Bilateral Cornual Resection for Uterine-sparing Removal of Tubal Sterilization Devices

Abstract

To describe a uterine-sparing minimally invasive surgical technique for laparoscopic resection of tubal occlusion devices using bilateral cornuectomy. This video reviews the background of the tubal occlusion device known as Essure, as well as the indications and methods for surgical removal with a stepwise demonstration of a minimally invasive technique with narrated video footage. The most cited reason for patients' desire for removal of the Essure device is pelvic pain. Both hysteroscopic and laparoscopic methods have been utilized for removal of these devices. Laparoscopy is indicated if it has been greater than three months since insertion, if a coil is noted to be malpositioned, or if the patient desires continued permanent sterilization. Techniques for removal include salpingostomy, salpingectomy, and cornuectomy. Removal of the entire device is essential, as any remaining coil or polyethylene terephthalate (PET) fibers may continue to cause symptoms. The coils of the device can easily be fractured; therefore, in our practice we perform a bilateral cornuectomy when uterine retention is desired, as fracture rates are higher with salpingectomy compared with cornuectomy. We demonstrate the steps of this method and highlight the critical aspects for surgeons to consider during the procedure. Laparoscopic bilateral cornuectomy approach to a uterine-sparing excision of Essure tubal occlusion devices to reduce the risk of coil retention and fracture: 1) Injection of dilute vasopressin at the uterine cornua for vasoconstriction and hemostasis 2) Circumferential dissection of the uterine cornua using monopolar energy 3) Confirmation of endometrial cavity entry using methylene blue 4) Excision of fallopian tube along mesosalpinx to include the fimbriated end 5) Closure of the myometrial layers using a unidirectional barbed suture in a running fashion CONCLUSION: In patients who desire uterine preservation, we recommend a minimally invasive technique of bilateral cornual resection for removal of tubal sterilization devices in order to avoid device fracture and inadvertent retention of coils.