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^ LAPAROSCOPIC TUBAL STERILIZATION


Laparoscopic sterilization is the most common type of female sterilization. There are essentially three major methods, however, occasionally a surgeon may still use thermal coagulation.

1. Electrosurgical:

a. Monopolar

b. Bipolar

2. Clips:

a. Hulka

b. Filshie

3. Bands (Fallope ring)

4. Thermal coagulation

All of the methods that will be described may be performed through either a single puncture technique using an operating laparoscope, or through a double puncture technique, using a 5 mm second puncture trocar that may be placed in the midline suprapubic area.

The double puncture technique uses a 5 mm or 10 mm laparoscope that is inserted through the umbilical port. Our preference in recent years has been to use the single puncture technique unless there is difficulty in mobilizing the Fallopian tube. If the single puncture technique is the method of choice, it is very important that a well functioning uterine manipulator be employed. By moving the manipulator it is possible to stretch the tube laterally. The surgeon can control the operative field by moving the laparoscope in and out, to obtain close up or panoramic view, and by moving the instrument inserted through the operative channel. One of the most common causes of sterilization failure is the misidentification of either the round ligament or the uteroovarian ligament for the Fallopian tube. Therefore, it is vital to identify all three structures and to trace the tube to the fimbriae if at all possible, prior to performing the sterilization. Although many of our sterilization procedures are performed under general anesthesia, a large number are accomplished under local. When local is the method, the skin and deeper tissues are blocked using lidocaine. The art, however, is to instil a mixture of 10 cc carbocaine and lidocaine transcervically via the uterine manipulator. The tubes can almost be seen to blanche.

Monopolar electrosurgery is still used by some gynecologists, however, it has lost favor because of its risks of thermal bowel burns. The technique of bipolar coagulation, as originally described by Dr. Richard Kleppinger, is still the most popular form of laparoscopic sterilization and is our suggested form of electrosurgical management.

BIPOLAR

The bipolar Kleppinger type forceps are mainly in use. The tips of the forceps are where the energy is distributed from one tong to the other. It is therefore important that the tips enclose the tube as much as possible. Bipolar coagulation provides a more localized area of tubal burn thus requiring at least 3 cm of tube to be coagulated. The tube is grasped in the isthmic portion of the tube at least 2 cm from the cornua. If too close to the uterus there is a risk of creating a uteroperitoneal fistula. The tips of the tongs should be minimally in the mesosalpinx to avoid too much damage to the blood supply of the tube and its anastamotic branches to the ovary. The electrosurgical generator should be set to deliver a power of 25 W in a nonmodulated or cutting mode to desiccate the tissue sufficiently. If too much energy is used, the tube tends to be rapidly coagulated on the periphery, rather than through slow coagulation. This may lead to a sterilization failure. The tube should be coagulated with 2 to 3 contiguous burns to provide an area of about 3 cm of coagulation. The endpoint of coagulation is the cessation of current flow. This will supply a relatively accurate indication of complete coagulation. Most electrosurgical generators have either a visual ammeter or an audio signal of this endpoint. After completing the coagulation, it has been our technique to sever the tube in the middle of the burn area with a laparoscopic scissors. However, there is some controversy regarding this and many surgeons do not cut the tube believing that it leads to a higher failure rate due to possible fistula formation.

CLIPS

Mechanical occlusion of the tube is most commonly performed using one of two types of clips. The most popular has been the Hulka-Clemens spring-loaded.

^ IMPORTANT NUMBERS

2 cm from fundus

3 cm of tube

2-3 continuous burns

25 W power

The clip requires a special laparoscopic applicator that may be passed through the single puncture operating laparoscope. This instrument is 7 mm and is inserted through the operating channel.

The clip applicator has four positions.

1. Safe open – In this position the clip is held on the end of the applicator and can be opened and closed without locking. This position is used when the applicator and clip are passed through the operating scope channel. 2. Safe closed – The tube is grasped with the clip and closed to this position. The clip may be removed by opening the clip applicator jaws. 3. Full closed – The thumb manipulator of the applicator drives the metal spring over the plastic jaws of the clip and locks it in place. 4. Full open – The ring on the handle is pulled back and the clip is thus removed from the applicator and left in place on the tube. The applicator jaws are then closed and the instrument is removed. The clip should be applied on the isthmus at least 2 cm from the uterus and should be placed completely across the tube. This can be assured by observing that the tube rests completely against the hinge of the clip. With correct application, the mesosalpinx is pulled up to resemble the shape of an envelope flap.


