Surgical Sterilization

Published on 10/04/2015 by admin

Filed under Surgery

Last modified 22/04/2025

Print this page

This article have been viewed 10005 times

Chapter 28 Surgical Sterilization

Thomas G. Stovall, Erin J. Saunders

INTRODUCTION

Procedures for performing sterilizations have become much more prevalent in recent years. Millions of couples have opted for sterilization to control their fertility, making it the most frequently used method of contraception in the United States. The demand for female sterilization is dramatically increasing, and it is now the third most common surgical procedure performed on females in the United States. Tubal sterilization is a relatively simple procedure. It is a safe, extremely effective method of permanent sterilization. This procedure may be performed on an outpatient or inpatient basis, using either an abdominal, vaginal, hysteroscopic, or laparoscopic approach, and may be performed as either a postpartum or interval operation. The choice of procedure depends on the facilities available, timing, and the experience of the surgeon.

HISTORY

The first female sterilization in North America was performed in 1880 by S.S. Lungren of Toledo, Ohio and was done at the time of cesarean section. For the next few decades, all tubal sterilizations were performed at the time of laparotomy as a concurrent procedure or at the time of cesarean section because the risk of mortality was too high to perform this operation for sterilization alone. Sterilization became better accepted with the advent of the Pomeroy method of tubal occlusion, which could be accomplished through a small incision.

In the 1970s tubal sterilization became widespread due to the introduction of minilaparotomy and laparoscopy as methods. Anderson ¹ is credited with performing the first laparoscopic electrocoagulation procedure in the United States in 1937. Steptoe² in 1967 reported the first large series of laparoscopic sterilizations, and Wheeless³ in 1973 reported the first single-puncture laparoscopic technique. These procedures allowed for interval surgery, surgery without hospital stay, reduced recovery time, less morbidity, and better cosmetic result.⁴ Sterilization is now the most commonly used method of family planning in the world.

PREOPERATIVE EVALUATION

Tubal sterilization should be available to any woman who desires permanent sterilization, assuming that she has proper informed consent (Table 28-1) and adequate knowledge regarding the procedure. The procedure should be considered purely elective. There are virtually no absolute contraindications to tubal sterilization except for gynecologic malignancy or gynecologic disease that requires hysterectomy or bilateral oophorectomy.

Table 28-1 Elements of Informed Consent for Sterilization

Review of alternative methods of permanent sterilization (e.g., vasectomy)

Indication that the procedure is considered permanent

Review of failure rate of procedure

Description of the planned operative technique

Discussion of potential surgical risks

Certain circumstances require specific mention. For example, if the patient has known extensive intra-abdominal adhesions, the potential for intraoperative morbidity may be so great as to consider another form of contraception. For the patient with a severe medical problem, it is probably advisable to consult with a specialist in the particular disease-related area or a maternal medicine specialist to determine exactly how pregnancy would affect the condition in question. Often, patients have been told by a well-meaning healthcare provider that pregnancy is contraindicated when in fact it is not. The family of a severely mentally retarded patient may request sterilization, but these are special circumstances that require discussion with the family and most often require a second opinion, an ethics committee recommendation, and, at times, a court order.

Informed Consent

Because most methods of sterilization are designed to be permanent, proper patient counseling and informed consent are important. The decision for sterilization should be made on an entirely voluntary basis after appropriate counseling on risk, benefits, and alternatives.

Various materials are available to assist the physician in counseling the patient. The American College of Obstetricians and Gynecologists (ACOG) distributes a pamphlet that discusses different techniques of sterilization as well as alternative methods for contraception. For couples desiring permanent sterilization, vasectomy should always be discussed because vasectomy is associated with fewer complications than tubal sterilization. When counseling the patient on the benefits of sterilization, it is important to include that all methods are extremely effective, are permanent, and have a low failure rate.⁵ Risks of the female sterilization procedure include risk of anesthesia, operative surgical risks, and the 1% to 3% risk of failure with an increased risk of ectopic pregnancy. It should be remembered that patients whose sterilization will be federally funded must sign a special consent document and must be at least 21 years old.

The patient’s husband is not required to give consent before the procedure is performed. Obviously, it is best if both partners have an understanding of the procedure as well as the benefits and potential risks of it. Thus, if a problem is encountered, the patient’s family is in a better position to deal with the problem.

