CHAPTER 152 Permanent Female Sterilization (Tubal Ligation)

In the United States, voluntary sterilization remains one of the most widely used contraceptive methods, chosen by nearly 20% of married women. Family physicians skilled with basic surgical technique are in an ideal position to discuss and perform permanent sterilization procedures for both men and women. Approximately 600,000 tubal ligations are performed each year in the United States. A similar number of vasectomies are carried out. No man has ever died from the vasectomy procedure itself. Between 10 and 14 women die each year (in the United States) from tubal ligation. The failure rate for vasectomy is 1 in 1200 in the United States, whereas tubal ligation failures occur in 1 in 200 procedures within the first year and may increase in frequency over time. Although vasectomy allows detection of failures, no simple technique allows the surgeon to find tubal ligation failures. The cost of a tubal ligation is five to six times that of an office vasectomy. When a patient asks about permanent contraception, it behooves the primary care physician to point out the benefits of vasectomy over a tubal ligation. Even the American College of Obstetricians and Gynecologists (ACOG) agrees that, all things considered, a vasectomy is the procedure of choice. Nevertheless, when vasectomy is inappropriate for any reason, tubal ligation remains an excellent choice for permanent surgical contraception.

Despite numerous variations, female sterilization consists of two basic steps: (1) exposing the fallopian tubes, and (2) partially resecting or occluding the tubes to prevent conception. This chapter discusses the minilaparotomy approach to permanent female sterilization, both as an interval and as a postpartum procedure.

Box 152-1 outlines basic terminology related to permanent female sterilization methodology. Minilaparotomy and laparoscopy are abdominal surgical approaches that are considered safe, quick, and readily available.

Box 152-1 Female Sterilization Terminology

Colpotomy: A vaginal approach to tubal ligation through the posterior vaginal fornix.

Interval tubal ligation: Tubal ligation performed at times other than during the immediate postpartum period—generally 6 weeks or more after delivery.

Laparoscopy: Involves inserting an illuminated telescope-like instrument into the abdomen that allows visualization of the fallopian tubes in order to accomplish electrocoagulation or application of clips or rings. For open laparoscopy, a small incision is made within or just below the umbilicus to allow passage of a special cannula, around which the skin makes an airtight seal. The cannula allows for insufflation of the abdomen, passage of the laparoscope and instruments, and occlusion of the tubes. Open laparoscopy is considered safer than traditional closed laparoscopy, especially in women with prior pelvic or abdominal surgery or infection. With the closed laparoscopic procedure, the laparoscope is inserted blindly through the abdominal wall.

Laparotomy: A relatively large abdominal incision performed to optimize surgical exposure for a variety of intra-abdominal surgeries.

Minilaparotomy: Sometimes referred to as a minilap; involves a small abdominal incision, usually less than 5 cm (2 inches).

Postpartum tubal ligation: Tubal ligation performed within 72 hours of delivery.

Technical failure: Inability to complete the planned sterilization during the operation, which results in a change of method or failure to perform the sterilization.

Table 152-1 shows advantages and disadvantages of the minilaparotomy and the laparoscopic techniques. Despite the recognized advantages of laparoscopy for certain situations, minilaparotomy—because of its reliance on readily available surgical equipment, fewer technical demands, and applicability to both interval and postpartum periods—is the method of choice for many primary care physicians. Box 152-2 summarizes the more common methods for ligating the tubes.

TABLE 152-1 Advantages and Disadvantages of Minilaparotomy and Laparoscopy

	Advantages	Disadvantages
Minilaparotomy	Easy to learn Basic surgical training and skill Inexpensive instruments Complications are usually minor Can be performed as a postpartum or interval	Takes longer than laparoscopy Difficult to perform on patients who are obese or who have pelvic scarring or adhesions Scar slightly larger More pain from the abdominal incision Higher infection rate than laparoscopy procedure
Laparoscopy	Very low complication rate Quick procedure (10–15 min) Very small incision Useful for other diagnostic and therapeutic purposes Less painful	Complications may be serious Requires abdominal insufflation, with its added risk More difficult to learn; requires specialized training for physician and staff Equipment is more expensive and requires more maintenance and repair Not recommended as a postpartum procedure

Box 152-2 Common Tubal Ligation Methods

Minilaparotomy (“Open” Procedure)

Electrocoagulation: A bipolar probe is passed through a small segment of tube to cauterize and obstruct the lumen.

Fimbriectomy: This method is accomplished by the complete removal of the fimbriated end of the tube. The procedure appears to have a higher pregnancy failure rate, and reversal is unlikely.

