Laparoscopic Tubal Sterilization Research Articles

Argon as distending medium in laparoscopy compared with carbon dioxide and nitrous oxide

The study investigated the inert gas argon as a distending medium during laparoscopic tubal sterilization under local anesthesia, and compared it with carbon dioxide (CO2) and nitrous oxide (N2O). Ninety women were assigned to three groups of 30 each, and one of three gases was randomly selected for abdominal distention. The chosen gas was blinded to surgeon, patient, and anesthetist. Induction and maintenance analgesia with midazolam and alfentanil were given by the anesthetist at a predetermined dosage as needed. Lidocaine 1% was given for paracervical block and in the subumbilical suprapubic areas for local anesthesia. A modified McGill pain assessment rating was used to record patients' pain at 1, 24, and 48 hours postoperatively. Postoperative analgesia requirement and time to return to work were also recorded. Intraoperatively, argon required similar analgesia as CO2 and N2O, but at 72 hours was associated with greater discomfort, probably relating to its lower solubility and retention in the abdomen. Time to return to work was not affected. Owing to its similar density (atomic weight 40) compared with molecular weight of 44 for CO2 and N2O, argon can be used interchangeably for distention in the standard insufflator machine. It should undergo further study for this purpose, however.

Evaluation of pain following electrocautery tubal ligation and effect of intraoperative fentanyl

Study Objective: To evaluate pain following laparoscopic tubal sterilization (LTS) and the effects of supplemental intraoperative fentanyl. Design: Open evaluation of pain intensity and opioid requirements with double-blind, randomized evaluation of intraoperative fentanyl. Setting: Outpatient center of a university-affiliated teaching hospital. Patients: 44 ASA status I patients who underwent LTS by electrocautery. Interventions: Patients received either intravenous fentanyl (F) 1 μg/kg or saline (S) at induction. Measurements and Main Results: Pain intensity was measured with patient assessments of visual analog scales (VAS) and cumulative opioid requirements. The group that received intraoperative fentanyl received 70.2 ± 3.7 μg at induction. VAS on postanesthesia care unit arrival was 4.9 ± 0.5 (F) and 5.9 ± 0.5 (S) (means ± SEM). VAS after one hour was 2.1 ± 0.2 in both groups. During that hour, the F group consumed 107.5 ± 14. 7 μg and the S group consumed 140.5 + 15.7 μg fentanyl. The range of fentanyl consumed by each group in the postoperative period was 0 to 250 μg. There were no statistically significant differences between the F and S groups. Conclusions: Pain following LTS by electrocautery is of significant magnitude and may require relatively large doses of opioids for adequate management. Supplemental intraoperative fentanyl 1 μg/kg did not produce a clinically significant reduction in either pain scores or opioid requirements.

A Simplified Procedure for Laparoscopic Tubal Sterilization Reversal: The One Tubal Stitch Technique

ABSTRACT The goal of this work is to describe and report the preliminary results obtained for laparoscopic tubal sterilization reversal. The technique is simple and atraumatic and requires only one stitch in the tube. After preparing the tube stumps and bringing the edges of the mesosalpinx together, laparoscopic anastomosis is achieved by one stitch placed at 12 o'clock on the antimesial edge of the tube. Between May 1994 and September 1995, we operated on 15 patients using this technique and carried out 27 tubal sterilization reversals, with 3 patients having a single tube or a contralateral tube that was too badly damaged for treatment. For the 14 patients who underwent postoperative hysterosalpingography during the first or second month after the operation, the rate of patency was 92.6% (25 of 27). The overall intrauterine pregnancy (IUP) rate was 46.7% (7 patients). The IUP rate for the 8 patients who were aged 38 years or under was 75% (6 patients). These encouraging results demonstrate that laparos...

Evisceration after laparoscopic sterilization

A 35-year-old multiparous woman underwent laparoscopic tubal sterilization without intraoperative problems. Postoperatively, she had nausea and vomiting that failed to respond to antiemetics. The cannula incision site was soaked with serosanguineous discharge. Exploration of the wound revealed evisceration of 10 cm of necrotic small bowel. Resection anastomosis was performed and the patient recovered uneventfully.

