome, but a general description includes an increase in dysmenorrhea, heavy menstrual bleeding, and premenstrual syndrome. Original studies examining this syndrome had a significant amount of recall bias and failed to evaluate for confounders, such as birth control use prior to sterilization or recent pregnancy.

The US Collaborative Review of Sterilization found a decrease in the number of days and amount of bleeding and menstrual pain in the female sterilization group. However, they did notice a slight increase in menstrual irregularity. There were no differences in these results among bipolar cauterization, the Falope ring, the spring clip, and partial salpingectomy. This study included peripartum and laparoscopic surgical sterilization procedures.[32]

Several other cohort studies with nonsterilized controls have found no association with pelvic pain, dysmenorrhea, cycle irregularity, or premenstrual syndrome.[33, 34, 35] Furthermore, a study comparing estrogen and progesterone levels between sterilized and nonsterilized patients showed no differences in hormone levels over 2 years.[36] According to the American Congress of Obstetricians and Gynecologists and a sterilization review, the evidence does not support the existence of a posttubal ligation syndrome.[12, 13]

There is an increased rate of hysterectomy in patients who have undergone a tubal ligation procedure. In the US Collaborative Review of Sterilization study, sterilized women had an 8% hysterectomy rate compared to 2% in the control group, or were 4–5 times more likely to undergo hysterectomy. This was regardless of the age of the patient at the time of sterilization or the type of sterilization procedure performed.[37]

Another US Collaborative Review of Sterilization analysis followed 10,698 women over 14 years and showed a hysterectomy rate of 17%. Patients with a presterilization gynecologic diagnosis had the highest risk. For example, women with leiomyomata at the time of sterilization had a 27% hysterectomy rate versus a 14% hysterectomy rate in the women without leiomyomata.[38] Older studies suggested that the hysterectomy rates increased as the patient age at the time of sterilization decreased, but more recent evidence suggests all ages are at risk. Again, these studies did not look specifically at laparoscopic sterilization techniques.[12, 13]

The US Collaborative Review of Sterilization followed 4,576 women over 5 years and surveyed patients about sexual interest and pleasure. Eighty percent of the women reported no change in sexual interest or pleasure. Several women had fluctuating levels of sexual interest and pleasure. Women with consistent scores were 10 times more likely to have more sexual interest and 15 times more likely to have more sexual pleasure. This was true regardless of age at the time of procedure or time from sterilization. There was a decrease in sexual interest or pleasure if regret was present. Overall, there was no change to a women’s sexuality attributed to sterilization.[39]

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 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.[40] While mortality is an extremely rare complication of laparoscopic sterilization, most of the deaths noted in older studies were attributable to anesthetic complications.[21] More recent studies have not seen this correlation, as no deaths were reported.[16, 23]

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.

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.[41]

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 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.[42] 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.[43] 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.[44]

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.

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.