Laparoscopic Tubal Sterilization Research Articles

The feasibility of reduced sutures in 3D laparoscopic tubal sterilization reversal

Study ObjectiveTo show the technique of reduced sutures in 3D laparoscopic tubal reanastomosis. DesignStep-by-step demonstration of the procedure using video. SettingLaparoscopic tubal sterilization reversal demands high precision and requires both skill and experience. Conventionally, 4 to 6 interrupted patterns using 6-0 to 8-0 absorbable sutures are used for laparoscopic tubal reanastomosis. We used fewer and larger sutures under a magnified 3D view to perform the procedure. InterventionsWe presented a case of a 42-year-old woman, gravida 3, para 3, who underwent tubal sterilization during Cesarean section 10 years ago. Preoperative hysterosalpingography (HSG) showed bilateral distal tubal occlusion. The procedure started with the subserosal injection of diluted vasopressin in both proximal and distal ends and in the mesosalpinx to facilitate dissection and hemostasis. After transection of tubal stump and removal of scar tissue, we used a 3 Fr ureteral catheter as the stent to facilitate suturing. Three interrupted 4-0 monocryl sutures were used for suturing both tubal mucosal and muscular layers at 6, 2, and 10 o'clock sites. We performed bilateral ampullo-ampullary reanastomosis. The tubes were successfully reanastomosed, and patency was confirmed by chromotubation performed at the end of the procedure (Figure 1). The operation lasted for 71 minutes. The operative blood loss was less than 50 ml. Patent right fallopian tube was confirmed on postoperative HSG 1 month later. The patient had a successful pregnancy 8 months after the operation. ConclusionOur experience shows the feasibility of 3D laparoscopy for tubal reanastomosis using reduced sutures. The technique alleviates the damage to the fallopian tube. The operative time, hospital stay, and postoperative adhesions were significantly lower than the conventional method with a comparable success rate.

Subsequent left distal tubal pregnancy following laparoscopic tubal sterilization: a case report

Background: Post-sterilization pregnancies are rare and many postulations were made for its mechanism. Abdominal pain in women with retained uterus mandates a pregnancy test, regardless of previous tubal surgery or sterilization surgery to exclude the possibility of ectopic pregnancy. Prevention via surgical approach not only prevents future occurrence but also confer prophylaxis measure against ovarian cancer. Case: A 39-year-old woman who had undergone open right salpingectomy due to tubal pregnancy presented with abdominal pain, a positive pregnancy test, and elevated beta-human chorionic gonadotropin (β-hCG) level. Furthermore, an ultrasound exam revealed the absence of a gestational sac in the uterine cavity but the presence of a left adnexal mass; hence ectopic pregnancy was suspected. Laparoscopy revealed a 3 × 4 cm bulging ectopic pregnancy at the left distal end of the remnant stump in the ampulla. The histopathological assessment confirmed ectopic pregnancy in the left distal tubal stump. Post-operation, β-hCG levels decreased. The patient fully recovered postoperatively. Discussion: Ectopic pregnancies after tubal sterilization are caused by fistula formation and intraperitoneal sperm transmigration. To avoid this possibility, surgical techniques should be used to obliterate the residual canal, including the precise location and depth of electrocautery to prevent fistula formation. Total salpingectomy is the recommended treatment approach for effective permanent sterilization and a prophylaxis measure against ovarian cancer.

The effect on postoperative bowel movements of intraoperative drain application during laparoscopic bilateral tubal sterilization

Purpose: The use of a drain during a laparoscopic bilateral tubal sterilization (L/S BTS) operation is not a routine procedure, but enables close follow up of a patient when there is suspected bleeding. The aim of this study was to investigate the potential benefits of drain placement during L/S BTS operation in respect of the gastrointestinal system postoperatively. Materials and methods: A retrospective evaluation was made of patients applied with L/S BTS at Turhal State Hospital between June 2019 and March 2021. The study included a total of 64 women; 22 applied with a drain during L/S BTS operation and 42 women not applied with a drain. The two groups of patients were compared in respect of age, time to postoperative gas-faeces output, abdominal pain, the formation of intra-abdominal abscess-hematoma, wound site infection, operation time, and time of hospital discharge. Results: In the comparison of the patients with and without a drain, there was seen to be earlier gas and faeces output in the patients where a drain was used (p=0.003, p=0.018). Greater abdominal pain was felt in the first 12 hours (p=0.029), and a higher rate of wound site infection was observed (p=0.008) in the patients with a drain. Conclusion: Perioperative placement of a drain in patients applied with L/S BTS was seen to result in earlier gas-faeces output but greater abdominal pain. Drain application in the early postoperative period can be considered to have a positive effect on the bowel movements evacuating laparoscopy gas.