Irving technique: An extremely effective, though more difficult, method that cannot be reversed easily. The tube is cut and the uterine end buried beneath the peritoneum within the wall of the uterus. The remaining end is buried within the mesosalpinx.

Laparoscopy clips: Under laparoscopic guidance, clips are applied to occlude the tubal lumen. Hulka (spring-loaded) and Filshie clips (titanium and silicone rubber) are commonly used. Clips destroy less than 1 cm of tissue, and reversals are considered much easier.

Parkland technique: A small length of tube is separated from the mesosalpinx and ligated at each end, about 2 cm apart; the free segment between the ligatures is removed (see Fig. 152-3).

Pomeroy technique: The most common procedure performed for both interval and postpartum tubal ligations. Absorbable catgut sutures are used to tie the base of a loop of midportion (ampullary) tube. The ligated loop of tube is then removed. As the suture absorbs, the ends pull apart and are obstructed by the healing and scarring process. From 3 to 6 cm of the tube is destroyed (see Fig. 152-2).

Tubal ring: A small Silastic ring is stretched and placed over a loop of fallopian tube and then released. The tube is blocked by compression. Usually a 2- to 3-cm segment of the tube is involved. Reversal is more successful than with the electrocauterization, Irving, or Uchida techniques.

Uchida technique: A technically demanding, yet extremely effective, method that is becoming more popular in the United States. The tube is severed and the uterine end is buried within the mesosalpinx.

Transcervical Approaches

Essure: In the fall of 2002, the Food and Drug Administration approved a new method, called Essure, whereby a device with a small stainless steel inner coil and superelastic outer coil (4 cm × 0.8 mm, after release 4 cm × 1.5–2 mm) is inserted hysteroscopically into the fallopian tubes for permanent sterilization. (See Chapter 148, Insertion of Essure [Hysteroscopically Assisted Female Sterilization].)

Others: Still considered experimental procedures, these methods of blocking the tubes from a transcervical-intrauterine approach continue to evoke interest. One method is to use Silastic “plugs” placed under hysteroscopic guidance. Various techniques are under development to provide a reversible sterilization by “pulling the plugs” when a pregnancy is desired.

This chapter outlines the minilaparotomy approach and the modified Pomeroy or “Parkland” method for ligation (Figs. 152-1 and 152-2). The ideal method is still under debate; however, the modified Pomeroy and Parkland methods (with their variations) remain popular in the United States. Prudent physicians should identify patients who may benefit by referral, either for alternative methods that the referring physician cannot offer because of a lack of skill, training, equipment, or facility or because of the patient’s clinical condition.

Figure 152-1 Modified Pomeroy technique. A, Lift loop. B, Double ligation 0 or 2-0 plain gut suture, no crushing. C, Each limb of tubal loop is cut separately. D, Loop is cut off. E, Later results.

Figure 152-2 Parkland method of tubal ligation. A, A relatively avascular area of the mesosalpinx is identified within the isthmic portion of the tube. B, A segment of tube is isolated and removed after double ligation with chromic suture.

Anatomy

Figure 152-3 demonstrates the anatomy relevant to a tubal ligation.

Figure 152-3 Basic anatomy of the parauterine structures.

Contraindications

Equipment

• A laparotomy pack contains most of the instruments necessary for basic abdominal surgery and is available in most hospital outpatient and inpatient surgical suites.

• Suction catheter: Generally, suction is not used during a routine minilaparotomy tubal ligation. Suction is available on demand at most surgical suites; it is mandatory if complications such as bleeding develop.

• Coagulation device: Most operative suites have a Bovie or similar coagulation device available. Some surgeons prefer to have this available for all cases; others use this electively, or when complications develop. Because a Bovie requires grounding, it should be set up in advance. A ground plate can be attached before the patient is draped and scrubbed.

• Sutures

Anatomic Site	Suture
Tubal ligation	0 Plain or chromic
Peritoneum	2-0 Chromic
Fascia	0 Dexon
Scarpa’s fascia	2-0 Chromic
Skin	Metal clips, 4-0 Dexon

• 8-inch Babcock forceps to separate and retract fallopian tube (Fig. 152-4A)

• Ring sponge (a ring forceps holding a tightly folded gauze pad)

• Small Richardson or Army-Navy retractors for holding the incision open (Fig. 152-4B)

• Adson tissue forceps with teeth for skin manipulation (Fig. 152-4C)

• Metzenbaum scissors for general tissue blunt dissection and incision (Fig. 152-4D)

• Kelly clamps for blunt dissection, and for grasping and tagging suture, bleeders, or tissue planes (fascia, peritoneum)

• Uterine manipulators for use with the cervical tenaculum or the newer uterine manipulators (Fig. 152-4E)

• 5-mL, 0.5% bupivacaine (Marcaine) (optional)

Figure 152-4 Instruments for tubal ligation. A, Babcock forceps; B, small Richardson retractor; C, Adson tissue forceps; D, Metzenbaum scissors; E, uterine manipulator. (Also see Chapter 144, Hysterosalpingography and Sonohysterography.)

