Minilaparotomy Tubal Ligation

Minilaparotomy is tubal occlusion through a small abdominal incision, suprapubic for interval cases and infraumbilical for postpartum cases. It needs only a minor theatre, simple instruments and local anaesthesia, so it is the most widely available female sterilisation technique and suits static and outreach sites that meet theatre and referral requirements.

Mechanism. The tube is interrupted by partial salpingectomy so that sperm and ovum cannot meet.

Occlusion methods. Modified Pomeroy (a loop of mid isthmus tied and its top excised), Parkland (the isthmus is divided between two ties after the mesosalpinx is opened), and Irving (the proximal stump is buried in the uterine wall). Pomeroy is the most used in routine practice.

Effectiveness. First-year pregnancies are 0.5 per 100 women with typical use and 0.5 per 100 women with perfect use. Partial salpingectomy gives lower long-term failure than clips or coagulation.

Return to fertility. None is expected. Reversal is possible only in selected women and cannot be guaranteed.

Suitable. Women of any parity who have decided on permanent contraception, with a mobile uterus, no pelvic adhesions needing a larger field, and no Special class condition.

Less suitable. Marked obesity, a fixed or retroverted uterus, previous pelvic surgery or infection with adhesions. These may need laparoscopy by an experienced surgeon, a longer incision or referral.

Delay. Current pelvic inflammatory disease, unexplained vaginal bleeding, haemoglobin under 7 g/dL, abdominal skin infection, acute systemic infection, sickle cell disease, current thromboembolism.

Special. Blood pressure 160/100 or higher, coagulation disorders, anticoagulant use, abdominal wall or umbilical hernia, fixed uterus, known pelvic tuberculosis, AIDS, chronic respiratory disease, allergy to local anaesthetics.

Pregnancy exclusion. Reasonably certain if 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.

Consent. Signed consent on file. Patient can withdraw at any time before surgery. Under 18 years give assent with consent in line with the law.

Regimen line. Procedure: minilaparotomy with modified Pomeroy partial salpingectomy. Anaesthesia: lidocaine 1% (10 mg/mL) infiltrated skin to peritoneum about 5 minutes before incision, up to 4.5 mg/kg without adrenaline (maximum 300 mg, 30 mL) or up to 7 mg/kg with adrenaline (maximum 500 mg), reduced in liver disease, avoided in allergy. Antibiotic prophylaxis is not routinely required. Protection immediate and lifelong. Backup none.

Equipment. Sterile drapes and gloves, uterine elevator (interval), small retractors, Babcock or tubal hook, artery forceps, needle holder, scissors, absorbable sutures, resuscitation equipment and emergency drugs.

Steps, interval case.

1. Empty the bladder, perform bimanual examination and place the patient supine.
2. Prepare and drape, infiltrate the skin, subcutaneous tissue and fascia.
3. Make a 2 to 3 cm transverse suprapubic incision, open fascia and peritoneum.
4. Elevate the uterus with the vaginal elevator, bring each tube into the wound with a Babcock forceps and follow it to the fimbria.
5. Lift a loop of mid isthmus about 2 to 3 cm long, tie its base with plain absorbable suture, excise the top of the loop, and check the cut ends for bleeding.
6. Repeat on the other side, close peritoneum and fascia with absorbable suture and skin with subcuticular or interrupted suture.

Steps, postpartum case. The steps are repeated through an infraumbilical incision without an elevator, because the fundus is near the umbilicus.

Operational limits. One surgeon performs no more than 15 procedures in a day and one operating room no more than 30.

Follow up. Observe until walking and passing urine. Wound review within 2 weeks. Return for fever, discharge, severe pain, fainting or missed period.

Expected effects. Incisional pain, bruising and mild swelling.

Complications. Bleeding from the mesosalpinx, bladder or bowel injury, wound infection, haematoma, anaesthetic reaction, failure and ectopic pregnancy.

Wound 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 severe penicillin allergy. Compatible with breastfeeding.

Analgesia. Paracetamol 1 g 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. Test any woman with a missed period or lower abdominal pain for pregnancy and exclude ectopic pregnancy.

Referral and escalation. Refer suspected visceral injury, persistent bleeding, deep infection and any procedure that cannot be completed safely under local anaesthesia.