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Subject: Laparoscopic Tubal Cauterization
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General endotracheal anesthesia
Oral gastric tube
Laparoscope with light source
Bipolar operating forceps
Hulka uterine manipulator (optional)
No. 11 blade
Two trocars—10 mm and 5 mm
0 and 4.0 absorbable monofilament
Patient requests permanent surgical sterilization
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
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.
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.
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.
PITFALL: In obese patients, the trocar is introduced directly into the abdomen at a 90-degree angle.
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.
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.
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.
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.