TUBECTOMY PPT by Dr Bandari Sajala, Ms OBGYN

All methods of famale permanent sterilization

1. TUBECTOMY Dr B Sajala

2. 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. CRITERIA FOR CASE SELECTION Age of the women- 22-49yrs Married Atleast one child above one year Sound state of mind Mentally ill patients- certified by psychiatrist and legal gaurdian consent Partner or spouse must not have undergone sterilization

4. PREOPERATIVE EVALUATION The candidate for sterilization should be counselled. The intended permanence of the procedure, other alternatives like vasectomy and the risks associated with the surgery should be explained. Women should be made aware that the sterilization failure can occur and chances of ectopic failure increase when it fails

5. Detailed history to be taken, physical examination, laboratory evaluation should be done. Pregnancy testing to be done necessarily to rule out the pregnancy at the time of sterilization. Women with gynaecologic disease or symptoms may require additional diagnostic or therapeutic measures. Informed and written consent should be taken.

6. ANAESTHESIA The operation can be done under general or spinal or local anaesthesia. General anaesthesia is more likely to be used in laproscopic methods and the risks associated should be explained. In case of local anaesthesia, premedication with injection morphine 15mg or injection pethidine 100mg with phenergan 50mg IM is to be administered 30-45minutes prior to surgery. The incisional area should be infiltrated with 1% lignocaine.

7. Operating under local anaesthesia incurs several possible disadvantages like patient’s anxiety , complications are seen in multiple pelvic abdominal surgeries, obese women. Additional anaesthesia may be required in the above cases if the procedure is prolonged or difficult if given locally.

8. 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

9. INCISION: In puerperal cases, where the uterus is felt per abdomen, the incision of 2-3cm is made two finger breadth below the fundal height. In interval cases, the incision is made two fingers breadth above the pubic symphysis. The incision may be in midline, paramedian or transverse. SURGICAL APPROACH FOR LAPAROTOMY

10. DELIVERY OF THE TUBE: The index finger is introduced through the incision. The finger is passed across the posterior surface of the uterus and then to the posterior surface of the broad ligament from where the tube is hooked out. The tube is identified by the fimbrial end and mesosalpinx containing utero-ovarian anastomotic vessels

11. Minilaparotomy  Can be done under local, regional or general anaesthesia Bladder is emptied before undertaking the operation Abdomen is opened and 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 

12. Methods of female sterilization by minilaparotomy : Various methods are present, those are : Most commonly used method is Pomeroy method Madlener method Irving method Uchida method Parkland operation Salpingectomy  Fimbriectomy ( Kroener technique) Aldridge method Shirodhkar method Cornual resection Simple ligation Double ligation

13. 1)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 .

14. 2)IRVING TECHNIQUE The tube is twice ligated with no 1 catgut about 2.5cm from the uterine cornu and then cut between the ligatures. The free ends of the proximal stump ligature are held long and a one cm incision is made in the serosa of the posterior uterine wall near the uterine cornu in an avascular area by mosquito forceps . The proximal stump is burried back in the myometrium obstructing the lumen. The distal end is burried in the mesosalpinx.

15. 3)UCHIDA TECHNIQUE About the 5ml of epinephrine in saline(1:200000) is infiltrated in the tubo-mesosalpingeal junction between the two leaves of the mesosalpinx to cause the elevation of the peritoneum off the fallopian tube. A 5cm incision is made in the tubal serosa. The serosa is elevated off and the muscularis of the tube is exposed by the incision. About 3-5cm of the tube is excised. The lateral cut end is ligated with no 2 chromic catgut. The medial cut end is ligated and burried between the two leaves of the broad ligament and leaving the lateral cut end in the peritoneal cavity.

16. 4)MADLENER TECHNIQUE The midsection of the tube is picked with babcock’s forceps to form a loop. The base of the loop is crushed with a clamp and ligated with a non- absorbable suture material like silk.

17. 5)PARKLAND OPERATION The part of the fallopian tube is excised between two hemostats applied one cm apart in the isthmic portion of the tube. Each hemostat is replaced with transfixion ligature of no 1 chromic catgut. Hemostasis is achieved between the cut ends and the result is similar to that after the Pomeroy technique.

18. 6)KROENER METHOD (FIMBRIECTOMY) The distal end of the tube is excised and the cutend is ligated with non absorbable suture material like no 1 silk

19. 7)ALDRIDGE METHOD The fimbrial end of the tube is burried between the two leaves of the broad ligament.

20. 8) SHIRODHKAR METHOD: The cut ends are folded back on the tube and sutured to it. 9) SALPINGECTOMY: The fallopian tube is resected distal to a non absorbable ligature placed near the cornu. 10) SIMPLE LIGATION: The fallopian tube is ligated in a single place with non absorbable suture like no 1 silk. 11) DOUBLE LIGATION: Ligated in two places with no 1 silk.

21. 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. 

22. . 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. 

23. .     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:

24. CANNULA TROCAR

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

26. . 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 

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

28. . 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.  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

29. .  Advantage : In bipolar coagulation, the current does not spread if application is prolonged as seen in unipolar .

30. FALOPE RING

31. CLIPS

32. INTRA TUBAL STENTS Intra tubal stents are 4-6cm long and are inserted in the fallopian tube through the fimbrial end laproscopically using three puncture technique. A clip applied over the tube keeps the stent in position. When pregnancy is desired, the clip and the stent are removed laproscopically. LASER: CO2 laser is used to destroy a localized area of the tube laproscopically without the need to touch the treated area.

33. . 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

34. HYSTEROSCOPIC METHODS OF FEMALE STERILIZATION Electrocoagualation of the tubal ostia Cryocauterization Chemichal sclerosis of the tube Silastic plugs Solid plugs

35. 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

36. 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 :

37. THANK  YOU