Intraperitoneal ropivacaine for post-operative pain following laparoscopic tubal ligation: a randomised double-blind placebo-controlled trial

Background: Female sterilisation is the most common method of contraception worldwide and laparoscopic tubal sterilisation is increasingly considered as a day-surgery procedure. Therefore, pain following this procedure should be seriously addressed. Instillation of 200 to 300 mg of ropivacaine intraperitoneally has been proven effective in controlling pain after laparoscopic tubal ligation (LTL). However, extreme caution must be taken as potential serum toxicity has been reported with the instillation of 150 mg of intraperitoneal ropivacaine. In search of the lowest, most effective dose, this study aimed to evaluate the effectiveness of 112.5 mg of ropivacaine intraperitoneally in reducing post-operative pain after LTL. Methods: This double-blind, placebo-controlled randomised trial was conducted in an ambulatory care centre in Malaysia. Sixty-two patients scheduled for LTL were recruited. Two patients were excluded from the trial because of intraoperative complications. Sixty patients were randomised to either the placebo group (intraperitoneal normal saline, n = 30) or the ropivacaine group (intraperitoneal ropivacaine, n = 30). Pain scores (using a visual analogue score), and the need for additional analgesia were assessed at 15, 60, 120, and 240 minutes post-LTL. Results: We observed no significant differences in pain scores or the need for additional analgesia between the groups. Conclusion: 112.5 mg of ropivacaine administered intraperitoneally is not more effective than normal saline in decreasing post-operative pain after LTL.

2172 Effect of GNRH Antagonist, Elagolix on Size and Quantity of Endometriotic Lesions Following 2 Months of Therapy

Study Objective Data on the effect of GnRH antagonist, Elagolix on pathological lesions of endometriosis is lacking. We present a case where second look laparoscopy was done on a patient treated with Elagolix, where the effect of the drug on implants is described. Design Case report and review of the English literature. Setting Tertiary care hospital. Patients or Participants A 39-year-old female patient. Interventions A 39-year-old G3P2A1 female patient had long-standing history of dysmenorrhoea, deep pelvic pain, and dyspareunia controlled by oral contraceptives. She underwent laparoscopic bilateral tubal sterilization and multiple endometriotic implants were observed in the left uterosacral ligament, posterior cul-de-sac, and deep peritoneal pocket. Postoperatively the patient was started on Elagolix 150 mg daily. The patient's symptoms improved, however, she requested surgery as a definitive treatment for her endometriosis. Therefore, laparoscopic resection and ablation of endometriotic implants were done two months after initiation of therapy with Elagolix. Measurements and Main Results Following initiation of therapy with Elagolix, the patient reported a significant improvement in her symptoms and quality of life. On second look laparoscopy, a marked reduction in size and number of implants were observed. Histopathological evaluation of biopsy from a residual implant was consistent with endometriosis. Conclusion Endometriosis is a chronic gynecological condition which often produces debilitating pain and infertility. Elagolix is a novel drug, which has been recently approved in the US for treatment of moderate to severe endometriosis-related pain. In this case report, a marked reduction of disease was observed both symptomatically and on direct visualization of lesions. There have been previous studies demonstrating the effect of Leuprolide, Danazol and aromatase inhibitors on endometriotic implants. However, more information is required to provide evidence on the effect of Elagolix on the disease process, duration of pain-free interval and recurrence of disease after cessation of therapy.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy Aided by Transcervical Instrumental Uterine Manipulation

