Dr. Sanjay Patel
HOD of Endoscopy Dept & Infertility Specialist
Jhala Consultant Endoscopic Surgeons
Dr. Rujul Patel
Associate Endoscopic Surgeon
Mayflower Women’s Hospital Drive In Road, Memnagar, Ahmedabad – 380052, India
Introduction.Laparoscopic microsurgery is a new discipline that synergizes the potential of classical microsurgery & laparoscopy.
It can overcome the deficiencies in each of the techniques. Advent of microsurgical technique began by Swolin in 1967.
First microsurgical reversal of the sterilization was done by Gomel & Winston in 1977.
Around 25-30% of the subfertile females have tubal damage and quite a few of them seek tubal micro-reconstruction for fertility enhancement, also those with tubal sterilization procedure seeking reversal for further child bearing are better candidates. This can now be achieved with principles of laparoscopic microsurgery.
Advantages of Laparoscopic Tubal Anastomosis:
- All microsurgical principles are well maintained like magnification, tissue handling, haemostasis & lavage.
- Avoids laparotomy & tissue trauma associated with packing & retractors
- Minimal tissue handling & trauma
- Adhesions are minimal
- Cosmetically far better
- Faster recovery
- Single step procedure as compared to IVF where multiple sittings may be required.
Pre-operative Work up
- Semen Analysis: to rule out male factor.
- Day 3 Serum FSH level to know the ovarian reserve.
- HSG to know the length & condition of the proximal tube.
- Saline infusion sonography and hysterosalpingography may be helpful.
- Reversal of tubal sterilization procedure
- Mid-tubal block secondary to various pathology
- Tubal occlusion secondary to ectopic pregnancy treatment
- Salpingitis isthmica nodosa
- Failed tubal cannulation for proximal tubal block
- Failed previous macrosurgical sterilization reversal
Contraindications: Absolute contraindications
- Aged 40 years or older
- Decreased ovarian reserve or ovarian failure
- Tubal infertility not amenable to tubal reconstruction
- Extensive tubal damage
- Hydrosalpinx with a diameter of more than 3 cm
- Inadequate proximal or distal tubal segment for reanastomosis
- Projected tubal length of less than 3 cm after the reconstruction procedure
- Extensive pelvic/peritubal adhesions
- Abnormal uterine cavity
- Any contraindication to pregnancy or surgery
- Severe male factor infertility or male sterility
Equipments & Instruments
Magnification, Resolution & Digital Enhancement:
- 25-40X magnification is essential to identify healthy mucosa of the fallopian tube. 10-15X magnification is adequate for micro suturing.
- Use of endoscope, digital three chip camera (Image 1) with monitor has a ‘Multiplier Effect’ and the magnification can be achieved up to 20-25X.
- It is collectively known as ‘Koh ultramicro series’ (Fig 1).
- Terminal serration of the jaw is specially treated so that micro suture material does not get crushed.
- Handle design should be such that least friction & max transmission of hand movement occur to the instrument tip. 130o angle between handle and shaft of the instruments provides better movements.
Sutures, Needles & Energy:
- More rigid needles are better for micro-endosuturing.
- The suture material should be 6-0 to 8-0 polypropylene, depending upon the surgeon’s experience of material handling & preference.
- Electrosurgery: 15-20W for cutting & 15W for fulguration, use minimum cautery to preserve sub-tubal vasculature (Fig. 12).
- Handlin’s Uterine Manipulator is a fine disposable instrument (Fig. 2), which allows administration of the dye and manipulation of the uterus without causing any significant trauma.
Fig.1 Kho ultramicro series
Fig.2 Uterine Manipulator
Selection of Cases
Length of Tubal Damage in Various Methods of Ligation
Other Non suitable cases are pathological tubes with PID, Salpingitis Isthemica Nodosa & Failed tubal cannulation.
Before proceeding for the tubal reconstruction one must evaluate the inside of the tube, so as to be confirmed that the anastomosis is going to be fruitful or not at all worthwhile.
This involves Salpingoscopy & Falloposcopy.
- Salpingoscopy allows direct inspection of tubal mucosa in the ampullary part.
- The degree of tubal mucosal damage is probably the major factor in establishing the prognosis for tubal surgery.
