Laparoscopic Tubal Cauterization

Danielle Cooper, MD
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Subject: Laparoscopic Tubal Cauterization

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Introduction

The laparoscopic tubal cauterization is a procedure used to permanently surgically sterilize a woman. This is an elective procedure with virtually no absolute contraindications unless the patient is a poor surgical candidate. There are numerous methods for achieving permanent sterilization, but many women prefer the laparoscopic technique due to its effectiveness, rapid recovery, and outpatient basis. Bipolar coagulation is now the most commonly used laparoscopic occlusion method in the United States. 
Even though this is considered a permanent form of contraception, reversal is possible. Informed consent is extremely important, with special attention given to the patient’s most common complaint postoperatively, which is regret. All other contraceptive options must be reviewed and documented as well as consent for a possible laparotomy incision if unexpected anatomy or complications are incurred intraoperatively. The patient must also be made aware of the risk of tubal ligation failure resulting in either an intrauterine pregnancy or an ectopic pregnancy. The 5-year cumulative probability of pregnancy for women with three or more sites of bipolar coagulation is 3.2 per 1,000 procedures. The 10-year cumulative probability of ectopic pregnancy after bipolar coagulation is 17.1 per 1,000 procedures. 
Another contraceptive method should be utilized for 1 month prior to the procedure, and a negative pregnancy test should be performed the day of surgery. Even though reversibility is an option, the patient must be made aware of the complications and expense associated with trying to reverse the tubal ligation. Even with reanastomosis, there is no guarantee of fertility. Younger age at the time of sterilization is a significant risk factor for developing future regret. There are nonsurgical, reversible, equally effective methods of contraception available to the patient, such as an intrauterine device or Depo-Provera, that should be discussed. The patient must be aware of the operative complications from both surgery and anesthesia. The option of male sterilization with vasectomy should be offered and explored with the patient prior to proceeding to the operating room. 

Equipment

  • Anesthesiologist

  • General endotracheal anesthesia

  • Oral gastric tube

  • Laparoscope with light source

  • Bipolar operating forceps

  • Ammeter

  • Blunt probe

  • Hulka uterine manipulator (optional)

  • No. 11 blade

  • Two trocars—10 mm and 5 mm

  • Needle driver

  • Veress needle

  • Saline

  • CO2 gas

  • Skin forceps

  • 0 and 4.0 absorbable monofilament

Indications

  • Patient requests permanent surgical sterilization

Contraindications

  • Poor surgical candidate due to cardiac or pulmonary disease

  • Morbidly obese, thus prohibiting laparoscopic use

  • Severe pelvic adhesive disease distorting anatomy, making fallopian tubes unidentifiable

  • History of previous tubal ligation failure—bilateral salpingectomy then indicated

The Procedure

Step 1

The patient is consented and taken to the operating room, where general endotracheal anesthesia is obtained and an oral gastric tube is inserted. She is placed in the dorsal lithotomy position utilizing Allen stirrups. 
  • Pearl: Positioning is very important to avoid unintentional injury. The arms of the patient may be tucked by her side to prevent brachial plexus injury; however, this may not be possible based on the patient’s body habitus. If the patient’s arms are perpendicular to her body, take precautions to not lean against her arms during the procedure.

  • Pearl: Some surgeons will utilize a shoulder harness because of the Trendelenburg positioning that will be necessary during the procedure. Others avoid these because of their high association with arm and neck injury.

Step 2

A bivalve speculum is inserted into the vagina. The cervix is cleaned with chlorhexidine cleanser. The anterior lip of the cervix is grasped, uterus sounded, and a Hulka uterine manipulator is inserted into the uterine cavity and attached to the anterior cervical lip. The initial tenaculum is removed. The speculum is removed from the vagina, and the bladder is drained. The nurse will then cleanse and drape the patient’s abdomen. 
  • PITFALL: It is possible to perforate the uterus with the uterine sound or the Hulka uterine manipulator; therefore, respect for the tissue needs to be maintained.

  • Pearl: The uterine manipulator is optional but will allow for better visualization and manipulation of the fallopian tubes. Some surgeons will just place a sponge stick in the vagina to raise the uterus into the visual field during the procedure.

Step 3

A 10-mm infraumbilical skin incision is made with the no. 11 blade. The abdominal cavity is lifted, and a Veress needle is inserted into the incision at a 45-degree angle until passing into the peritoneal cavity. 

Step 4

Placement is confirmed with saline dropped into the abdomen through the Veress needle. 
  • PITFALL: Umbilical hernias or previous surgeries may prevent Veress needle use, and a cutdown procedure may be needed to avoid bowel injury.

  • Pearl: In obese patients, the Veress needle is introduced directly into the abdomen at a 90-degree angle.

  • Pearl: If you are unable to manually grasp the abdomen and lift, towel clamps may be placed lateral to the incision and used to lift the abdominal wall.

Step 5

CO2 gas is instilled into the peritoneal cavity until 15 to 18 mm Hg of intra-abdominal pressure is achieved; usually at least 3 L of CO2 gas is needed for sufficient insufflation. 