Study ObjectiveTo describe the technique of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy with the aid of transcervical instrumental uterine manipulation. DesignVideo with step by step description of technique. SettingMinimally Invasive Gynaecological Surgery Department, Naval Multi Speciality Hospital, Jalgaon, India. PatientA 47-year-old woman. InterventionvNOTES hysterectomy. Measurements and Main ResultsA 47-year-old patient presented with history of menorrhagia since 4 years as well as a history of failed medical management for menorrhagia. Ultrasonography showed an enlarged uterus with findings suggestive of adenomyosis. Body mass index of the patient was 27. She had a history of 2 normal vaginal deliveries and had undergone laparoscopic tubal sterilization in the past. During vNOTES hysterectomy, an instrument was placed transcervically into the uterus for manipulation, providing leverage that helped gain good exposure of all uterine attachments. It also prevented unintentional rotation of uterus and its attachments. Therefore, the surgeon did not need to use a second hand for retraction of the uterus during surgery, allowing that second hand for retraction of bowel and adnexa. Hysterectomy was completed without any complications. Total estimated blood loss was 55 mL, and the patient was discharged on the third day. ConclusionBecause the tip of instrument is not completely visible in vNOTES surgery, manipulation helps to deflect the uterus and its attachments away from important structures, thus preventing inadvertent thermal damage from the tip of the instrument. This is a feasible and safe technique for vNOTES hysterectomy.

An uncommon spontaneous right distal tubal pregnancy post bilateral laparoscopic sterilization

Rationale:Tubal sterilization as a contraception method has a high success rate; however, it also carries a low risk of incidental pregnancy. A majority of these pregnancies are ectopic. In this study, we report a rare case of spontaneous right distal tubal pregnancy after bilateral laparoscopic tubal sterilization.Patient concerns:A 36-year-old woman who had undergone bilateral laparoscopic tubal sterilization presented with abdominal pain and a positive test for pregnancy.Diagnosis:Ectopic pregnancy was suspected based on absence of gestational sac in the uterine cavity on ultrasound and elevated beta-human chorionic gonadotropin (β-hCG) level.Intervention:Since the patient had unstable vitals, emergency laparoscopic surgery was performed, which revealed a right distal fallopian tube pregnancy. We performed a complete bilateral residual tubal stump excision.Outcomes:The patient recovered well after surgery, with a reduction in β-hCG level, and was discharged after 3 days.Lessons:To ensure complete sterilization, the gap at the excised end needs to be adequately widened and enhanced with electro-destruction to prevent formation of a fistula.

Weighing the Options for Tubal Sterilization: Hysteroscopic or Laparoscopic?

To evaluate the outcomes of hysteroscopic versus laparoscopic tubal sterilization, investigators in France conducted an observational cohort study

Update on the Essure System for Permanent Birth Control

In 2002, the U.S. Food and Drug Administration approved the Essure system for permanent birth control. Implantation with this device offers a minimally invasive option for permanent female contraception that is placed during a brief office visit. Unlike laparoscopic tubal sterilization, the Essure procedure requires no hospitalization or general anesthesia, resulting in minimal recovery time. After a decade of stability in the report of adverse effects, the U.S. Food and Drug Administration noted a sharp increase in patient-reported adverse events, including chronic pelvic pain, irregular bleeding, allergic reactions, and autoimmune-like reactions. In response to this increase in complaints, the U.S. Food and Drug Administration issued updated guidelines for patient education and counseling. This article discusses those updates, as well as implications for nurses who provide health care to women seeking permanent contraception.

Incidence of Unintended Pregnancy after Laparoscopic Tubal Sterilization at Dr.Sardjito Hospital

Background: Laparoscopic tubal ligation is one of the most commonly performed sterilization procedures and has many advantages such as high success rate and early return to normal activity. In Indonesia, the incidence of unintended pregancy in a study was 0,15 %. This rate is comparable with pregnancy rates for women using another contraceptive method. Objective: To assess the incidence of unintended pregnancy on women who underwent laparoscopic tubal sterilization at Dr. Sardjito Hospital. Method: A descriptive observational study with retrospective cross-sectional design was conducted. The data were acquired from medical record from January 2009 to April 2015. Reports of unintended pregnancy within two years after procedure were recorded. Result and Discussion: 55 women met the inclusion criterion and none were excluded. Method failures resulting on pregnancy occured in 3 cases (5.45 %), so the success rate of the procedure was 94.55 %. All of the reported pregnancies happened within two years after the procedures. There was no major complication occured in the procedure, but minor bleeding (<50 cc) did occur in some cases. Conclusion: The incidence of unintended pregnancy on women who underwent laparoscopic tubal sterilization at Dr. Sardjito Hospital was higher than the average incidence reported on another studies. Keyword: female sterilization, laparoscopic tubal sterilization, unintended pregnancy.

