Improvement of minilaparotomy technique to allow for reversal of extensive sterilization procedures

Abstract

In a previous study of outpatient reversal of tubal sterilization by a combined approach of laparoscopy and minilaparotomy, postoperative intrauterine pregnancy rates were 71%, and total costs were 40% lower than for those women undergoing anastomosis by a traditional laparotomy. However, the technique, which involved exteriorization of the uterus and adnexa, could not be easily applied when difficult cases with little remaining oviduct were encountered. With a modification of technique and the addition of a new retractor, it became feasible to consider more difficult cases for minilaparotomy outpatient reversal of sterilization. We prospectively studied 11 such patients with weight < IBW + 30% and < 4 cm of operable oviduct for technical feasibility, cost, complication rates, and reproductive outcome. A vaginal pack was used to elevate the uterus and a Babcock clamp was used to bring the fundus toward the incision by traction on the round ligament. A small self-retaining retractor designed for back surgery (Cloward retractor) was used for the abdominal wall. With the aid of an operating microscope a two-layer anastomosis was performed with 7-0 and 9-0 polydiaxone sutures. In all cases minilaparotomy reversal of tubal sterilization could be performed without prolonged technical difficulty. The mean age of the patients was 34.1 years (range 25-41 years) and operating time 110 minutes (87-158 min). There were no intraoperative or perioperative complications during the same day hospitalization. The mean time of follow-up was 16.7 months. Postoperatively, five women had ongoing or delivered pregnancies (45%) and one woman had two ectopic pregnancies. This study demonstrated a method for outpatient reversal of extensive tubal sterilization which was technically feasible in the 11 attempted patients. Based on the preliminary data from this study we encourage patients who have had extensive tubal sterilization procedures to consider both outpatient, minilaparotomy anastomosis and IVF as reasonable alternatives.