Sterilization Regret

Anywhere from 3% to 25% of women have regret about sterilization, and 1% to 2% of these patients actually seek tubal reversal. Some reasons for regret (Table 28-2) include change in marital status, death of a child, and wanting another child after other children have gotten older. Studies have shown that there is an increased risk of regret with change in marital status, age less than 30 at the time of sterilization, psychiatric history, postpartum sterilization, poor outcome with previous delivery, and ongoing marital, financial, health, or personal problems at the time of sterilization.⁵

Table 28-2 Factors That Have and Have Not Been Associated with Regret After Sterilization

Factors Associated with Regret	Factors Not Associated with Regret
Marital status change	Religion
Family stress (e.g., death of a child)	Socioeconomic level
Desire for additional children as the “baby” grows up	Education level
Post-tubal ligation syndrome symptoms	Low parity
Postpartum procedure	Decision made with husband’s approval
Sterilization before age 30	Interval procedure

TIMING

Postpartum Sterilization

Sterilization after delivery, during the patient’s postpartum hospital stay, is a convenient, effective, and efficient way to prevent future pregnancy. In the immediate postpartum period the uterus is enlarged to the level of the umbilicus, making it convenient to perform sterilization with a small 1- to 2-cm infraumbilical incision. Any of several techniques could be used. The longest period that the patient may wait before undergoing sterilization is controversial. In some circumstances, a delay of 12 to 24 hours may be needed to assess the infant’s condition, or delays secondary to staffing patterns or availability of anesthesia may be encountered. Studies done show no increased risk of morbidity if the sterilization is delayed for the first postpartum day.^6,⁷ If it is not feasible during this time period to perform the sterilization, the patient should probably wait at least 6 weeks so that the uterine architecture will be back to normal. Before this time, the uterus may be enlarged, making laparoscopy more difficult, and there may be an increased risk of infection during the postpartum period. The patient who has a postpartum endometritis or has had premature rupture of the membranes, intrapartum fever, or manual placental removal is probably at risk of a postsurgical infection. Therefore, it may be prudent for this patient to wait and undergo interval sterilization.

If cesarean section is required and the patient desires sterilization, the two procedures should be performed concurrently. The addition of sterilization to cesarean section adds little to the operative risk of the procedure or to the postoperative morbidity. Also, performance of the sterilization procedure at the time of cesarean section or shortly after vaginal delivery allows the patient to recover from the two procedures simultaneously and therefore does not add to the patient’s hospitalization or convalescence period.

Interval Sterilization

Interval sterilization after the immediate postpartum period should be delayed for 6 or 8 weeks. Most of these procedures are performed by laparoscopy and can be done using local, conduction, or general anesthesia. Performance of the procedure during the menstrual or proliferative phase of the cycle reduces the chance of pregnancy at the time of the procedure. However, if this is not practical, a sensitive urine or serum pregnancy test can be done on the day the procedure is performed. This too has been shown to decrease the risk of luteal phase pregnancy.⁸ Finally, sterilization can be performed in conjunction with other surgical procedures, such as cholecystectomy or plastic surgical procedures.

STERILIZATION METHODS

More than 100 sterilization techniques have been described in the gynecologic literature. A discussion of the risks, benefits, technical aspects, and failure rates of each of these procedures is beyond the scope of this chapter. Therefore, only those techniques that are currently popular or are widely used are discussed. For the most part, interval sterilizations are performed by laparoscopy and postpartum sterilizations are done by minilaparotomy.

Madlener Technique

The Madlener technique involves forming a loop of tube, of which a portion is crushed at the base of the loop and ligated with a nonabsorbable suture. Occlusion but not division of the lumen is achieved (Fig. 28-1). The end result is similar to the laparoscopic placement of a Silastic band for occlusion, as described in the section on the Falope ring in this chapter. Failures are often attributed to fistula formation at the ligature site. This technique is generally of historic interest only.

Figure 28-1 Madlener technique for tubal ligation.

