Tubectomy, Non Scalpel Vasectomy ( sterilization)

Types of permanent sterilization

1. TUBECTOMY

2. FEMALE STERILIZATION INDICATIONS Permanent contraception after completion of family Severe degree of mental retardation : to avoid pregnancy through rape Genetic disease which will be transmitted to the offspring Medical indications: as for medical termination of pregnancy Severe Rh isoimmunization Uterine rupture: if treated by suturing the tear Previous Caesarean section: 3 or more

3. FEMALE STERILIZATION CONTRAINDICATIONS Pelvic infection Lack of informed consent TECHNIQUE : Sterilization is done in puerperium, postabortal period or follicular phase of menstrual cycle METHODS : Laparotomy or Minilaparotomy   Laparoscopic sterilization Hysteroscopic  sterilization Colpotomy

4. Minilaparotomy   Can be done under local, regional or general anaesthesia Bladder is emptied before undertaking the operation Abdomen is opened by a transverse incision just above the suprapubic hair line The uterus is manipulated with Hulka's manipulator .Uterus is elevated or pushed to one side or the other by the elevator that has already been introduced transvaginally into the uterine cavity. This helps manipulation of the tube in bringing it close to the incisional area ) After ligation of tubes the abdominal wall is closed in layers If the operation is done under local anaesthesia, the patient can be sent home on the same day 

5. Methods of female sterilization by minilaparotomy : Various methods are present, those are : Most commonly used method is Pomeroy method Madlener method Irving method Salpingectomy  Fimbriectomy   Cornual resection Simple ligation Double ligation

6. Pomeroy method : The fallopian tube is grasped with a Babcock's forceps at about its middle It's loop is held up & ligated with No. 1 plain catgut transfixion ligature passing through the mesosalpinx. The loop is then cut off beyond the ligature The 2 ends separate out when the catgut is absorbed .

7. Laparoscopic sterilisation Position of the patient— The patient is placed in lithotomy position.  The operating table is tilted to approximately 15 degrees of Trendelenburg position. Usual aseptic precaution is taken as in abdominal and vaginal operations.  The bladder should be fully emptied by a metal catheter. Pelvic examination is done methodically. An uterine manipulator is introduced through the cervical canal for manipulation for visualization of tubes and uterus. 

8. . Laparoscopic sterilization is usually performed in the hospital under general anaesthesia but can be performed under local anaesthesia with conscious sedation In the standard laparoscopy technique, the abdomen is inflated with a gas (carbon dioxide or nitrous oxide) through a special needle ( veress needle) inserted at the lower margin of the umbilicus. A hollow sheath (cannula) containing a pointed trocar is then pushed through the abdominal wall at the same location, the trocar is removed, and the laparoscope is inserted into the abdominal cavity through the sheath to visualize the pelvic organs.  A second, smaller trocar is inserted in the suprapubic region to allow the insertion of special grasping forceps.  Alternatively, an operating laparoscope that has a channel for the instruments can be used; thus, the procedure can be performed through a single small incision. 

9. .     TIMING OF OPERATION: Laparoscopy best used for interval sterilisation or following abortion of less than 12 weeks. Direct visualisation and manipulation. Associated pelvic abdominal abnormality detected. Hospitalisation not needed Cosmetic advantage. Minimal postop pain and discomfort. Reversibility more after clip application. Advantages:

10. CANNULA TROCAR

11. . Contraindications: Severe cardiopulmonary disease Prior abdominal surgery Postpartum sterilisation Extreme obesity, umbilical hernia.

12. . METHODS  : 1)Electrocoagulation(Monopolar and bipolar) 2)Application of a small Silastic rubber band ( Falope ring),  3)The plastic and metal Hulka clip or the Filshie clip 

13. . Monopolar coagulation : Complications Bowel Burn Bleeding Longer portion of tube is damaged Failures and ectopic pregnancy Transection is frequent

14. . Bipolar electrocoagulation   The midisthmic portion of the tube and adjacent mesosalpinx are grasped with special bipolar forceps, and radiofrequency electric current is applied to three adjacent areas, coagulating 3 cm of tube. The tube alone is then recoagulated in the same places.  Disadvantages: Pregnancy may result from tuboperitoneal fistula and is ectopic in more than 50% of cases.  If inadequate electrical energy is used, a thin band of fallopian tube remains that contains the intact lumen and allows intrauterine pregnancy to occur.  Reversals are potentially more difficult

15. .  Advantage : Bipolar coagulation can be used with any fallopian tube. 