- Brosen’s classification is useful for evaluation according to degree of mucosal atrophy and mucosal adhesions.
|Salpingoscopy Grade 1: (Fig. 6)
Normal intra-luminal findings with healthy
Major (Primary) & Minor (Secondary) folds.
| Salpingoscopy Grade 2: (Fig. 7)
Mucosal nuclear staining with Methylene blue dye.
|Salpingoscopy Grade 3: (Fig. 8)
Minimal flattening & minimal adhesion ( ) of endosalpinx
| Salpingoscopy Grade 4: (Fig. 9)
Moderate flattening of endosalpinx with intraluminal adhesion.
| Salpingoscopy Grade 5: (Fig. 10)
Severe flattening of mucosa with severe intraluminal adhesions.
Total 5 ports are used (Fig. 11)
- 10mm laparoscope through the primary umbilical port.
- Four ancillary ports, two 5 mm & two 3 mm.
- The lower pelvic port of 5 mm is placed 4cm medial & above the anterior superior iliac spine i.e. Ipsilateral Port.
- Contralateral port of 3 mm size placed exactly opposite to ipsilateral port.
- Another ipsilateral port of 3 mm is para-umbilical & laterally in the anterior axillary line.
- One 5 mm central port, 2-3 cm above the pubic symphysis.
‘The position of the ports is critical in enabling fluent two handed operating as well as suturing. The so-called ‘fulcrum effect’ is virtually eliminated by adopting specific port positions.’ Port Positioning Sub-tubal Vessels
Important Surgical Steps
- Distention of the proximal segment of the tube by trans-cervical chromo perturbation to know the exact site of the block.
- Excision of pathological segment of the tube.
- Make sure that the incision does not extend beyond the mesosalpinx.
- Ensure the right angled cut of the tubal ends for better alignment & approximation.
- Free spillage of the dye.
- Mesosalpinx is sutured first, using 6 ‘0’ polypropylene.
Most difficult & important step – end to end anastomosis in two layers.
First Layer, the mucosal-muscularis layer.
- Most important is 6 o’clock position stitch.
- To keep the knot outside the lumen, stitches are taken from outer to inner side on proximal end and vice versa on distal end.
- Rests of the stitches are taken at 12, 3, & 9 O’ clock position in the similar manner.
Second layer, the sero-muscularis layer; sutured with 6-0 Polypropylene.
- Thorough peritoneal irrigation with Ringer’s Lactate solution throughout the operation.
Types of Anastomosis
Isthmo- Isthmic Anastomosis
- Lumen size is 500 μm-1mm
- Equal lumen size & thick muscularis allows technically easier & better anastomosis.
Fig. 13 Falope ring excision
Fig. 14 Re-freshening of edges
Fig. 15 Free dye flow
Fig. 16 Magnified view
Fig. 17 Mesosalpinx stitch
Fig.18 6 O’clock stitch
Fig.19 12 O’clock stitch
Fig. 20 Second layer
Fig.21 End result
- Luminal disparity is the potential problem which can be adjusted by cutting the isthmic end.
Fig. 22 Refreshening ends
Fig. 23 First layer
Fig. 24 Second layer
Fig. 25 Free spill
- Technically difficult anastomosis due to thin muscularis and tendency for mucosal folds prolapse.
Fig. 26 Refreshening ends
Fig. 27 First layer
Fig. 28 Second layer
- Wedge excision in the cornual end mobilises good length of interstitial tube
Fig. 30 Cornual Pathology
Fig. 31 Wedge Incision
Fig. 32 Interstitial Anastomosis
Fig. 33 Mild Hydrosalpinx
Fig. 34 Cornual Pathology
Fig. 35 Proximal Tubal Block
Salpingoscopy plays a key role in decision making for reconstructive surgery of such tubes
Study between 1996 to April 2005
Types of Anastomosis:
Types of anastomosis:
Types of anastomosis & its result:
Case type versus result:
Out of the 184 successful surgeries, 145 (78.8%) conceived, including 6 cases of ectopic pregnancy (4.2%).
- Pregnancy rates were comparable with open tubal re-canalization.
- Salpingoscopy is very helpful in presence of pathological block.
- In cases of ectopic pregnancies segmental excision is best option as compared to salpingostomy or total salpingectomy, if the ectopic sac is < 2cm of size.
- There is no place of tubal implantation rather interstitial tubal anastomosis is preferable & more fruitful.
- The average surgical duration was 2 hours and 30 minutes.
- The average hospital stay was 2 days.
- More cost-effective than IVF in the long run.
- Single step treatment as compare with IVF which requires multiple steps in each cycle.
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