Irving Procedure

The Irving procedure was introduced as a technique for ligation and division of the oviduct at the time of cesarean section. At the ampullary–isthmic junction, the proximal stump is buried within the myometrium and the distal stump is buried between the leaves of the broad ligament (Fig. 28-2). As the uterus undergoes involution postpartum, the buried proximal and distal ends of the tubes become compressed and eventually obliterated. This procedure takes longer and there is often more blood loss; however, the chances of tubal recanalization or pregnancy in the proximal stump are remote.

Figure 28-2 Irving procedure for tubal ligation.

Pomeroy Method

The Pomeroy method (Fig. 28-3) or its modifications are probably the most commonly used sterilization procedures today. A knuckle of tube is grasped at the midportion using a Babcock clamp. This segment of tube, approximately 2cm in length, is then ligated at the base with an absorbable suture, preferably plain gut. This segment of tube is then excised and sent to the pathology laboratory for confirmation. The use of absorbable sutures allows the proximal and distal segments of the tube to separate, thus decreasing the risk of recanalization of the tube. The advantages to the Pomeroy method are that it is easy and quick to perform and highly effective. Its acceptance for both postpartum and interval sterilization is quite high.

Figure 28-3 Pomeroy method for tubal ligation.

Uchida Technique

The Uchida technique is one of the more complex methods of tubal sterilization. It involves injection of a saline–epinephrine solution to the subserosal aspect of the tube, separating the muscular portion of the tube from the serosa. The serosa is then dissected off the muscular tube and a 5-cm segment of tube is excised while the proximal end is ligated and allowed to retract into the mesosalpinx. The mesosalpinx is then closed and a pursestring stitch is placed around the distal end to secure its position open to the abdomen (Fig. 28-4). A fimbriectomy may be added to this procedure to enhance effectiveness and prevent reanastomosis. The Uchida technique is more complicated than the other procedures but has been associated with very few failures.

Figure 28-4 Uchida technique for tubal ligation.

Fimbriectomy

The technique of fimbriectomy described by Kroener employs the ligation of the distal ampulla with two permanent sutures and division and removal of the tubal infundibulum (Fig. 28-5). The simplicity of this procedure accounted for its popularity, but fimbriectomy does not seem to have many advocates due to the availability of easier and much more effective procedures.

Figure 28-5 Kroener fimbriectomy.

Vaginal Approach

Theoretically the vaginal approach (Fig. 28-6) seems ideal for safe and rapid tubal sterilization and has the advantage of avoiding an abdominal incision. However, the potential complications and complexity of the procedure prevent its widespread popularity. The possible complications from this procedure are cellulitis, hemorrhage, infection, cuff abscess, and bowel and bladder damage. Deep dyspareunia may also be a complication with some patients.

Figure 28-6 Vaginal tubal ligation.

The vaginal approach is particularly helpful in very obese patients or patients who have an umbilical hernia or previous umbilical hernia repair. Relative contraindications include multiple pelvic surgical procedures, endometriosis, known extensive pelvic adhesive disease, or uterine immobility on examination.

The patient is placed in the dorsal lithotomy or knee-chest position. A right-angle or Dever retractor is used to expose the cervix, which is grasped on its posterior lip with a single-toothed tenaculum. The posterior cul-de-sac is exposed, and a colpotomy incision is performed using Mayo scissors. The tips of the scissors are placed in the peritoneal opening and spread to enlarge the incision. The anterior retractor is placed posterior to the cervix just inside the incision and is elevated. This maneuver results in retroflexion of the uterus. The fallopian tube is grasped with a Babcock clamp and brought into the operative field. The sterilization can be accomplished using tubal bands, electrocautery, or clips.⁹ However, the most common method described is the use of the Pomeroy technique.¹⁰ Once completed, the colpotomy incision is closed using interrupted figure-of-eight sutures or a single running suture of an absorbable suture material.

Intraoperatively, the most common problem encountered is difficulty in exposing the fallopian tube. Placing the anterior retractor too deeply into the incision will antevert the uterus rather than cause uterine retroflexion. Suprapubic pressure can be used to facilitate uterine retroversion. Postoperatively, pelvic infection is the most serious potential complication after vaginal sterilization. Therefore, a single dose of prophylactic antibiotic should be administered approximately 30 minutes before the procedure.

