LOUPES OR MICROSCOPE FOR TUBAL ANASTOMOSIS? AN EXPERIMENTAL STUDY*

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FERTILITY AND STERILITY Cpyright e 1980 The American Fertility Sciety Vl. 4, N., September 1980 Printed in U.SA. LOUPES OR MICROSCOPE FOR TUBAL ANASTOMOSIS? AN EXPERIMENTAL STUDY* BERNARD HEDON, M.D.t MYRA WINEMAN, B.

1 FERTILITY AND STERILITY Cpyright e 1980 The American Fertility Sciety Vl. 4, N., September 1980 Printed in U.SA. LOUPES OR MICROSCOPE FOR TUBAL ANASTOMOSIS? AN EXPERIMENTAL STUDY* BERNARD HEDON, M.D.t MYRA WINEMAN, B.Sc. ROBERT M. L. WINSTON, M.D., M.R.C.O.G.:j: Department f Obstetrics and Gynaeclgy, Hammersmith Hspital, Lndn, England. Standardized tubal anastmses were perfrmed alternatively using magnifying lupes r an perating micrscpe in 44 rabbits. The surgen's persnal assessment f the integrity f the anastmses was subsequently cmpared with the histlgic result and with pregnancies and nidatin indices. After an initial learning perid, the surgen became equally satisfied with his intraperative assessment f the anastmses in bth treatment grups. Healing was marginally better when the micrscpe was emplyed. Animals which had tubal anastmsis perfrmed with the use f the micrscpe became pregnant in 81 'k f cases, whereas when the lupes were emplyed nly 50/, became pregnant. Measurement f the nidatin index shwed similar trends. It is cncluded that the use f the micrscpe will ffer superir results nce the surgen has gained limited experience with its use. Fertil Steril 4:64, 1980 There has recently been enrmus interest in the applicatin f micrsurgical techniques in infertility surgery. Currently the best results fr human tubal anastmsis have prbably been achieved with the use f the micrscpe, 1, but sme surgens have prduced apparently cmparable results using lupes, and Williams 4 has achieved excellent results using nly the naked eye. Hwever, since the selectin f cases fr surgery varies cnsiderably in different centers,5 it is impssible t make valid cmparisns. This study was designed t cmpare the functinal and pathlgic sequelae f tubal anastmsis with the use f either lupes r a micrscpe and a standardized surgical technique in an ex- Received July 7, 1979; revised September 19, 1979; accepted July 5, *Supprted by the Tubal Surgery Research Fund, Hammersmith Hspital, and by a grant frm the Academie Franc;aiset B.H. tpresent address: Service de Gyneclgie Obstetrique(Prf. G. Durand and Prf. J. L. Viala), 4000 Mntpelier, France. :j:reprint requests: Rbert M. L. Winstn, M.D., M.R.C.O.G., Department f Obstetrics and Gynaeclgy, Hammersmith Hspital, 150 DuCane Rad, Lndn W1 OHS, England. perimental mdel. Thrughut this experiment, the anastmses were perfrmed in the rabbit tubal ampulla. The rabbit ampulla was chsen as it is cmparable in size t the human tubal isthmus (Fig. 1) and presents rughly similar surgical difficulty. All f the anastmses were perfrmed by the same surgen, wh had n previus micrsurgical experience. In rder t bviate bias due t the learning prcess, each dd-numbered rabbit in the FIG. 1. Cmparisn f rabbit tubal ampulla <R) and human tubal isthmus (Wl. 64