BANDS

Yoon and associates introduced the silastic band in 1974. This small silastic band is applied to the tube by use of a special 8 mm applicator that may be used through the single puncture 12 mm operating laparoscope. The bands are preloaded onto the instrument using a special plastic loading device. The applicator is then passed down the channel and grasping hooks are deployed from the end of the applicator. The tube is grasped in the isthmic area about 3 cm from the cornua of the uterus. The tube is then drawn up into the inner cylinder of the applicator by the grasping hooks and the silastic band is applied by moving the outer cylinder forward. It is important that a sufficient knuckle of tube is brought back into the applicator to assure that two complete lumens have been occluded. After application of the band, the grasping tongs are moved forward out of the inner cylinder to release the occluded tube. Several problems have been described with the bands. There have been a signif- icant number of complications secondary to tears in the mesosalpinx. Bleeding from this problem can usually be controlled by bipolar coagulation. Postoperative pain is more frequent than with clips or bipolar coagulation. A large number of these patients require an oral analgesic for several days postoperatively.


^ ECTOPIC PREGNANCY

Pregnancy outside the confines of the uterine cavity has been described for hundreds of years. In the 1800s, the mortality associated with ectopic pregnancy was >60%. Today it accounts for 9% of pregnancy related mortality and less than 1% of overall mortality in women. Although ectopic pregnancy has been recognized for over 400 years, it continues to be an ever-increasing affliction affecting greater than 2% of all pregnancies. Theoretically, anything that impedes migration of the conceptus to the uterine cavity may predispose a woman to develop an ectopic gestation. These may be intrinsic anatomic defects in the tubal epithelium, hormonal factors that interfere with normal transport of the conceptus, or pathologic conditions that affect normal tubal functioning. Besides the symptoms commonly associated with early pregnancy, women with ectopic pregnancy commonly experience pelvic pain and bleeding. The pain is often one sided and the bleeding is often variable and may be the only sign of a complication. It should be noted, however, up to 20% of women with first trimester bleeding will go on to have a healthy pregnancy. Table 2 lists some of the more common signs and symptoms of an ectopic pregnancy to assist the practitioner in differentiating ectopic pregnancy from other gynecologic and non-gynecologic conditions. Until 1970, more than 80% of ectopic pregnancies were diagnosed after rupture, resulting in significant morbidity and mortality. With excellent resolution obtained from pelvic ultrasound, highly sensitive radio-immunoassays for human chorionic gonadotropin (hCG) and increased vigilance by clinicians, greater than 80% of ectopic pregnancies are now diagnosed intact which allows for more conservative management. Awareness of the possibility of an ectopic pregnancy is most critical for early detection. Measurement of hCG with a doubling time of 2-3 days should occur if it is a normal gestation.


^ SIGNS AND SYMPTOMS SUGGESTIVE OF ECTOPIC PREGNANCY

• Nausea, breast fullness, fatigue, amenorrhea

• Lower abdominal pain, heavy cramping, shoulder pain

• Uterine bleeding/spotting

• Pelvic tenderness, enlarged, soft uterus

• Adnexal mass, tenderness

• Positive pregnancy test

• Serum levels of hCG <6000 mIU/mL at 6 weeks

• Less than 66% increase in hCG titers in 48 hours.

• Serum progesterone <25 ng/mL

• Aspiration of non-clotting blood on culdocentesis

• Absence of gestational sac in the uterus by U/S when the hCG titer exceeds 2500 mIU/mL

• Gestational sac outside the uterus by U/S


^ DIFFERENTIAL DIAGNOSIS IN CASES OF SUSPECTED ECTOPIC PREGNANCY

• Spontaneous abortion

• Ruptured ovarian cyst

• Corpus luteum hemorragicum

• Adnexal torsion

• Pelvic inflammatory disease

• Endometriosis

• Urolithiasis

• Urinary tract infection

• Appendicitis


^ TREATMENT OPTIONS

Treatment options for ectopic pregnancy have broadened substantially in the past 10-15 years. Prior to this, laparotomy with salpingectomy was the standard of care. Due to better resolution ultrasound and earlier diagnosis, improved microsurgical laparoscopic techniques and chemotherapeutics, a more conservative approach has been taken in order to preserve tubal function. Laparoscopic treatment of this condition is growing in popularity and is currently considered the standard of care. Even hemodynamic instability is not an absolute contraindication to laparoscopy. The availability of optimal anesthesia, advanced cardiovascular monitoring, ability to convert quickly to laparotomy, and superior magnification given by laparoscopy make it a viable option and possibly the best choice. Laparoscopy also has lower morbidity, shorter hospital stays and decreased costs as well as decreased need for postoperative analgesia, and some studies have also shown that laparoscopy achieves superior pregnancy rates to laparotomy. Since the 1970s, a conservative approach to unruptured ectopic pregnancy has been advocated by many of the leading authorities in our field. There are several different types of conservative surgery that can be performed. These include linear salpingostomy, partial salpingectomy with anastomosis, and ‘milking’ the pregnancy from the distal ampulla.


