Sterilization by laparoscopy

Abstract

Today, female sterilization is most easily accomplished by single-puncture laparoscopy and, ideally, is carried out under local anesthesia. In experienced hands, electrocoagulation offers slightly fewer failures if a large portion of tube or two segments are destroyed. Fulguration of a small portion of tube, bands, or clips offer a better chance of reversal. It is extremely important that the operator be familiar with and use proper equipment, along with following a rigid format, if complications are to be kept to a minimum. The underlying theme for this article, and all of the articles published, shows that, regardless of the method employed to interrupt the tubes, the complication and failure rates are usually more a function of the experience of the operator than of the method employed.

PIP: This discussion of sterilization by laparoscopy reviews the following: indications and contraindications; preoperative patient preparation; anesthesia; the procedure; preparation and draping; tubal interruption (unipolar electrocoagulation, bipolar electrocoagulation, silastic bands, and Hulka clips); pregnancy rates; complications (electrothermal burns, bleeding, infection); and reversibility. The major indication for laparoscopy should be permanent sterilization. There are no absolute contraindications. Each surgeon needs to establish his/her own limitations. Conditions such as previous multiple abdominal surgical procedures, known adhesions, and serious medical disease increase the risk of complications and fall under a classification of relative contraindications. Each patient should have a complete history, physical examination, and Papanicolaou smear before the laparoscopy. The surgery may be performed any time throughout the menstrual cycle. Currently, female sterilization is most easily accomplished by single puncture laparoscopy and, ideally, is performed under local anesthesia. In experienced physicians, electrocoagulation offers slightly fewer failures if a large portion of tube or 2 segments are destroyed. Fulguration of a small portion of tube, bands, or clips offer a better chance of reversal. In regard to the reported statistics for pregnancies following sterilization, there is a wide variation in the results. Pregnancies after laparoscopic sterilization by any method occurs for 2 reasons and in 2 ways. Luteal phase pregnancies, which occur before the procedure is performed, are reported with an average rate of 2.4/1000 cases. In an effort to reduce these, some surgeons insist on good contraception before surgery and limit the operation to the preovulatory time of the menstrual cycle. The procedure may fail because the method may fail or may be performed incorrectly. Assuming the tube has been burned, banded, or clipped correctly, failures may occur because of uteroperitoneal fistual formation or recannulization of the tube. This may occur if less tube is destroyed or if it is not separated. If the failure is secondary to the operator, there will be more intrauterine pregnancies. If it is due to the method, the incidence of ectopic pregnancies will usually be higher. With proper training, operator failures should be eliminated. Loffer and Pent report no failures in 2249 cases; the author has had none in 5500 cases. The complication as well as the failure rates are usually more a function of the operator than of the method used.