10 LAPAROSCOPIC TUBAL ANASTOMOSIS Carlos Rotman, Nasir Rana, Jonathan Y. Song, Edgardo Yordan, Carlos E. Sueldo prior to performing tubal surgery. An office hysteroscopy I 1TRODUCTIO N and/or a sonohysterogram should be performed during the Bilateral tubal ligation as a form of permanent sterilization has preoperative work up. been carried out in females for more than a century ( I). Assessment of the type of tubal ligation performed is also Patients who have completed their desired family size and are important since it might determine \\·hether or not a tubal re­ certain about the lack of interest in future pregnancies find this ''ersal is indicated. For example, tubal cauterization, especially procedure to be cost eiTective, relatively simple, and generally by unipolar energy, typically causes significant damage to the free of complications. Patients find this permanent procedure blood supply of the fallopian tube and is unlikely to result in convenient since they do not have to deal "'ith the costs and a successful outcome if tubal anastomosis is performed, despite potential complications of different types of ongoing contra­ the results published recently by Yoon et al. (8). On the other ceptive methods, such as birth control pills and intrauterine hand, silastic rings, clips, as well as the Pomeroy-type of tubal contraceptive devices. li ga tion (commonly done for puerperal sterilization and also at The procedure can be accomplished effectively by different the time of cesarean sections) typically result in limited damage routes, including ,·aginal or abdominal approaches, either to the fallopian tubes. l\lost often, a tubal anastomosis can be through a mini-laparotomy or by laparoscopy. The timing of performed in those cases. the procedure is ,·ariable as it can be performed right after a The success rate of tubal anastomosis, measured as the rate \-aginal delivery or at the time of a cesarean section. Also, it can of intrauterine gestations after surgery, is generally quite high, be accomplished in a gynecologic patient (inten·al tubal ligation) especially if there is an appropriate patient selection and eval­ during the preovulatory phase of the menstrual cycle, commonly uation prior to surgery. Large series frequently quote intrauter­ bv laparoscopy. As for the methods used, the fallopian tubes can ine pregnancy rates in the 60-80 percent range (9). be sectioned and a segment of the tube removed, or if a laparo­ As in other areas of reproductive medicine, the age of the --copic approach is used, bipolar cauteriza tion of the tubes or female is an important factor in determining success, and eval­ application of silastic rings or clips arc popular alternatives (2-4). uation of the ovarian reserve, either with an antral follicle count It is estimated that as many as 700,000 procedures are per­ and/or with hormone evaluation on cycle day three in patients formed each yea r in the United States, roughly half after de- older than thirty-fiYe years ( I 0), may be a contributing factor in 1\•ery or at the time of a cesarean section and half by determining the best treatment approach. Also, as mentioned, laparoscopic (inten·al) tubal ligation (5). the presence of other infertility factor(s), especially male factor A number of these patients, howe\•er, change their minds infertility, may be enough reason to indicate assisted reproduc­ later in life, most commonly due to divorce followed by a new tive technology procedures instead of tubal surgery ( ll ) since relationship, leading to a desire for a new pregnancy. A sub­ by using intraqtoplasmic sperm injection for fertilization, the <equent consultation with a reproductive surgeon takes place, patient is more likely to get pregnant, as opposed to undergoing discussing the possibility of having the tubal ligation re,·ersed. tubal surgery and subsequent sexuaJ intercourse or intrauterine it is estimated that approximate!}' I percent of all patients will insemination. 41 -eek consultation for a tubal reversal within a few years after the Once the couple has made a decision about having a tubal procedure (6); prior to surgery, an appropriate evaluation of anastomosis, the surgeon determines the best surgical approach the couple is required to determine whether tubal reversal or ro be used in order to accomplish a successful tubal reversal. perhaps in \'itro fertilization-embryo transfer would be a better The procedure can be accomplished by laparotomy or by lap­ reproductive option. aroscopy; laparotomy is the more traditional method, and over Documenting the presence of ovulation and perfor~ing..a the }'ea~s, by using tubal microsurgical techniques, it has de~ complete semen analysis including a strict morp'hology a~ess­ veloped· a- prown record of good pregnancy rates (12). With !llent (Kruger) to rule out the presence of a male factor prob­ improvements in laparoscopic equipment and the availability em (7), even in those that have fathered children in the past, of experienced laparoscopic surgeons, more and more patients are required. Also, it is important