a. Original unipolar technique was described by Steptoe.
b. The introduction of laparoscopy made it a popular procedure not associated with pregnancy.
c. Vaginal sterilization by fimbriectomy was the only interval form of tubal ligation before laparoscopy.
d. Types (all done through the laparoscopy).
(1) Unipolar coagulation
(a) The tube was grasped and burned until blanching.
(b) Scissors were used to excise the blanched portion, which was sent to pathology.
(c) A current ran through patient’s body. Morbidity is secondary to bowel and skin burn.
(d) No longer used because morbidity, secondary to extensive tissue destruction, is too high.
(2) Bipolar technique: developed independently in the 1970s by Kleppinger (United States), Rioux (Canada), and Hirsh (Germany)
(a) This is the most common laparoscopic tubal ligation.
(b) This technique is the easiest to perform.
(c) The bipolar technique works by concentrating the electricity between two paddles; therefore, the patient does not carry the current.
(d) Kleppinger recommends that the tube be burned in three places so there is at least a 3-cm gap between healthy portions of tube.
(e) It is recommended that the cauterization begin 2 to 3 cm from the cornual angles, preventing uteroperitoneal fistu-lization and ectopic pregnancy formation.
(3) Falope Ring (silastic band)
(a) The Falope Ring is safer than cautery.
(b) It was developed in the 1970s.
(c) The fallopian tube is grasped into a metal cylinder with grasping prongs.
(d) The silastic ring occludes the base of a 3-cm portion of tube, which necroses.
(e) It is associated with a 2.5% incidence of hemorrhage secondary to stretching of vessels beneath the tube or tearing of the tube.
(f) The patient has pain from 48 to 96 hours from tubal hypoxia.
(4) Spring clip
(a) Of the laparoscopic methods, it is the most difficult technically.
(b) The clip must go across the whole tube.
(c) The spring clip is applied across the isthmus of the tube.
(d) Most procedures are reversible; destroys only 5 mm of the tube.
(e) This is the best method for women under 30 years. (5) Minilaparotomy tubal
(a) Minilaparotomy tubal may be used if there is a contraindication to laparoscopy.
(b) It is described as a technique using local anesthesia and intravenous sedation. General anesthesia also may be used.
(c) A 2-cm to 5-cm suprapubic incision is made. The Pomeroy technique, clips, or silastic rings may be used on the tubes.
(d) A dilator is placed in the uterus before the technique is done for manipulation and uterine elevation.
e. Failure rates of sterilization: All laparoscopic tubal ligations have a failure rate of between 2 and 10 pregnancies per 1000 operations (Tables 5-6 and 5-7).
|Table 5-7 . Technical Failures|
f. Posttubal syndrome: an irregular cycle and dysmenorrhea post—tubual ligation.
(1) Studies have been done, but none have been conclusive.
(2) Menstrual irregularities and dysmenorrhea are probably not caused by tubal ligation.
(3) It is more likely that the woman’s own cycles are surfacing.
(4) Complication rate (Table 5-8).
(a) Defined as those requiring laparotomy for repair.
(b) Has stayed below 2 in 1000 for the past decade.
(c) Mortality has not been reported since 1982.
(d) Major vessel laceration from trocar needle insertion in 1/1000 to 1/10,000 cases.
(e) Thermal bowel injury in 1/1000 cases.
g. Essure: Hysteroscopic placement of tubal plugs inserted at the uterotubal junction. Another form of birth control must be used for 3 months while the coil scars over. Long-term sterilization is quoted at 85% to 90%. Advantage is that it is quick, and may be done without anesthesia.
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ln a comparative study of 1437 women using the sponge versus diaphragm and a study of 1394 women using the cervical cap versus diaphragm, the 12 months failure rate was diaphragm, 5.2% and 6.9%; cervical cap 11.4%; sponge 11.7%. Failure rates increased to 26.4% for the cap and 20% for the sponge among parous users. The failure rate for condoms was estimated at 2.7%. J. Trussel, Office of Population Research, Princeton University.