Clinical presentation of endometriosis identified at interval laparoscopic tubal sterilization: Prospective series of 465 cases

ObjectivesWomen seeking sterilization are usually parous and have no major complains, such as pelvic pain. This could be a good model to indirectly assess the prevalence of endometriosis in the general population. Prevalence of endometriosis in women undergoing tubal sterilization by laparoscopy has been assessed in 17 published reports. Results indicate a surprising wide variation of prevalence of endometriosis, ranging from 1.4% to 43.3%. This clinical study describes the prevalence and clinical presentations of endometriosis identified at interval laparoscopic tubal sterilization, as a close representation of endometriosis in general population. Material and methodsFrom July 1989 to February 2009, 465 women undergone interval laparoscopic tubal sterilization and were included in this series. Surgery was realised in a non universitary centre of gynecologic surgery. All patients were operated on by the same surgeon. A complete assessement of pelvic organs was achieved with a particular attention paid for endometriotic lesions. Endometriosis when present was staged according to r-AFS classification. Biopsies were sent for pathological examination to assess endometriosis. ResultsMean age of women was 40.7 years (range 15–49 years). 20 women were nulliparous and 12 others had a past history of endometriosis. Endometriosis was visually identified in 55 patients (11.82%), and confirmed by histologic examination in most of cases (50/55: 90.9%). The mean age of women presenting endometriosis at the onset of tubal ligation was 41.27 years. Cases with endometriosis were classified according to the r-AFS. 39,7,8 and 1 cases corresponded to stages I, II, III and IV respectively. In the 20 nulliparous women, the prevalence of endometriosis was 20% (4/20). At the time of laparoscopic sterilization, 91 women presented a painfull condition (dysmenorrhea mainly or dyspareunia). Endometriosis was identified in 16 of them (17.58%). In the group of 360 asymptomatic parous women, the prevalence of endometriosis was 10% (36/360). Nulliparity, associated pelvic pain and retroverted uterus were associated with increased prevalence of endometriosis, without being significant. ConclusionIn our study, the prevalence of endometriosis identified at interval laparoscopic tubal sterilization was 11.82%. In parous asymptomatic women, the prevalence of endometriosis was 10%. The prevalence of endometriosis was slightly increased in nulliparous women, when pain was associated and in women with a retroverted uterus.

Post-Approval Clinical Studies of Essure: Quality of Evidence and Future Outlook [16G

INTRODUCTION: Approved in 2002, Essure offers a method to achieve permanent sterilization via an office-based procedure. In late 2015, the FDA to re-investigated the device due to a rise in patient complaints ultimately leading to a new black box warning and the requirement of a new post-marketing study. Understanding the post-marketing clinical data surrounding the device’s safety and efficacy would inform clinicians in their patient counseling. METHODS: MEDLINE was queried using the search terms: Essure; hysteroscopic sterilization; postmarket approval; efficacy. The FDA and the manufacturers’ executive summaries on Essure, published in 2015, were mined as well. The quality of each study was rated using the Oxford Centre for Evidence-based Medicine Levels of Evidence scheme. A Grade 1 rating indicates a well-designed systematic review or randomized controlled trial while a Grade 5 rating indicates the weakest evidence quality (e.g. expert opinion). RESULTS: The search produced 231 unique references, of which 61 were considered relevant based on title and abstract. In aggregate, a total of 110,546 women were involved. The number of participants in each study ranged from 18 to 71,875. Overall, the majority of studies (74%) were rated Grade 4 (e.g. retrospective cohort, case-series, or case-controlled studies). Only 13% of studies were rated Grade 1 or Grade 2. CONCLUSION: The available post-marketing data is not of ideal quality, but the available evidence suggests that Essure is a safe and effective device for permanent female sterilization. The controversy will likely continue until completion of the new post-marketing study (n=2,800) comparing Essure with laparoscopic tubal sterilization.

Should we use visual entry techniques in patients with previous laparotomies?