to conduct some form of are being treated by laparoscopy, with equal degrees of success a:;sessment of the uterine cavity, even in asymptomatic patients, as those seen with laparotomy in the past. n order to rule out significant intracavitary pathology (e.g., The advantages of laparoscopy are the same as in other ubmucous fibroids, large pol}'pS, or intrauterine adhesions) areas of gynecology: an ambulatory procedure, a more rapid 9 2 CARLOS R OTMAK, NASIR R ANA, } OKATHA~ Y. SONG ET AL. • recovery after surgery, less postoperative morbidity, and equal distal segment but it will also not accurately determine the rates of pregnancy as those performed ,·ia laparotomy. There length and quality of the proximal segment. Only after entering are many laparoscopic techniques described for tubal anasto­ the abdomen are the surgeons able to ascertain pertinent infor­ mosis: sutureless technique ( 13), application of titanium sta­ mation for the procedure. A pelvic ultrasound and sonohystero­ ples ( 14}, robotically assisted laparoscopic tubal reversal ( IS ), gram are performed in the office on all potential candidates. If and the use of LAS ER ( 16). we identify __an y intrauteri ne pathology (e.g., submucous fib- · Our group has vast experience wi th laparoscopic recon­ ·roi'tls, polyps, and intrauterine adhesions}, they are either structive surgery in the management of tubal conditions result­ addressed at the time of our laparoscopic tubal surgery or be­ ing from a myriad of pathological conditions. This presentation forehand, depending on the type and severity of the pathology. however, will be limited to the use oflaparoscopy as a means to During our preoperative counseling and work up, the restore fertility in patients that have previously undergone tubal patients are informed of our pregnancy, ectopic, and abortion .. sterilization. rates as stated in the results section later in this chapter. Also, ·our laparoscopic technique of tubal anastomosis was we discuss the main advantages and disadvantages of this pro­ developed in 1998 after many years of performing mini­ cedure versus the use of in vitro fertilization-embryo transfer. laparotomy and traditional microsurgery in several hundred After the preoperative work up is completed, the patient is cases. The laparoscopic approach is essentially identical to that scheduled fo r laparoscopic surgery. of the open-abdomen technique except for the use of specialized instrumentation "to facil itate its performance via laparoscopy. SURGICAL TECH NIQUE f\ lost tubal anastomosis at our center are performed for steril­ ization reversal, but the same technique is applied to cases of Prior to commencing, the entire surgical team gets together to tubal occlusion secondary to pathologic processes. review all pertinent information about the case. The patient is As our experience evolved, numerous changes were imple­ then reassured, and anesthesia is given. mented to overcome technical challenges, enhancing the pro­ Patient positioning is the responsibility of the primary sur­ cedure to make it easier, faster, and hopefully more successful. geon. If this step is done by other team members, the surgeon These changes included selection of suture material, type of should walk around the operating table to ensure that every­ tubal closure (one vs. two layers}, tubal stump preparations, thing is in place prior to proceeding. We prefer a dorsolithot­ tubal can nulation, and the type of electric current best suited omy position with arms tucked in, shoulder stoppers placed to for these cases. Last but not least, placement of interrupted prevent intra-operative sliding, and legs slightly bent at the sutures versus a continuous closure was also investigated. knees and hips. Well-cushioned, adjustable leggings are a must Videotaping of the surgical procedure from beginning to to prevent lower-limb nerve injury. end is crucial for evaluating the different steps. It also allows the With the anesthesiologist's permission, a thorough pelvic surgeons to return later and review the surgery, providing the examination is performed, and the patient is prepped and dra­ opportunity to think, study, and improve, enhancing the tech­ ped in the usual manner. A Foley catheter (connected to a bag) nique to make it better and more efficient. is placed in the bladder. After completion of any hysteroscop}' or endometrial biopsy where warranted, a manipulator is in­ troduced into the uterine cavity. A vaginal assistant, responsible PRELI MI NARY WORK U P for keeping the uterus properly positioned as per the surgeon's Prior to surgery, the preliminary work up consists of the fol­ instructions duri ng the procedure, is seated between the lowi ng: l) a thorough review of all pertinent medical records patient's legs, facing a slave monitor located overhead or at if available; 2) a carefully obtained medical and surgical his­ either side of the surgical table. A primary monitor is placed tory and full examination; 3) a day 3 serum FSH and estradiol behind the vaginal assistan t, directly facing the surgeons.