A NEW APPROACH TO TUBAL STERILIZATION BY LAPAROSCOPY

Transcription

1 FERTILITY AND STERILITY Copyright < 1978 The American Fertility Society Vol. 30, No.4, October 1978 Prinred in U.SA. A NEW APPROACH TO TUBAL STERILIZATION BY LAPAROSCOPY RAFAEL F. VALLE, M.D.* HECTOR A. BATTIFORA, M.D.t Department of Obstetrics and Gynecology, Northwestern University Medical School and Prentice Women's Hospital and Maternity Center, and Department of Pathology, Northwestern University Medical School and Northwestern Memorial Hospital, Chicago, Illinois Laparoscopic tubal sterilization has been rapidly gaining acceptance as a nonpuerperal method of permanent fertility control. A number of problems have nonetheless been associated with this technique. For example, tubal destruction often exceeds that necessary for tubal occlusion, increasing the danger of thermal injuries and possibly such dysfunctional disorders as abnormal uterine bleeding and dysmenorrhea. Furthermore, excessive destruction precludes any possibility of later tubal reconstruction. In an attempt to avoid these problems, a new low-voltage unit with a rechargeable battery was evaluated. With this unit, cautery is provided under laparoscopic view with a spring-activated hook which retracts the fallopian tube into a Teflon shield, where it is coagulated and transected. Histopathologic studies of the healthy fallopian tubes off our women in their reproductive years treated by this method while the abdomen was open prior to an elective hysterectomy demonstrated minimal destruction of the mesosalpinx, with complete tubal occlusion and a coagulated area 10 mm in length. One hundred and sixty-five patients have been sterilized successfully by this method. Indications are that it may provide safe tubal occlusion without unnecessary destruction of the fallopian tubes and surrounding vasculature. Fertil Steril30:415, 1978 Surgical sterilization has achieved a role in the control of human fertility that is second only to oral contraceptives in importance. In the United States, for married couples over the age of 30 who have as large a family as they want, sterilization is currently the most frequently chosen method of family planning.! The number of sterilized men and women in the United States is well over 10 million. 2 Received November 7, 1977; revised March 20, 1978; accepted June 1, * Assistant Professor, Department of Obstetrics and Gynecology, Northwestern University Medical School. To whom reprint requests should be addressed at Prentice Women's Hospital and Maternity Center, 333 East Superior Street, Suite 150-C, Chicago, Ill tprofessor, Department of Pathology, Northwestern University Medical School. 415 Laparoscopic sterilization is presently one of the most commonly performed gynecologic operations and appeals to patients because of its cosmetic results, speed, minimal expense, relative safety, and short recovery time without undue interference with daily life. Over 90% of the sterilizations utilize electrosurgical techniques. 3 With the increasing numbers of laparoscopic sterilizations, problems and complications have been reported, particularly related to electrocoagulation with the unipolar system and spark-gap generators, producing thermal injuries in structures surrounding the fallopian tubes. Although improvements in instrumentation and techniques (such as high-frequency, low-voltage, isolated units, bipolar coagulation,4 and endothermic coagulation as recommended by Semm 5) have resulted in a marked decline in the

2 416 VALLE AND BA'ITlFORA October 1978 FIG. 1. Waters thennocautery unit model 138 with ancillary equipment for tubal coagulation and transection. The unit is provided with buttons which light when charging, testing, or operating. number of thermal complications, those that do occur generally have serious consequences. 6 Furthermore, with the large amount of tubal destruction produced by electrocoagulation, reanastomosis is virtually impossible-a fact that is of concern particularly to young women who might desire later reversal of the procedure. Considerable research interest has focused on mechanical methods of sterilization utilizing Silastic bands, rings, and other devices that eliminate the need for electrosurgery.7 Another possible approach, however, is the use of a batterycharged, low-voltage thermocautery unit which, while producing a lesion that achieves symmetrical tubal division, causes limited, discrete tissue destruction. One such unit, utilizing 6 volts of current, has been evaluated; the results of a preliminary study are reported here. MATERIALS AND METHODS Instrumentation. The thermocautery unit (model 138; Waters Instruments, Inc., Rochester, Minn.) used in the study is a compact, portable, self-powered unit which has a rechargeable battery and operaties with an audible and visible signal when activated. The system cannot be activated when the battery-charging cord is connected to the back of the cabinet, thus ensuring safety and independent operation. Because the electrical circuit is complete within the cautery hook assembly, no electric current passes through the body tissues, eliminating need for a ground plate (Fig. 1). A spring-loaded, semidisposable hook is used to grasp the tube and provide adequate cauterization before division. A Teflon cannula 8 mm in diameter and a pyramid type trocar are required for a second puncture to permit the introduction of the coagulator and transector (Figs. 2 and 3). Technique at Laparoscopy. Laparoscopy is performed in the usual fashion. Before activation of the unit, adequate pneumoperitoneum, empty bladder, uterine mobilization, and adequate Trendelenburg position are assured. The accessory trocar is introduced through the second