Laparoscopic surgery has become the method of choice for treating an ever increasing number of gynaecological disorders that require surgery. However, primary port insertion is a potentially dangerous step especially in patients with previous laparotomies. The aim of this study is to identify whether visual entry technique has any advantage over the closed one in patients with previous laparotomies. This is a retrospective observational case control study of 2541 patients with previous laparotomies who underwent laparoscopic surgery from January 1992 to September 2003 at Vijaya Hospital, Kochi and from October 2003 to October 2015 at Department of Endoscopy, Paul’s Hospital, Kochi, India. The control group comprised of 1261 patients, operated between January 1992 and September 2003 at Vijaya Hospital, Kochi, in whom closed technique of abdominal access for primary port creation was used. The study group comprised of 1280 patients, operated between October 2003 and October 2015 at Department of Endoscopy, Paul’s Hospital, Kochi, in whom visual entry (EndoTIP) was used for primary port creation. Procedures included in both groups were total laparoscopic hysterectomy, laparoscopic myomectomy, laparoscopic ovarian cystectomy, laparoscopic conservative surgery, laparoscopic tubal reanastomosis, laparoscopic sacrocolpopexy, laparoscopic sacrocervicopexy, laparoscopic adhesiolysis and laparoscopic sterilisation. There was no evidence of intestinal or vascular injury during visual entry using a blunt EndoTIP cannula. There were three cases of bowel injury with the closed, blind entry technique using a sharp linear trocar in the control group. The p value (Chi-square test) is 0.04, which is statistically significant. Visual entry, as an approach to abdominal access in patients with previous laparotomies, wherein chances of encountering peritoneal and bowel adhesions are very high, is safer than the closed blind entry technique in preventing bowel injuries.

Cardiac arrest: an unexpected complication during laparoscopic bilateral tubal ligation - a rare case report

Data consistently show that in experienced trained hands, laparoscopic tubal sterilization is safe and highly effective regardless of the approach or occlusive method. The known mortality rate is between four and eight deaths per 100,000 cases and the rate of intraoperative and postoperative major complications is less than 1%. The anesthetic complication rate for laparoscopy is between 0.016% and 0.75%. Carbon dioxide (CO2) pneumoperitoneum effects are still controversial. Here the authors present a case report of patient who suffered from intraoperative cardiac arrest during laparoscopic tubal ligation under general anesthesia. No definite cause has been identified. The authors outline several possible mechanisms that could have been involved and attempt to discuss these events in the face of published reports describing similar complications.

The effect of obesity on intraoperative complication rates with hysteroscopic compared to laparoscopic sterilization: a retrospective cohort study.

BackgroundSurgical sterilization is a common method of contraception. There have been few studies evaluating the effect of obesity on procedural complications with either laparoscopic or hysteroscopic methods of sterilization. The purpose of this study was to compare the incidence of intraoperative complications of hysteroscopic tubal occlusion with laparoscopic tubal ligation among obese and nonobese women.MethodsThis retrospective cohort study compared women undergoing interval laparoscopic or hysteroscopic sterilization in the operating room between September 2009 and December 2011 at a single hospital. Serious complications included: unintended surgery, uterine perforation, anaphylaxis, blood transfusion, infection requiring antibiotics, hospital admission, fluid overload, myocardial infarction, and venous thromboembolism. Post-operative events included: nausea/vomiting, doctor evaluation or additional pain medication required in the recovery room, and emergency department visit within 2 weeks of surgery. The association between sterilization type and incidence of complications was examined overall, separately by BMI group, and also among patients who received general anesthesia.ResultsA total of 433 laparoscopic and 277 hysteroscopic procedures were reviewed. The BMI distribution of the sample was 35 % normal weight, 31 % overweight, and 34 % obese which is comparable to the general US female population. No life-threatening events were identified. Serious complications were similar with 20 (4.6 %) in the laparoscopic group and 11 (4.0 %) in the hysteroscopic group (p = 0.9). The most common serious complications were bleeding from the tube, cervical laceration, and uterine perforation. Although not statistically significant, women with a BMI of 30 or greater had only 1 (1 %) serious complication in the hysteroscopic group compared to 7 (5.2 %) in the laparoscopic group. Postoperative events were increased in the laparoscopic group (16.2 %) compared to the hysteroscopic group (6.9 %), especially among overweight and obese women (p <0.01). Failure to complete the intended bilateral occlusion occurred for 14 women in the hysteroscopic group compared to just one woman in the laparoscopic group (p <0.001).ConclusionBoth laparoscopic and hysteroscopic tubal sterilization are safe with few serious complications based on these data. No cases of laparotomy, blood transfusion, or life-threatening events were identified. There was no difference in serious complication rate by sterilization method. Overweight and obese women were no more likely to experience a serious complication with either method than women with a BMI <25. There were fewer postoperative events (p <0.01) with hysteroscopic sterilization, but far fewer failed laparoscopic procedures (p <0.001). These study findings can be used to enhance sterilization counseling.