2 Vl. 4, N. LOUPES OR MICROSCOPE FOR TUBAL ANASTOMOSIS? 65 FIG.. Histlgically "gd" anastmsis (arrw shws suture material). series was perated upn using the micrscpe and each even-numbered rabbit, the lupes. Histlgic assessment was made n a strictly blind basis s that the bserver was nt aware which technique had been used fr surgery. MATERIALS AND METHODS Mature female New Zealand White rabbits weighing between.8 and.8 kg were used thrughut. They were individually caged and had access t a standard pellet diet and water ad libitum. They were hused in a rm at 18 C ± n a light/dark cycle f 16 hurs/8 hurs/4 hurs. Anesthesia was induced using fentanyl (Hypnrm; Janssen ChemIcals, CraWley, England), 1 t 1.5 ml intramuscularly depending n the animal's weight. Maintenance was achieved with up t 1% fluthane given by mask in pure xygen ( liters/ minute). Instruments were rutinely sterilized befre surgery, but ttal aseptic technique was nt emplyed. The abdmen was pened using a flank incisin 6 in rder t minimize tissue handling, starting invariably n the right side. Surgery was always cnducted with standard micrsurgical principles such as avidance f peritneal abrasin and istnic irrigatin with Ringer's-lactate slutin. Adjuvants such as sterids were nt used. Altgether, 44 animals were used. Twenty-tw animals underwent bilateral tubal anastmsis using the Zeiss perating micrscpe (magnificatin between x.5 and x 5), and alternately twenty-tw animals underwent bilateral anastmsis using Keeler perating lupes (fixed magnificatin x 4.5). The tubal ampulla was first divided t cm frm the ampullary-isthmic junctin and immediately rejined ver a plyethylene splint f 0.45 mm external diameter. Hemstasis was cmpleted using biplar cagulatin and Winstn tubal clamps (Spingler-Tritt, Jestetten, West Germany). The anastmsis was made using 10-0 mnfilament nyln n a rund-bdied needle in ne layer, using six t eight interrupted sutures, aviding the mucsa. Vital staining f the mucsa with methylene blue was used as an aid t delineatin fthe epithelium and musclaris in each case. Care was taken t btain cmplete reperitnealizatin, and the messalpinx was repaired with 10-0 nyln after each anastmsis. Befre the wund was clsed in layers, the spint was remved and all bld clts were carefully washed frm the peritneum. The Ringer's-lactate slutin was left in the abdminal cavity. Chlramphenicl (00 mg) was given intramuscularly fr days after surgery. All anastmtic prcedures were timed frm "skin-t-skin," using a stpwatch, and n cmpletin f surgery the peratr scred hw gd an anastmsis he thught he had achieved. The fllwing scring system was emplyed: 1, the anastmsis appeared t have n chance f success;, the anastmsis appeared kinked r distrted but therwise cmplete;, the anastmsis lked satisfactry but difficulties with hemstasis r tissue handling had been encuntered; 4, the surgen was cmpletely satisfied with the anastmsis. Fifteen days after the first peratin, the rabbits were anesthetized and lapartmy was again perfrmed. In successive animals the left r right tube was alternately remved tgether with its ipsilateral vary. At this lapartmy, tubal patency t dye was tested n the side prir t salpingectmy and adhesins were measured using the scring FIG.. Histlgically "mderate" anastmsis (arrws shw ectpic mucsa).

66 HEDON ET AL. FIG. 4. Histlgically "bad" anastmsis (arrw shws intraluminal suture material>. Nte that the anastmsis can be patent even thugh the tube is very badly damaged. system reprted by Winstn.