^ SURGICAL MANAGEMENT BASED ON LOCATION

The location, size, and extent of the tubal pregnancy are observed laparoscopically. The management of each ectopic pregnancy is based upon these factors. Whatever the surgical approach chosen, adequate hemostasis with minimal trauma is optimal and should be obtained with as little cauterization as possible. All surgical approaches start by identification and mobilization of the involved fallopian tube and inspection of the uninvolved side.


^ AMPULLARY ECTOPIC

Once diagnosed, if the pregnancy is in the mid-ampullary segment as in the majority of cases, a 5-7 mL dilute solution of vasopressin (20 U/100mL of NS) is used. This is injected with a laparoscopic needle into the mesosalpinx just below the pregnancy and over the anti-mesenteric surface of the segment containing the gestation. It is extremely important to make sure that the vasopressin is not injected directly into a blood vessel as it can cause arterial hypertension, bradycardia and death. Using a laser, microelectrode, scissors, or harmonic scalpel a linear incision is made over the pregnancy approximately 1-2 cm in length. As one makes this incision the contents of the pregnancy usually begin to extrude. This can be completed by hydro dissection or using gentle traction with laparoscopic forceps. In some cases, more forceful irrigation in the salpingostomy incision may be required to dislodge the pregnancy from its implantation site. Occasionally, coagulation is used to secure hemostasis and is best accomplished with bipolar micro-forceps. Oozing from the tubal bed is common and usually ceases spontaneously. Copious irrigation is used to dislodge trophoblastic tissue and remove blood from the peritoneal cavity. The tubal opening is left to heal by secondary intention, unless the defect is wide and the edges do not come together spontaneously. For such cases, the edges may be approximated with a single 4-0 absorbable suture. If the pregnancy is located in the distal ampullary segment of the tube, then, occasionally, the tubal segment can be grasped and the pregnancy ‘milked’ out the fimbriae of the tube. This can also be done for partially extruded tubal pregnancies and infundibular pregnancies.


^ ISTHMIC ECTOPIC

When the ectopic pregnancy implants in the isthmic portion of the tube, linear salpingostomy is not as successful because typically these pregnancies grow through the lumen of the tube and erode the muscularis. Isthmic ectopic pregnancies have a higher rate of persistence and tubal patency is seldom preserved. With isthmic tubal pregnancy, segmental tubal resection is preferred. This can be accomplished by various means (i.e. bipolar, laser, sutures, or stapling devices). Bloodless resection is optimal and may be accomplished by using bipolar forceps, grasping both proximal and distal to the gestation and coagulating from the anti-mesenteric surface to the mesosalpinx. This is then cut and the mesosalpinx cauterized and cut in a similar fashion. The tube may be reanastomosed at a later date if desired.


SALPINGECTOMY

This technique is chosen in the presence of uncontrolled bleeding, tubal destruction, recurrent ectopic in that tube, patient desire, or severe adhesion or hydrosalpinx. The tube is removed from its anatomical attachments. This can be accomplished by numerous methods including laser, stapling devices, harmonic energy, endoloops, or progressive bipolar coagulation. Progressive coagulation and cutting the mesosalpinx begins at the proximal isthmus of the tube and progresses to the fimbriated end. The products of conception can be removed through a 10 mm trocar sleeve with or without the use of a plastic bag.


^ INTERSTITIAL/CORNUAL ECTOPIC

Fortunately, these types of ectopic pregnancies are rare with a prevalence of 1 in 5000 live births. Late diagnosis of this type of ectopic pregnancy, and the vascular nature of the cornua account for a mortality rate of 2%-2.5%. Some 2% to 4% of all ectopic gestations are interstitial/cornual. The traditional management of this type of ectopic gestation is laparotomy with salpingectomy and/or cornual resection. This surgery occasionally culminates in hysterectomy. It is important, however, to make a distinction between the interstitial ectopic and a true cornual ectopic pregnancy. The interstitial portion of the fallopian tube is approximately 1 cm long, has a narrow lumen and follows a tortuous course through a thick layer of myometrium. The cornual pregnancy, however, implants in this section of tube but opens to the uterine cavity, allowing hysteroscopy to be a potential method of surgical correction. The interstitial pregnancy implants deeper in this segment of the fallopian tube and is not accessible from the uterine cavity, thus, it is not amenable to hysteroscopic resection. If the diagnosis is made early and the patient is stable, more conservative approaches should be considered. These options include methotrexate locally or systemically, potassium chloride injections locally and prostaglandin administration. Once the diagnosis is confirmed and medical management is not possible, surgical treatment options are explored and consist of immediate laparotomy or a combined laparoscopic, and hysteroscopic approachEarly detection may afford one the option of a combined treatment using laparoscopy/hysteroscopy and methotrexate. If the gestation is truly cornual and accessible by hysteroscopy, it is resected using electrosurgery and removed. If the overlying myometrium is thin, a laparoscopic resection may be possible. But it is always prudent to have these patients typed and crossed for several units of packed red blood cells as well as consented for laparotomy.


