///ROLE OF LAPAROSCOPIC TUBAL RECANALISATION IN MODERN ERA OF ART

ROLE OF LAPAROSCOPIC TUBAL RECANALISATION IN MODERN ERA OF ART

Dr. Sanjay Patel
HOD of Endoscopy Dept & Infertility Specialist
Dr. Yogendra
Jhala Consultant Endoscopic Surgeons
Dr. Rujul Patel
Associate Endoscopic Surgeon
Mayflower Women’s Hospital Drive In Road, Memnagar, Ahmedabad – 380052, India
www.mayflowerhosptial.com, contact@mayflowerhospital.com

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.


Indications

  • 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.


Micro-instrumentation:

  • 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
Fig.1 Kho ultramicro series
fig 2  

Fig.2 Uterine Manipulator

 

Selection of Cases
Length of Tubal Damage in Various Methods of Ligation

tabella

Other Non suitable cases are pathological tubes with PID, Salpingitis Isthemica Nodosa & Failed tubal cannulation.

 fig 3

Fig.3

fig 4

Fig.4

fig 5 

Fig.5

Intra-operative evaluation
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.

fig 6

 Salpingoscopy Grade 2: (Fig. 7)
Mucosal nuclear staining with Methylene blue dye.

fig 7

 

Salpingoscopy Grade 3: (Fig. 8)
Minimal flattening & minimal adhesion ( ) of endosalpinx

fig 8

 

 Salpingoscopy Grade 4: (Fig. 9)
Moderate flattening of endosalpinx with intraluminal adhesion.

fig 9

 

 Salpingoscopy Grade 5: (Fig. 10)
Severe flattening of mucosa with severe intraluminal adhesions.

fig 10

 


Surgical technique 

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

 

 fig 11

Fig. 11

 fig 12

Fig. 12

 

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 fallope ring excision

Fig. 13 Falope ring excision

fig 14 refreshing the edges

Fig. 14 Re-freshening of edges

fig 15 free die flow

Fig. 15 Free dye flow  

 fig 16 magnified view

Fig. 16 Magnified view

 fig 17

Fig. 17 Mesosalpinx stitch

fig 18

Fig.18 6 O’clock stitch  

 fig 19

Fig.19 12 O’clock stitch

fig 20

Fig. 20 Second layer

 fig 21

Fig.21 End result

Isthmo-Ampullary Anastomosis:

  • Luminal disparity is the potential problem which can be adjusted by cutting the isthmic end. 
fig 22

Fig. 22 Refreshening ends  

 fig 23

Fig. 23 First layer

 fig 24

Fig. 24 Second layer

fig 25

Fig. 25 Free spill

Ampullo-Ampullary Anastomosis:

  • Technically difficult anastomosis due to thin muscularis and tendency for mucosal folds prolapse.

fig 26

Fig. 26 Refreshening ends  

 fig 27

Fig. 27 First layer

 fig 28

Fig. 28 Second layer

Tubo-Cornual Anastomosis:

  •  Wedge excision in the cornual end mobilises good length of interstitial tube

fig 29

 fig 30

Fig. 30 Cornual Pathology

fig 31

Fig. 31 Wedge Incision

 fig 32

Fig. 32 Interstitial Anastomosis

 fig 34

Fig. 33 Mild Hydrosalpinx

fig 35

Fig. 34 Cornual Pathology  

fig 36

Fig. 35 Proximal Tubal Block  

Pathological tubes
Salpingoscopy plays a key role in decision making for reconstructive surgery of such tubes

Our Experience

Study between 1996 to April 2005
tab 2

Types of Anastomosis:
tab3

Types of anastomosis:
tab4

Types of anastomosis & its result:

tab5

Case type versus result
Out of the 184 successful surgeries, 145 (78.8%) conceived, including 6 cases of ectopic pregnancy (4.2%).

tab 6

 

Conclusion

  • 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.


References

  • Dubuisson JB, chaperon C, Nos C, et al: Sterilization reversal: fertility results. Hum Reprod 1995 May; 10(5): 1145-51.
  • Gomel V: Microsurgical reversal of female sterilization: a reappraisal. Fertil Steril 1980 Jun; 33(6): 587-97.
  • Reich H, McGlynn f, Parente C, et al: Laparoscopic tubal anastomosis. J Am Assoc Gynecol Laparosc 1993 Nov; (1): 16-9.
  • Swolin K: [50 fertility operations. I. Literature and methods]. Acta Obstet Gynecol Scand 1967; 46(2): 234-50.
  • American College of Obstetricians and Gynecologists: ACOG technical bulletin. Sterilization. Number 222—April 1996 (replaces no. 113, February 1998). Int J Gynaecl Obstet 1996 Jun; 53(3): 281-8.
  • Cetin MT, Demir SC, Toksoz L, Kadayifci O. the effect of laparoscopic reversal of tubal sterilization on pregnancy rate.
  • American Fertility Society (1985): Fertil. Steril., 43:351-352.
  • Bateman, B.G., Nunley, W.C. Jr., and Kitchin, J.D. (1987): Fertil. Steril., 48:523-542.
  • Mage, G., Pouly, J.L., Bouquet de Jolinière, J., Chabrand, S., Riouallan, A., and Bruhat, M.A. (1986): Fertil.Steril., 46:807-810.
  • Reich, H. (1987): J. Reprod. Med., 32:736-742.
  • Sauer, M.V. (1991): In: Infertility, Contraception &Reproductive Endocrinology, 3rd ed., edited by D.R. Mishell, V. Davajan, and R.A. Lobo, pp. 682-707. Blackwell Scientific Publications, Boston.
  • Williams, T.J. (1987): Obstet. Gynecol. Clin. North Am., 14:1037-1048.
  • Comparison of Tubal Ligation Reversal Procedures. Clinical Obstetrics & Gynecology. 43(3):641-649, September 2000. Van Voorhis, Bradley J. MD
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