Comparing Outcomes of Hysteroscopic and Laparoscopic Tubal Sterilization

In the U.S., some 600,000 female tubal sterilization procedures are performed annually, most often laparoscopically or hysteroscopically if outside the

Comparison of Healthcare Costs Among Commercially-Insured Women in the U.S. Who Undergo Hysteroscopic Sterilization vs. Laparoscopic Bilateral Tubal Ligation Sterilization

Comparison of Healthcare Costs Among Commercially-Insured Women in the U.S. Who Undergo Hysteroscopic Sterilization vs. Laparoscopic Bilateral Tubal Ligation Sterilization

Glutathione S-transferase M1 and T1 gene polymorphisms in Brazilian women with endometriosis.

The glutathione family (GST) genes appear to play a role in the genesis of endometriosis. This case-control study aimed to compare the frequencies of GSTM1 and GSTT1 polymorphisms in women with endometriosis and women without endometriosis. Polymerase chain reaction was performed to analyze the GSTM1 and GSTT1 genotypes among women with surgically and histologically confirmed endometriosis (case group n = 121) and in women without evidence of endometriosis confirmed by laparoscopy for investigation the infertility or for laparoscopic tubal sterilization (control group n = 97). No differences in the frequencies of GSTM1 polymorphism (null genotype) were observed between the cases and controls: odds ratio (OR) = 1.13; 95 % CI 0.656-1.93 (p = 0.659). The GSTT1 polymorphism (null genotype) was more prevalent in the endometriosis group than in the control group (OR = 0.53; 95 % CI 0.94-0.29 (p = 0.039). No relationship between menstrual cycle interval and GSTM1 null genotype frequency was observed in either cases or controls (p = 0.370 and p = 0.664, respectively). In addition, no relationship between menstrual cycle interval and GSTT1 null genotype was observed in cases (p = 0.797) or controls (p = 0.052). GSTM1 null genotype frequency was similar between cases and controls. The GSTT1 null genotype was more frequent in the control group.

Essure microinsert hysteroscopic tubal sterilization: eight-years follow-up results

Objectives: To evaluate the effectiveness and reliability of microinsert hysteroscopic sterilization method at short- and long-term. Materials and Methods: In the period between January 2004 and December 2005, 34 patients who submitted to the present gynecology outpatient clinic seeking for permanent contraception and accepted tubal sterilization with microinsert method were included in this prospective, interventional study. Results: Bilateral microinsert placement was successful in 28 (87.5%) of 32 patients that underwent the procedure. In all of the 30 patients (100%) in whom the placement procedure was attempted, bilateral tubal occlusion was documented by hysterosalpingogram (HSG) including the two patients in whom unilateral placement was carried out. First three procedures were performed under general anesthesia. Local or general anesthesia was not administered in any other cases (97.5%). The mean visual analogue scale score for pain felt during the procedure was 3.1. The mean procedure time was 11.5 &#x00B1; 4.88 (5-22) minutes, the average time from beginning the procedure to discharge of the patients was 41.7 &#x00B1; 18.5 (15-94) minutes . One intrauterine pregnancy was detected in one of the patients nine months after cessation of the alternative contraceptive period. This patient was excluded from the follow-up. At short-term all patients rated their microinsert-wearing tolerance as good or excellent. At eighth year, three patients were lost to follow-up. Mean follow-up time was 83.4 &#x00B1; 15.0 (36-103) months. During 2,420 woman-months of follow-up, no other pregnancies were detected. Almost all of the patients were happy with the procedure and recommended it to a friend. Conclusion: Essure microinsert is a safe, effective, minimally invasive sterilization method which can be performed in outpatient settings without any anesthesia requirement. It appears to be a good alternative to laparoscopic tubal sterilization. The procedure time and the time to discharge are brief. Patient tolerance during the procedureand at long-term is very good.

Tubal ectopic pregnancy on a patient with two previous consecutive laparoscopic tubal sterilisation techniques

Tubal ectopic pregnancy on a patient with two previous consecutive laparoscopic tubal sterilisation techniques