^ OVARIAN PREGNANCY

Pregnancy located in the ovary itself is a rare occurrence. The incidence is 1 in 6970 live births and 0.7 per 100 ectopic gestations. Table 4 delineates Speigelberg’s criteria for the diagnosis of ovarian pregnancy established in 1878 and still in use today. Management of ovarian pregnancy can be either medical or surgical. Typically, they are diagnosed in the first trimester and can be definitively treated by oophorectomy. The ovarian ligament is grasped with bipolar forceps, cauterized and cut. The mesoovarium is then taken down in a progressive fashion. This can also be performed using an endoloop or with the harmonic scalpel.


^ CERVICAL PREGNANCY

This type of ectopic pregnancy is also very rare and in the past was treated by hysterectomy. Rubin first described criteria for diagnosis of a cervical pregnancy in 1911 as: cervical glands must be present opposite the placental attachment, 2) the attachment of the placenta to the cervix must be intimate, 3) the placenta must be below the peritoneal reflection of the anterior and posterior surfaces of the uterus, 4) fetal elements must not be within the uterine cavity. Conservative management now is by medical therapy with methotrexate when possible to avoid blood loss and hysterectomy. This has been proven safe, effective and preserves the patient’s fertility options for the future. Multiple case reports and a case series from Albert Einstein College of Medicine in New York have shown successful treatment of cervical pregnancies with selective uterine artery embolization along with methotrexate. This may also be an effective conservative therapeutic option for this complex condition especially when associated with significant vaginal bleeding.


ABDOMINAL PREGNANCY This type of ectopic can either be primary or secondary based on the initial implantation site. Occasionally, a tubal pregnancy will rupture and implant abdominally and continue to evolve. This can also occur with tubal abortions. The management for abdominal ectopic is strictly by laparotomy as these pregnancies are usually not diagnosed until third trimester. Implantation of the placenta can occur on any organ in the abdominal cavity. The delivery is by laparotomy and there is controversy on removal of the placenta at that time or at a later date. It may be more prudent to leave the placenta in situ after delivery and use the interventional radiologist to embolize the placental bed prior to removal in an attempt to conserve blood loss in this potentially catastrophic situation.


MANAGEMENT OF RUPTURED ECTOPIC PREGNANCY Presently, laparoscopy is considered the gold standard in treating patients with an unruptured ectopic pregnancy. Sometimes patients may present with ruptured ectopic pregnancy and surgical abdomen full of blood and blood clots. Those patients may frequently be approached laparoscopically and there may be no need for laparotomy in patients with a ruptured ectopic pregnancy. There are several factors you need to keep in mind when performing laparoscopy in these patients. Establishment of the pneumoperitoneum and placement of the trocar may be just as quick as performing laparotomy. When placing the Veress needle in the abdomen filled with blood, you may encounter higher initial insufflation pressures, since the tip of the needle may be immersed in blood. Only a sponge stick should be placed in the vagina for uterine manipulation, to avoid disruption of a possible intrauterine pregnancy. After the placement of the umbilical trocar and insertion of the laparoscope, the patient should be placed in steep Trendelenburg position and a suprapubic port should be inserted and grasper introduced for quick localization of the ruptured tube, and to tamponade the bleeding site. After the bleeding area has been compressed, attention should be turned toward the removal of blood and blood clots. A cell saver is a great way to replace the patient’s blood loss with her own blood and it may be utilized whenever a large blood loss is encountered. Blood clots should be removed with the help of the 5 mm laparoscopic suction device. The 10 mm suction does not offer any advantages since it is reduced to 5 mm in the instrument’s handle. The best way to remove blood clots is to apply constant suction on the suction device, and to aspirate the clots and break them by pulling the suction tip into the 5 mm trocar. This maneuver breaks the clots and helps to evacuate them through the suction aspirator. Try to avoid excessive irrigation since the fluid in the abdomen lifts the bowel, which in turn decreases your area of vision. After the blood has been removed from the abdominal cavity, proper assessment of the ectopic pregnancy can be made and an adequate treatment plan developed.


CONCLUSION

Ectopic pregnancy remains an increasing health problem. Its incidence continues to rise, paralleling the progressive increase in the incidence of its etiologic factors, especially sexually transmitted diseases and advanced reproductive technologies. With improved ultrasonography and minimally invasive techniques, the surgical management of this worrisome condition can be accomplished with minimal trauma. Minimally invasive surgery and medical management have similar success to laparotomy with less morbidity and improved patient care and fertility.

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