3 Vol. 30, 0.4 T BAL RILIZATI. ' BY LAPAR OPY 417 FI J. 2. Tubal hook. T flon outer cannula i ctor. Th pyramid t p trocar with th carre pondin Fl. 3. Tip of th coa uta or-tran ctor.

4 418 VALLE AND BATTIFORA October 1978 FIG. 4. Laparoscopic view of the tubal coagulator-transector lifting the fallopian tube for identification. puncture while the abdominal wall is transilluminated, to avoid damage to crossing vessels, and is advanced under direct vision. The tube is lifted by the spring-loaded hook about 3 to 4 cm from the cornual junctions without including the mesosalpingeal vessels. Having been retracted by releasing the spring-loaded hook, the tube is then separated from the surrounding structures. The FIG. 5. Laparoscopic view of the fallopian tube retracted into the Teflon shield by the thermocautery hook coagulator and transector.

5 Vol. 30, No.4 TUBAL STERILIZATION BY LAPAROSCOPY 419 FIG. 6. Tubal segments after coagulation a rl transection, as viewed through the laparoscope. unit is activated; after 35 to 40 seconds of electrocautery, the hook automatically transects the fallopian tube under the Teflon shield, indicating the end-point of the procedure. Some smoke is produced at the end of the cauterization, but this escapes freely through the cannula without interfering with vision (Figs. 4 to 6). Method. In order to document obstruction and FIG. 7. Photomicrograph of the transverse histologic sections of the fallopian tube on either side of the division after thermocautery.

6 420 VALLE AND BA TTIFORA October 1978 FIG. 8. Photomicrograph of the longitudinal sections of the fallopian tube on either side of the division after thermocautery. The left side of the upper segment and the right side of the lower segment have been cauterized. Note the microrule indicating size in divisions of 0.1 mm. the length of tube actually cauterized, four women underwent tubal electrocautery and division by this method at laparotomy. These were women in their reproductive years without evidence of pelvic pathology, who were scheduled for hysterectomy to treat benign conditions. ~'hile the abdomen was open and the pel vic structures were exposed, prior to the clamping of any vessel and to the hysterectomy itself, cauterization was performed on the fallopian tubes as it would be during laparoscopy. Transverse sections of the cauterized segments were fixed in formalin and reviewed for luminal obstruction, and longitudinal sections were studied to determine the amount of cauterized tissue on either side of the division. RESULTS The following macro- and microscopic changes were noted: Macroscopic Description. The usual blanching of the tissues secondary to electrocautery was noted. Minimal mesosalpingeal destruction had occurred and there was no apparent destruction of ovarian collateral vessels. No bleeding was observed after the completion of the procedure, and the remaining segments were clearly visible. The changes seen at laparotomy were identical with those observed through the laparoscope. Microscopic Description. Histopathologic studies revealed that the total length of tubal destruction was 10 mm (Figs. 7 and 8). The transverse sections showed complete luminal occlusion. The longitudinal sections demonstrated a TABLE 1. Patients Sterilized with a Shield Cautery Technique under Laparoscopy Period of time January 1, 1976 to December 31, 1976 January , to December Total No. of patien

