CLINICIAN to CLINICIAN

Practical advice from community ob/gyns

A novel approach to tubal sterilization

By Michael G. Judd, MD

There are two surgical approaches to tubal sterilization: open and closed. The open approach is commonly used for postpartum tubal sterilization, concomitant cesarean delivery, and interval minilaparotomy. The closed approach applies to laparoscopic or hysteroscopic tubal sterilization, which usually is performed in the gynecologic surgical setting. The precise method of occlusion, ligation, division, or resection differs among surgeons and institutions.

Practically speaking, the choice of sterilization technique should be based on the rate of success and the ease of application. Based on the U.S. Collaborative Review of Sterilization, the most effective methods are postpartum partial salpingectomy and laparoscopic unipolar coagulation (3.2–7.5 pregnancies per 1,000 procedures).^1-3

In an open surgical approach, the fallopian tubes traditionally are ligated with suture and either divided or resected, as in the Pomeroy and Parkland techniques. Traditionally a segment of tube is also submitted to pathology for confirmation of structure. Rarely is a segment of tube submitted when using a closed approach.

Submitting tubal segments wastes health-care dollars, and in today's world of ever-increasing costs, we as providers have an obligation to abandon such useless processes. As an alternative, I propose unipolar electrosurgery during "open" sterilization. I've safely used this simple technique on more than 50 cases over 18 months and the operating time is shorter. The unipolar procedure is modeled on laparoscopic electrosurgical desiccation, which has been performed more than 2,500 times at my institution over the last 25 years for tubal sterilization, with no failures.

Only one of my patients has had a complication—bleeding from the proximal tubal stump. In that case, the electrosurgical generator setting was 30; I now use a setting of at least 40 and crush both the proximal and distal stumps with a Kelly clamp prior to readdressing the free ends with electrosurgery. There is no reason to believe that the fistula rate would be any higher with unipolar electrosurgery than with the traditional approach.

To perform unipolar electrosurgery, place two Babcock clamps around the isthmic portion of the tube, creating a "window" in an avascular portion of the mesosalpinx (Figure 1). Then brush the electrosurgical pen along the tubal segment until it divides hemostatically (Figure 2). This technique is cost effective, decreases operative time, and ensures hemostasis without compromising effectiveness.

REFERENCES

1. Benefits and risks of sterilization. ACOG Practice Bulletin; No. 46, September 2003.

2. Pati S, Cullins V. Female sterilization. Evidence. Obstet Gynecol Clin North Am. 2000;27:859-899.

3. Peterson HB, Xia Z, Hughes JM, et al. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol. 1996;174:1161-1170.

DR. JUDD is in private practice at Chesapeake Women's Health, L.L.C. and practices at The Memorial Hospital at Easton, Easton, Md.

 

Michael Judd. Clinician to Clinician: A novel approach to tubal sterilization. Contemporary Ob/Gyn Jun. 1, 2004;49:24-25.