3 66 HEDON ET AL. FIG. 4. Histlgically "bad" anastmsis (arrw shws intraluminal suture material>. Nte that the anastmsis can be patent even thugh the tube is very badly damaged. system reprted by Winstn. 6 The resected tube was fixed in buffered 10% frmaldehyde and cded fr blind histlgic study later. Functinal Evaluatin. One week after salpingectmy each animal was mated with a buck f prven fertility. After successful mating had been bserved, 50 IV f human chrinic gnadtrpin were given intravenusly t augment vulatin. Twelve t sixteen days after mating, dublepuncture laparscpy was perfrmed thrugh tw midline substernal incisins. The remaining vary was carefully inspected and the crpra lutea were cunted. The uterine hrn was als carefully inspected and the number f gestatinal sacs was recrded. If the animal was pregnant it was immediately killed, its abdmen was pened, and the numbers f crpra lutea and gestatinal sacs were checked by an independent bserver. In six cases after use f the micrscpe and in thirteen after use f lupes the animals were nt pregnant after the first mating. These rabbits were mated a secnd time, 1 days later. The nidatin index, that is, the rati fnidatins divided by the number f crpra lutea, was subsequently calculated. Histlgic Evaluatin. Fllwing fixatin, each resected tube was embedded in paraffin. The anastmsis was munted transver,sely, and 5-/-lm serial sectns were cut frm 100-/-lm strips. An interval f 00 /-lm was left unmunted between eeich strip, and the entire specimen was sectined t make certan that the whle fthe anastmsis and its immediate vicinity were included fr histlgic evaluatin. Sectins were stained with Ehrlich's hematxylin and esin fr general architecture and Gmri's trichrme stain fr cllagen and fibrsis. September 1980 Each set f serial sectins was given a cde number s that the qualified histlgist reading the sectins was unaware f the methd f anastmsis r its stage in the experiment. After the evaluatin f histlgic changes, the slides were again checked by a secnd bserver wh was als unaware f the nature f the anastmsis. Histlgic evidence f damage was recrded with regard t the number f sectins shwing fibrsis and excess cllagen, ectpic islands f mucsa in the muscular layer, flattening r agglutinatin f mucsal flds, desquamatin r lss f mucsa, the presence f inflammatry exudates, and disrganizatin f the general tubal architecture. The anastmsis was then assessed as fllws: "gd," when there was n grssly abnrmal change, and nly minr disturbances were apparent in three r fewer 100-/-lm strips (i.e., damage extending fr less than 1 mm) (Fig. ); "mderate," when the tubal architecture was partially destryed r when damage extended int mre than three loo-/-lm strips (i.e., damage invlving mre than 1 mm f tube) (Fig ); "bad," when the tubal architecture was cmpletely disrupted in ne set f sectins r mre (Fig. 4). RESULTS Tw animals which had undergne anastmsis with the use f the micrscpe died 4 hurs after surgery. This appeared t be due t prblems with anesthesia early in the experiment. Duratin f the Anastmtic Prcedure (Fig. 5). After an initial learning perid (five animals with Time needed fr bilateral tubal anastrrsis Micrscpe: lupes: Number f ani mal FIG. 5. Duratin f prcedure frm the first incisin t skin clsure in successive animals.

4 Vl. 4, N. LOUPES OR MICROSCOPE FOR TUBAL ANASTOMOSIS? 67 1 Surgen's assessment.18. II ::=:=:=: III11111 :::::::: ::=:=:=: :.:.:.:..:.:.:.: :::::::: lupes Mic. FIG. 6. Surgen's assessment f the anastmsis. See text fr explanatin f scring system. each technique), the ttal perating time fell by half and thereafter each experiment required prgressively less time t cmplete. The mean time fr bilateral anastmsis using the micrscpe was hurs and 4 minutes; with lupes, hurs and 56 minutes. Operating with lupes, therefre, decreased the perating time by nly 14%. Surgens's Assessment (Fig. 6). After the initial learning perid, the surgen's assessment f hw well the prcedure had gne was nt markedly different whether lupes were emplyed r the perating micrscpe. Pstperative Adhesins. There was n difference between adhesin frmatin in the tw grups f rabbits. Tubal Patency (Fig. 7). Tubal patency was marginally better fllwing surgery with the use fthe micrscpe. The patency rate was greater than 90% in bth grups. Histlgic Study (Table 1). Fifty per cent f the anastmses perfrmed using the micrscpe were regarded as "gd," as ppsed t % f thse perfrmed using lupes. All f the anastmses classified as "bad" were perfrmed during the first third f the experiment. If the early anastmses are eliminated, then 71.5% f the micrscpe grup can be classified as "gd" as ppsed t 50% f thse perfrmed with lupes. These figures are nt statistically significant (Wilcxn rank-sum test). Pregnancy and Nidatin Index (Fig. 8). The number f pregnant animals fllwing surgery with the micrscpe was nearly 0% mre than the number achieving pregnancy after anastmsis using lupes. Mrever, the disparity between the nidatin index in the tw grups was even mre marked, suggesting that the efficiency f tubal functin was much mre impaired when lupes were emplyed. This disparity was apparent even in animals perated upn at the end f the experiment, when the surgen had gained cnsiderable micrsurgical experience. Unfrtunately, the difference des nt quite reach the level f statistical significance, and mre animals are needed t demnstrate this trend. DISCUSSION Althugh ur results d nt quite shw a statistically significant difference in the tw treatment grups, the trends undubtedly suggest that peratins in the experimental mdel are mre likely t be succesful when the micrscpe is emplyed. In view f the fact that the lumen f the rabbit ampulla is actually larger than the luminal diameter f the human isthmus, we believe that these 1 Patency test. lupes.55 Mic. FIG. 7. Assessment ftubal patency., fully patent;, patent with hld up; 1, patent with extravasatin; 0, cmpletely blcked.