7 Vol. 30, No.4 TUBAL STERILIZATION BY LAPAROSCOPY 421 ~ rffi 2 3 FIG. 9. Schematic representation of the shielded cautery technique followed by automatic symmetrical division of the fallopian tubes. 5-mm segment of tube cauterized on either side of the division, providing symmetrical destruction of the remaining segments. On the basis of these findings, this method of sterilization was then successfully used in 165 patients ranging in age from 22 to 38 (mean age 28) who requested sterilization by laparoscopy during a 2-year period (Table 1). The longest follow-up period is therefore no longer than 2 years, but 80 patients have had at least 12 months of follow-up after the operation. All patients have at least two living children, with the exception of two women sterilized for medical and psychiatric indications. In 25 women, sterilization was performed simultaneously with a firsttrimester pregnancy termination. To date, no complications or failures have resulted from this method of tubal sterilization. DISCUSSION Oflate, "permanent" contraceptive methods have been sought which avoid massive destruction of the fallopian tubes and the mesosalpinx 2 FIG. 10. Schematic representation (1 and 2) of the "burn and division technique" by mechanical methods. In 3a, division is closer to the proximal tubal stump; in 3b, division is closer to the distal tubal stump. 3b 2 3 FIG. 11. Representation of the "burn and division technique" utilizing the Palmer type biopsy tongs for excision of a tubal segment. Note the division occurring close to the noncoagulated tubal segments. with the collateral ovarian vessels, while maintaining adequate effectiveness and simplicity, thus theoretically reducing the possible sequelae of dysfunctional uterine bleeding and dysmenorrhea. 8-1o A method was tested whereby, using a low-voltage fallop an tube coagulator and transector, division of the tubes can be accomplished exactly at the middle ofthe cauterized area, producing symmetrical coagulated segments on either side of the division (Fig. 9). Because destruction of the fallopian tubes is confined to an area 10 mm in length, it is more likely that tubal patency could be restored, should this be desired. Although the failure rate after 2 years' follow-up is zero, review of our results at a later date may give a more realistic evaluation of the success of this technique. Histologic studies demonstrating complete occlusion of the tubes, however, indicate that this method of sterilization will probably compare favorably with other conventional electrosurgical methods. Furthermore, the symmetrical division achieved eliminates subjective estimates of tubal destruction and precludes risk of the peripheral division which may possibly explain the occurrence of fistula formation (Figs. 10 and 11) This method may be particularly applicable for young women who may seek reanastomosis of previously sterilized fallopian tubes because of factors such as divorce or death of a spouse and subsequent remarriage, or loss of children. Because of the extensive tubal destruction resulting from standard electrocoagulation methods, reversal becomes impossible or extremely difficult with conventional 13 and even with microsurgical techniques of anastomosis. Although a single perfect method offemale sterilization applicable to all patients may never be achieved, presently there is great research interest in and patient demand for methods of

8 422 VALLE AND BATl'IFORA October 1978 contraception that, while highly effective, safe, and simple, are potentially reversible. 16, 17 Indications are that the method of female tubal sterilization described here may provide safe total tubal occlusion, without unnecessary destruction of the fallopian tubes and surrounding collateral vasculature of the ovary. REFERENCES 1. Westoft' CF, Jones EF: Contraception and sterilization in the United States, Fam Plann Perspect 9:153, Ravenholt RT: World epidemiology and potential fertility impact of voluntary sterilization services. In New Advances in Sterilization; Proceedings of the Third International Conference on Voluntary Sterilization, Edited by ME Schima, I Lubell. New York, Association for Voluntary Sterilization, Inc, 1976, p Phillips J, Keith D, Hulka J, Hulka B, Keith L: Gynecologic laparoscopy in J Reprod Med 16:105, Rioux JE, Yuzpe AA: Electrosurgery untangled, with emphasis on advances in laparoscopic tubal sterilization. Contemp Ob/Gyn 4:118, Semm K: Endocoagulation: a new field of endoscopic surgery. J Reprod Med 16:195, Schwimmer WB: Electrosurgical burn injuries during laparoscopy sterilization. Treatment and prevention. Obstet GynecoI44:526, Richart RM (Moderator): Sterilization: five experts compare the techniques. Contemp Ob/Gyn 9:56, Debrowski W, Hafez ESE: The uterus and control of ovarian function. Acta Obstet Gynecol Scand [Suppl] 12, Ringrose GAD: Post-tubal ligation menorrhagia and pelvic pain. Int J Fertil 19:168, Neil JE, Hammond GT, Noble AD, Rushton L, Letchworth AT: Late complications of sterilization by laparoscopy and tubal ligation. Lancet 2:699, Sheikh HH, Yussman MA: Ruptured ectopic pregnancy after bilateral laparoscopic tubal fulguration. Am J Obstet Gynecol 125:469, Shah A, Courey NG, Cunanan RG: Pregnancy following laparoscopic tubal electrocoagulation and division. Am J Obstet GynecoI129:459, Wheeless CR: Problems with tubal reconstruction following laparoscopic sterilization using the electrocoagulation and resection technique. Fertil Steril 28:723, Valle RF, Sciarra JJ: Microsurgical tubal reconstruction following laparoscopic tubal fulguration and division. Unpublished data 15. Winston RML: Microsurgical tubocornual anastomosis for reversal of sterilization. Lancet 1:284, Sciarra JJ, Droegemueller W, Speidel JJ (Editors). In Advances in Female Sterilization Techniques. Hagerstown Md, Harper and Row Publishers, Speidel JJ: The future of female sterilization technology. Int J Gynaecol Obstet 14:17,1976