Precautions

Tubal ligation is elective surgery and should be performed when optimal preparation of both the patient and surgical environment are at hand. Patients must be competent to offer informed consent or the appropriate arrangements (legal guardianship for health care decisions) made to assure legal basis to proceed with permanent sterilization. As with all elective surgeries, the patient’s medical condition should be optimized for the stress of regional or general anesthesia to allow for this intra-abdominal surgery. It is not uncommon to postpone a postpartum tubal ligation, which was planned well in advance, because of intrapartum complications such as unexpected blood loss or unstable condition of the newborn. In these instances, delaying a postpartum tubal ligation as well as reevaluation for other contraceptive options may be prudent and appropriate.

Preprocedure Patient Preparation

Preprocedure Visits

Preprocedure evaluation and counseling for women who want permanent sterilization warrant focused attention. A special visit should be scheduled to discuss contraceptive options, risks, technique, and follow-up demands of sterilization surgery. (See the sample patient education form online at www.expertconsult.com.) In addition, many insurance companies require preauthorization, which should be obtained at this visit. The counseling session should not be hurried or added to the end of a visit for an acute illness. Written materials should be given to the patient at this time. Federal payment programs require that counseling precede surgery by at least 30 days and not more than 180 days. Special forms need to be signed, and the patient must be at least 21 years of age. If the patient is involved in a monogamous relationship, it is wise to have the partner present during the consultation to address any concerns. Partner written consent is not mandatory, but if there is disagreement with this decision, it should be discussed and the reasons explored. It is also important to address the issues and benefits of vasectomy (refer to the opening paragraph of this chapter).

A preprocedure examination, which requires a reasonable amount of time, should occur within 10 days (some hospitals require less than 5 days) of anticipated surgery. Review the patient’s complete medical history, paying particular attention to prior pelvic or abdominal surgery and infection. Are there drug allergies or drug intolerances? Are there medications (such as aspirin) that should be stopped? Is the patient on chronic anticoagulants? Is there a history of heart disease, diabetes, bleeding disorder, endometriosis, or dysfunctional uterine bleeding? Is other concomitant surgery necessary (e.g., dilation and curettage [D & C], breast biopsy, or procedure for urinary incontinence)? Is the Pap smear normal? Discuss the method of anesthesia that is to be used. Carefully review anticipated postprocedure morbidities (e.g., pain, the necessity of limited lifting). Remain mindful of the risk factors for regret (see later discussion under General Information). Review current contraceptive methods. Is pregnancy a possibility at the time of surgery? If the patient smokes, can she quit before surgery?

Preprocedure examination should be thorough. Focus on the heart, lung, breast, and abdominal examinations. During the pelvic examination, assess for the presence of vulvar, vaginal, or cervical disease. Obtain specimens for culture (e.g., gonorrhea, chlamydia) as necessary. Assess the degree of uterine prolapse and urinary incontinence; have the patient bear down and cough. Perform a bimanual examination to assess uterine size, shape, and tenderness. Palpate the ovaries for enlargement. Pay particular attention to uterine mobility. Can the uterus be brought out of the pelvis easily, or is it frozen in a particular direction? Estimate the degree of abdominal wall obesity. Show the patient the location and size of the anticipated abdominal incision and eventual scarring.

Perform laboratory tests as necessary. Typically, hospitals require hemoglobin levels and a urinalysis as the minimum prerequisites for general anesthesia. Perform a pregnancy test if there is any question of pregnancy. If there is clinical evidence of cervicitis or pelvic inflammation, obtain specimens for culture, and treat the condition accordingly. In this case, schedule the surgery only when treatment and clinical response have been adequate.

Many same-day and outpatient surgery services offer preanesthesia counseling. The patient can meet with the anesthesia clinician to discuss anesthesia, risks, time to arrive at the hospital, how long to fast before surgery, and other issues. This counseling should be used whenever it is available; for many hospitals, it is a requirement.

Call the hospital surgery personnel with any special requests for the anticipated surgery. Will a D & C be performed? (If so, it should be done after minilaparotomy.) Is a uterine manipulator necessary, and what type will be used?

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