5 68 HEDONETAL TABLE 1. Histlgic Assessment f Anastmses Visual aid Micrscpe Lupes AssessmentO f anastmsis "Gd" "MOderate" "Bad" 10 (50%) 6 (0%) 4 (0%) 7 (1.8%) 10 (45.4%) 5 (.8%) asee text fr criteria fr assessment. Ttal n. frabbita 0 bservatins are directly relevant t techniques used fr human tubal anastmsis. The accuracy f the anastmsis is prbably even mre imprtant in humans, as usually nly ne egg travels the tube in a given menstrual cycle. Mrever, there is cnsiderable evidence that minr disturbances f the tubal architecture after anastmsis may lead t the develpment f ectpic pregnancy-a cnditin unknwn in the rabbit. The decrease in nidatin index fllwing the use flupes may be particularly imprtant in this respect, suggesting minr, histlgically undetectable, areas f damage which may have impaired the ver-all efficiency f tubal transprt in these animals. It is interesting that the surgen was quite satisfied with the anastmsis in mst cases, that results f patency test were gd, and that adhesin frmatin was nt nticeably different in either grup. Therefre, we believe that the use f lupes may give a false sense f the perfectin f the anastmsis. Furthermre, it is clear that patency tests prvide an inadequate assessment f functinal status. Several f ur anastmses which were fully patent were subsequently seen by histlgic experimentatin t have undergne severe changes. Althugh it was pssible t realize a histlgically satisfactry anastmsis using lupes, anastmses prduced using the micrscpe were generally f better quality and cntained less fibrsis and ectpic mucsa. It has been predicted that the micrscpe will never be widely used because f inherent technical difficulty in perfrming peratins with it. In this study, the micrscpe was used by a surgen with n previus micrsurgical experience, and we have shwn that the use f the micrscpe lengthened the time f the prcedure by nly 14%. Equally pertinent is 100 ~O % 81.5 September 1980 Pregnancy rates & nidatin indices I Mic. Lupes Mic. Lupes Pregnancies. Nidatin index FIG. 8. Pregnancies and nidatin index fllwing mating after unilateral salpingectmy. Nidatin index was calculated as rati f number f embrynic sacs divided by number f vulatins. the bservatin that in bth grups adequate anastmses were cnsistently btained after a learning prcess invlving nly five r six animals in each grup. Acknwledgments. The authrs are grateful t P. Mre, histlgic technician, and t Mr. P. O'Dnghue and his staff fr care given t animals in the study. REFERENCES 1. Winstn RML: Micrsurgical tubcrnual anastmsis fr reversal f sterilizatin. Lancet 1:84, Gmel V: Tubal reanastmsis by micrsurgery. Fertil Steril 8:59, Jnes HW Jr, Rck JA: On the reanastmsis f fallpian tubes after surgical sterilizatin. Fertil Steril9:70, Williams EA: Results f reversal ffemale sterilizatin. In Reversibility f Female Sterilizatin, Edited by I Brsens, R Winstn. New Yrk, Academic Press, 1978, p Pauerstein CJ: Frm Fallpius t Fantasy. Fertil Steril 0:1, Winstn RML: Micrsurgical reanastmsis f the rabbit viduct and its functinal and pathlgical sequelae. Br J Obstet Gynaecl 8:51, 1975

AN ANALYSIS OF MACROSURGICAL AND MICROSURGICAL TECHNIQUES IN THE MANAGEMENT OF THE TUBOPERITONEAL FACTOR IN INFERTILITY

FERTILITY AND STERILITY Cpyright 979 The American Fertility Sciety Vl. 32, N.4, Octber 979 Printed in U.s.A. AN ANALYSIS OF MACROSURGICAL AND MICROSURGICAL TECHNIQUES IN THE MANAGEMENT OF THE TUBOPERITONEAL