16. FALOPE RING

17. CLIPS

18. . Complications Laparoscopic sterilization : Anaesthetic complications Injury to large vessels Bleeding from epigastric vessels-trocar Tearing of mesosalpinx and haemorrhage Bowel injury Thermal burns Surgical and mediastinal emphysema

19. COMPLICATIONS OF FEMALE STERILIZATION TECHNIQUE : Complications of operative approach(laparotomy, laparoscopy, hysteroscopy & colpotomy) complications of tubal sterilization Mesosalpingeal tear Broad ligament haematoma Tubal transection & bleeding Extensive tubal damage from use of unipolar cautery Pelvic infection Tubal ectopic gestation if recanalization occurs Menorrhagia due to engorgement of uterine venous circulation caused by impaired uterotubal circulation 3.  Psychiatric complications

20. METHOD Failure Rate (%) Potential for reversibility Pomeroy 0 – 0.4 good wood Nil  Very good Irving  Nil  Good  Fimbriectomy   Nil  Poor  salpingectomy 0 - 1.9 Poor  Simple ligation  20 Very good Electrocoagulation  0.1 - 2.0 Poor  Clips  0.2 - 18 Very good Falope ring Nil  Good  Failure rates & potential of reversiblity of various female sterilization methods :

21. VASECTOMY ..

22. . A surgical procedure to resect / close the vas deferens (the tubes that carry sperm to the penis) Conventional vasectomy – one or two incisions are made in the scrotum to reach the vas deferens  No-scalpel vasectomy – a puncture  is made in the scrotum  

23. Vasectomy techniques: • Suture ligature • Surgical clips • Thermal or electrocautery • Chemical occlusion • Vas plugs • Vas excision • Open-ended vas • Fascial interposition • Vas irrigation

24. NO SCALPEL VASECTOMY This technique was developed from sichuan in china by Dr shunqiang li NSV training was started first in 1987 in Thailand and other developing countries By 1988, 10 million vasectomies were done in china In 1988 sponsered the king’s birthday vasectomy festival in thailand where 1023 vasectomies were performed in 1 day

25. ADVANTAGES OF NSV Less time (10 min)50% faster operating time Improved method of anaesthesia (vas block ) has made it less painful Less Tissue injury, Bleeding, Hematoma Less infection, Fast recovery No incision, no stitches- Patient less nervous Complication rate is 1/10 of conventional vasectomy Less postoperative pain

26. PREOPERATIVE PREPARATION Any skin disease in the genital area is treated adequately Scrotum, underside of the penis and the inner thighs are shaved Cleansing is done with benzalkonium chloride or 1% solution of chlorhexidine to reduce the bacteria Atropine sulphate 0.6mg is given intramuscularly 30 mins prior to surgery  

27. POSTOP MANAGEMENT Scrotal dressing is kept dry until the suture comes off or is removed after 7 days Scrotal support is worn for up to 1 week An ice bag applied to the scrotum also helps counteract swelling and reduce discomfort Can return to work the same day No sexual intercourse for 5-7 days even with condoms Intercourse without any contraceptive is allowed only when 3 consecutive semen samples show no sperm These samples are obtained at 12 weeks after the surgery, and then every 2 to 4 weeks until two consecutive sperm count are 0

28. ADVANTAGES No routine contraceptive required No interference with intercourse No significant long-term side effects Simple procedure Less invasive and more cost-effective than tubal ligation Allows the male partner to assume some responsibility for birth control

29. DISADVANTAGES Difficult to have reversal Post-sterilization regret  Short-term surgery-related complications: pain and swelling; vasovagal reaction; infection No protection against STIs Not effective immediately. Additional methods required for 2.5-3 months till follow-up sperm analysis shows no sperm

30. COMPLICATIONS Operative Sperm granules Spontaneous recanalization Autoimmune response Psychological response

31. THANK  YOU

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