Laparoscopic Tubal Occlusion

Laparoscopic tubal occlusion closes the fallopian tubes through small abdominal ports under direct vision, using a clip, silicone ring, bipolar coagulation or removal of the tube. It is an interval procedure and is not suited to the immediate postpartum period. Bilateral total salpingectomy is an alternative that also removes the tissue of origin of many ovarian cancers.

Mechanism. Mechanical or thermal closure, or removal, of the tube prevents sperm and ovum meeting.

Techniques. A clip is placed across the isthmus, a silicone ring is applied to a loop of isthmus, bipolar current coagulates and divides a length of isthmus, and salpingectomy removes the tube up to the cornua with bipolar sealing.

Effectiveness. First-year pregnancies are 0.5 per 100 women with typical use and 0.5 per 100 women with perfect use. Bipolar coagulation and clips carry higher long-term failure and a higher proportion of ectopic pregnancy among failures than salpingectomy, and failure is higher in women under 30.

Return to fertility. None is expected. Reversal after clips and rings is more feasible than after coagulation or salpingectomy, and salpingectomy leaves assisted reproduction as the only route.

Ideal candidates. Women having interval sterilisation with a mobile uterus, no major adhesions and no cardiopulmonary contraindication to pneumoperitoneum.

Avoid laparoscopy. Fixed uterus from surgery, pelvic inflammatory disease, endometriosis or suspected adhesions; abdominal wall or umbilical hernia; chronic respiratory disease or significant cardiac disease; very large fibroids; severe obesity where access is unsafe. Choose minilaparotomy or refer.

Delay. Young age with no living children, current pelvic inflammatory disease, unexplained vaginal bleeding, haemoglobin under 7 g/dL, sickle cell disease, thromboembolism, acute infection, active hepatitis, gynaecological cancer.

Special. Blood pressure 160/100 or higher, complicated valvular disease, hypertension with vascular disease, diabetes with vascular complications, coagulation disorders, anticoagulation, chronic respiratory disease, AIDS, local anaesthetic allergy.

Caution. Obesity, controlled hypertension, uncomplicated diabetes, epilepsy, depressive disorders, prior abdominal surgery.

Investigations. Pregnancy exclusion, blood pressure, haemoglobin when anaemic, anaesthetic review.

Choice between occlusion and salpingectomy. Clips and rings keep the option of reversal and take less time. Salpingectomy has the lowest failure and removes the tube for cancer risk reduction, takes longer and cannot be reversed.

Regimen line. Procedure: laparoscopic clip, ring, bipolar occlusion or salpingectomy. Anaesthesia: general anaesthesia or deep sedation, or local infiltration with lidocaine 1% (10 mg/mL) up to 4.5 mg/kg without adrenaline (maximum 300 mg, 30 mL) or 7 mg/kg with adrenaline (maximum 500 mg) at the port sites and with light sedation, reduced in liver disease. Protection immediate and lifelong. Backup none.

Pregnancy exclusion. No intercourse since last menses, consistent reliable method, within 7 days of menses start, within 4 weeks postpartum, within 7 days of an abortion, or fully breastfeeding amenorrhoeic under 6 months postpartum. Otherwise test. A positive test stops the procedure.

Switching. Pills: finish the pack. Injectable: operate before the next injection is due. Intrauterine device in the first 7 days of menses: remove and operate with no backup. Later: operate and keep the device until the next menses.

Technique steps.

1. Empty bladder, lithotomy position, uterine manipulator placed.
2. Make a small subumbilical incision, insert the Veress needle or open-entry cannula, and insufflate carbon dioxide to an intra-abdominal pressure of 12 to 15 mmHg.
3. Insert the laparoscope trocar, inspect the pelvis, and place a second port for the instrument.
4. Identify each tube from cornua to fimbria.
5. Apply a clip across the isthmus about 2 to 3 cm from the cornua, or ring a loop of isthmus, or coagulate and divide with bipolar current, or remove the tube.
6. Check haemostasis, release pneumoperitoneum, remove ports and close fascia at 10 mm ports and skin.

Follow up. Observe until recovered, usually day case. Wound review within 2 weeks. Return for fever, severe or worsening abdominal pain, shoulder pain lasting over 72 hours, vomiting, fainting or missed period.

Expected effects. Shoulder tip pain and bloating for up to 72 hours, port site discomfort.

Complications. Vascular injury at entry, bowel or bladder injury, thermal injury with coagulation, gas embolism (rare), anaesthetic complications, port site infection or hernia, clip or ring slippage, failure and ectopic pregnancy.

Port site infection regimen. Cefalexin 500 mg orally every 6 hours for 5 to 7 days, maximum 4 g daily, reduced to 250 mg every 8 to 12 hours when creatinine clearance is 15 to 29 mL/min and 250 mg every 24 hours under 15 mL/min. Clindamycin 300 mg orally every 6 hours for 5 to 7 days, maximum 1.8 g daily, in serious penicillin allergy. Compatible with breastfeeding.

Analgesia. Paracetamol 1 g orally every 6 hours, maximum 4 g daily (3 g in liver disease or under 50 kg), with ibuprofen 400 mg every 8 hours with food for up to 3 days, maximum 1.2 g daily, avoided in creatinine clearance under 30 mL/min.

Failure. Missed period or pelvic pain needs a pregnancy test and exclusion of ectopic pregnancy.

Referral and escalation. Convert or refer for suspected visceral or vascular injury, and refer patients in the Special class when the team and equipment for general anaesthesia are not available.