Step 6

A 10-mm trocar is passed through the incision at a 45-degree angle, and a laparoscope is inserted to confirm intra-abdominal placement. The entire abdomen and pelvis are visually surveyed. 
  • PITFALL: In obese patients, the trocar is introduced directly into the abdomen at a 90-degree angle.

Step 7

The patient is placed in the Trendelenburg position. The uterine manipulator lifts the uterus into the visual field. A second 5-mm midline incision is made with the no. 11 blade, 2 cm above the pubic symphysis. A 5-mm trocar is placed through this incision under direct visualization with the laparoscope. 
  • PITFALL: Failure to empty the bladder prior to the start of the procedure can result in bladder perforation.

  • PITFALL: The trocar is aimed at the patient’s sacrum in the midline, and too lateral of placement can result in significant injury and hemorrhage.

  • Pearl: The uterus can be placed anterior to the bowel and protect both large and small bowel from injury with introduction of the second trocar.

  • PITFALL: Aggressive manipulation of the uterus can result in uterine perforation.

Step 8

A blunt probe used to expose the entire fallopian tube and ovary on each side and maneuver the remainder of the bowel out of the pelvis. 
  • PITFALL: Severe pelvic adhesive disease may limit the ability to visualize the entire fallopian tube, but this must be achieved. If significant adhesive disease is encountered, it may be managed laparoscopically; alternatively, convert the case to an open procedure, and perform a laparotomy.

Step 9

Bipolar operating forceps are used to grasp each tube in the ampullary region (approximately 2 to 3 cm from the cornu), placed on tension to ensure no contact with any other structures, and electrodessication is begun. Current is applied until an ammeter shows that tissue grasped has been completely desiccated. 

Step 10

Regrasp the tube adjacent to this area, and begin desiccation. This is performed until at least 3 cm of contiguous tube is destroyed. Repeat on the opposite fallopian tube. 
  • PITFALL: Care must be taken to ensure that no other structures contact the desiccating forceps due to peripheral burn that occurs causing injury. The most common reason for failure of this method is related to incomplete desiccation of the endosalpinx.

Step 10
Step 10

Step 11

Remove all instruments from the abdomen and pelvis. A single 0 absorbable monofilament suture is used to close the fascial incision at the infraumbilical port site. Any other port sites >5 mm will also need to be closed in a similar fashion. The skin is reapproximated with a 4.0 absorbable monofilament in a running subcuticular fashion. Operative sites are bandaged. The Hulka uterine manipulator is removed. The patient is awakened and taken to recovery room. Once postoperative anesthesia protocols are met, the patient may be discharged home. 
Step 11
Step 11

Complications

  • Mortality: Risk of death from tubal sterilization is 1 to 2 cases per 100,000 procedures; most of these are complications of general anesthesia. Cardiopulmonary arrest and hypoventilation are reported as the leading cause of death. Sepsis as a cause of death is directly related to bowel perforations or electrical bowel burns.

  • Unintended laparotomy occurs with 1% to 2% of laparoscopic procedures.

  • Bowel injury can occur during the insertion of the insufflation needle or trocar or during electrocoagulation. Small injuries from the needle or trocar with no bleeding or leakage of enteric contents can be managed expectantly; all others require prompt laparotomy.

  • Vascular injury can occur during insufflation needle or trocar insertion. Injury to a large vessel is life threatening, and immediate laparotomy with direct pressure to control bleeding until repair (usually by a vascular surgeon) can be performed.

  • Pain: Chest and shoulder pain may be experienced postoperatively due to trapped CO2 gas.

  • Tubal failure: Surgical sterilization is highly effective and considered a definitive form of contraception; however, it has a failure rate of 0.1% to 0.8% in the first year. At least one third of these are ectopic pregnancies.

  • Regret: Poststerilization regret is a complex condition caused by unpredictable life events. Young age, low parity, single-parent status, or being in an unstable relationship are risk factors for regret.

Postprocedure Instructions

The patient is advised to use over-the-counter nonsteroidal anti-inflammatory drugs for pain. A narcotic pain prescription may be given for any breakthrough pain she may be experiencing. If the patient experiences any fever (>100.4), heavy bleeding (> one pad per hour), abdominal pain (unrelieved by pain medication), and excessive nausea or vomiting, she should return to the hospital immediately. Follow up on an outpatient basis in 2 weeks to ensure proper healing of the incisions. 

Coding Information and Supply Sources

ICD-9 Code

Bibliography

American College of Obstetricians and Gynecologists. Benefits and Risks of Sterilization . ACOG Practice Bulletin 46. Washington, DC: Author;  2003.
Peterson HB, Xia Z, Wilcox LS, et al. for the U.S. Collaborative Review of Sterilization Working Group. Pregnancy after tubal sterilization with bipolar electrocoagulation. Obstet Gynecol.  1999;94:163–167. [View Abstract]
Stovall TG, Mann WJ. Surgical sterilization of women. Up to Date. Available at http://www.uptodate.com. Accessed July 1, 2008.
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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