Laparoscopic Sterilization

Laparoscopic sterilization has become quite popular over the past few decades. This procedure provides superb visualization not only of the pelvic organs, but also of the entire abdominal cavity. Since the introduction of laparoscopy, women have had access to a safe, effective, and dependable method of sterilization.

Tubal Ligation Under Local Anesthesia

This type of tubal ligation is ideal for patients without contraindications for local anesthesia, opportune for a nonoperating room setting, and ideal for patients who have a great fear of general anesthesia or have cardiac or pulmonary disorders preventing the use of general anesthesia. This approach is contraindicated in the anxious patient or obese patient who might require greater manipulation of abdominal organs. Local anesthesia should not be used by inexperienced surgeons due to its complexity.

Advantages of this are that it avoids the risks associated with general anesthesia and decreases the cost of anesthesia. This is due to the fact that anesthesia time is decreased and recovery time is shortened with less postoperative nausea and vomiting with local anesthesia compared to general anesthesia.

Disadvantages to local anesthesia are that the technique requires precise and gentle surgical manipulation with mild to moderate discomfort to the patient. Local anesthesia can also make the procedure more difficult for the surgeon because of the increased risk of patient movement during surgery and an increased need for close verbal contact between the surgeon and the patient during the procedure.

Regimens

Local anesthesia regimens usually consist of three types of drugs: systemic agents that sedate the patient and block pain (midazolam, fentanyl, sufentanil, alfentanil), local analgesics that relieve pain at the incision site (bupivicaine),⁴ and systemic drugs that prevent nausea or disturbance of heart function (promethazine, atropine).

After sedation the tubal ligation is performed as it would be under general anesthesia, paying close attention to the fact that the patient is awake, able to move, and can occasionally feel more sensation than under general anesthesia.

Results of tubal ligation under local anesthesia are similar to those found under general anesthesia, with similar patient satisfaction, but less operating time. In a study by Mackenzie and colleagues that looked at postoperative effects of local anesthesia, they found that 21% of patients left the clinic within 4 hours of the operation and all patients had left after 7 hours. Ninety eight percent of patients were satisfied with the procedure under local anesthesia, and 94% would actually recommend the procedure to a friend.¹⁴

Hysteroscopic Sterilization

Hysteroscopy is another method by which permanent sterilization can be achieved and is the newest method used for sterilization. One advantage of hysteroscopic sterilization is that it can be performed in the office setting under local anesthesia. Three approaches are being investigated at this time, and one procedure has received FDA approval. These include coagulation of the ostia, chemical sclerosis of the endosalpinx, and use of a plug to obstruct the tubal lumen.

Electrocoagulation

Unipolar or bipolar electrocoagulation can occlude the tubes by introducing a conductive electrode into the ostia. Once the electrode is applied to the intramural portion of the tube, permanent occlusion should occur from electrocoagulation of the endosalpinx and the proximal layer of muscularis. Due to the difficulty involved, the FDA has not yet approved the method. Actually the ostia can only be identified 80% of the time and the procedure becomes blind once the probe is advanced into the tubal ostium, which could lead to bowel injury. The failure rate at present is far too high to approve this procedure for use (15% to 30%).

Chemical Agents

The use of chemical agents has also been suggested to cause sclerosis of the endosalpinx. Many substances have been tried, such as silver nitrate, formaldehyde, phenol, talc, quinacrine, and methylcyanoacrylate. Various methods of delivery have been studied, such as direct instillation to the tubes through hysteroscopic guidance, fluoroscopic-guided injection, blind injection, and loading the agent in an IUD type device. The latter two seem to be the most promising, with a closure rate between 88% and 94%, but still none have been approved by the FDA.

Plugs

Three plugtype devices have reached human clinical trials, and the Essure device has been approved by the U.S. FDA (Fig. 28-10). The Essure procedure is a nonincisional surgical procedure that involves placing a small, flexible device called a micro-insert into each of the fallopian tubes. The micro-inserts are made from polyester fibers and metals (nickel–titanium and stainless steel).¹⁵ Once the micro-inserts are in place, tissue ingrowth occurs into the micro-inserts, blocking the fallopian tubes. Nickel allergy, recent pelvic infection, and possibly hydrosalpinx are contraindications to the procedure. A hysterosalpingogram must be done 3 months after the procedure to ensure and document tubal occlusion.