Tuesday, July 28, 2015
Laparoscopy is the commonly employed method of endoscopic sterilization. It is gradually becoming more popular—especially, in the camps. The procedure is mostly done under local anesthesia. The operation is done in the interval period, concurrent with vaginal termination of pregnancy or 6 weeks following delivery. It should not be done within 6 weeks following delivery.
The procedure can be done either with single puncture or double puncture technique. The tubes are occluded either by a silastic ring (silicone rubber with 5 percent barium sulfate) devised by Fallope or by Filshie clip is made of titanium lined with silicone rubber. Only 4 mm of the tube is destroyed. Failure rate is 0.1 percent. Hulka-Clemens Spring Clip is also used. Electrosurgical methods—Dessicates the tissue by heating. Unipolar or bipolar method of tubal coagulation is used. Bipolar cautery is safer than unipolar one but it has higher failure rates (2.1 percent). Laser photocoagulation is not popular because of high recanalization rate.
Principal steps (Single puncture technique)
Premedication — Pethidine hydrochloride 75–100 mg with phenergan 25 mg and atropine sulfate 0.65 mg are given intramuscularly about half an hour prior to operation.
Local anesthesia—Taking usual aseptic precautions about 10 mL of 1 percent lignocaine hydrochloride is to be infiltrated at the puncture site (just below the umbilicus) down up to the peritoneum.
Position of the patient—The patient is placed in lithotomy position. The operating table is tilted to approximately 15 degrees of Trendelenburg position. Usual aseptic precaution is taken as in abdominal and vaginal operations. The bladder should be fully emptied by a metal catheter. Pelvic examination is done methodically. An uterine manipulator is introduced through the cervical canal for manipulation for visualization of tubes and uterus at a later step.
Producing pneumoperitoneum—A small skin incision (1.25 cm) is made just below the umbilicus. The Verres needle is introduced through the incision with 45° angulation into the peritoneal cavity. The abdomen is inflated with about 2 liters of gas (carbon dioxide or nitrous oxide or room air or oxygen). Choice of gas depends upon the method of sterilization.
Introduction of the trocar and laparoscope with ring
loaded applicator—Two silastic rings are loaded one after the other on the applicator with the help of a loader and pusher. The trocar with cannula is introduced through the incision previously made with a twisting movement. The trocar is removed and the laparoscope together with ring applicator is inserted through the cannula
The ring loaded applicator approaches one side of the tube and grasps at the junction of the proximal and middle third of the tube. A loop of the tube (2.5 cm) is lifted up, drawn into the cylinder of the applicator and the ring is slipped into the base of the loop under direct vision. The procedure is to be repeated on the other side.
Removal of the laparoscope: After viewing that the rings are properly placed in position, the tubal loops looking white and there is no intraperitoneal bleeding, the laparoscope is removed. The gas or air is deflated from the abdominal cavity. The abdominal wound is sutured by a single chromic catgut suture.