Local anaesthetic on Filshie clips for pain relief after tubal sterilisation: a randomised double-blind controlled trial

SummaryPain during tubal sterilisation is thought to be due to either ischaemia or pressure at the site of impact of sterilising devices on the fallopian tubes. We have evaluated the effiectiveness of an application of 2% lignocaine gel to Filshie clips to relieve postoperative pain.In a randomised double-blind placebo-controlled study, 80 healthy women undergoing tubal sterilisation under general anaesthesia at the County Hospital, Lincoln, UK, were allocated to be sterilised by Flishie clips covered with 2% lignocaine gel or K-Y gel as placebo. Pelvic pain was assessed, with a 100 mm visual analogue scale, at 1 hour, at hospital discharge, and time of first analgesia or any other time analgesia was demanded. The lignocaine-treated group had significantly longer time to first analgesia, less pain at 1 hour, less nausea and vomiting, and shorter recovery time. Fewer lignocaine-treated patients needed additional analgesia and they required fewer opioids. There was no case of failed sterilisation or adverse reaction to lignocaine.The application of local anaesthetic gel to Filshie clips is a safe, non-invasive, and effective method of relieving postoperative pain during laparoscopic tubal sterilisation.

Argon Gas as the Distending Medium in Laparoscopic Surgery: A Preliminary Report

The objective of this study was to determine whether the inert gas argon may be used as a distending medium during laparoscopic tubal sterilization under local anesthesia and IV analgesia/sedation. Twenty-five patients scheduled for laparoscopic tubal sterilization under local anesthesia were given argon as a distending gas. Lidocaine was used as the local anesthetic. Operative pain was measured based on intraoperative analgesia requirements, and a modified McGill pain questionnaire was used to assess pain at 15 mins, 1 h, and 24 h postoperatively. Insufflation with argon gas caused no discomfort during surgery and minimal or no discomfort postoperatively, thus requiring minimal analgesia. Because of its similar density to carbon dioxide (CO2) and nitrous oxide (N2O) (atomic weight 40 compared with molecular weight of 44 for CO2 and N2O), this gas was used interchangeably in the standard laparoscopic insufflation machine. In this preliminary study, the inert gas argon was shown to be well tolerated by the patient. Because of the hazards of N2O (supports combustion, pollutant in the operating room) and CO2 (carbonic acid formation with peritoneal irritation and absorption with elevation of blood pH and PCO2), argon gas may prove to be a preferred alternative in selected cases for abdominal distention in laparoscopy. Although studies with helium have been conducted with laparoscopic cholecystectomy under general anesthesia, showing a reduced PCO2 and acidosis compared with CO2, to our knowledge this is the first report of argon gas being used for distention in laparoscopy. (J GYNECOL SURG 11:233, 1995)

A Comparison of Local and General Anesthesia for Laparoscopic Tubal Sterilization

Despite extensive international experience with local anesthesia for laparoscopic tubal sterilization, this technique has been slow to gain acceptance in the United States. The purpose of this study was to compare local and general anesthesia for laparoscopic sterilization. The design of the study was a retrospective review of all laparoscopic sterilizations at San Francisco General Hospital performed over a 2-year period. Patients receiving local anesthesia were compared to patients receiving general anesthesia, and the mode of anesthesia was determined by patient preference. The main outcome measures were completion of planned procedure, patient satisfaction, and cost. We reviewed 209 cases, with 202 patients (97%) receiving the type of anesthesia initially requested. General anesthesia was employed in 81 cases (39%). The two groups were similar with respect to complications and postoperative disability. In both groups, 85% of the patients stated that the procedure met or exceeded their expectations. The average cost of each procedure was $1200 for local anesthesia and $3971 for general anesthesia. We conclude that local anesthesia is an effective and inexpensive alternative to general anesthesia for female sterilization. More widespread use of this technique could decrease significantly the costs of family planning programs nationwide.

Technology follies. The uncritical acceptance of medical innovation

WHAT procedures or practices are we involved in now which will rank with bloodletting as a folly of our time? 1 The need for ongoing assessment of both new and old medical technologies is undisputed. 2-6 Nevertheless, much, if not most, of contemporary medical practice still lacks a scientific foundation. 7,8 Recent reviews of emerging technologies suggest that little progress has been made in requiring rigorous evidence of efficacy or validity before adoption and dissemination of new technologies. 9-11 The road to medical progress has been littered with potholes—or, more accurately, craters. While some new technologies have clearly improved health and reduced costs, others have not. For example, the introduction of D immune globulin dramatically reduced hemolytic disease of the newborn in the United States, as did the use of vaccines for several infectious diseases. Similarly, the advent of laparoscopic tubal sterilization improved the safety of this operation and made

Technology Follies

"WHAT procedures or practices are we involved in now which will rank with bloodletting as a folly of our time?"¹ The need for ongoing assessment of both new and old medical technologies is undisputed.^2-6Nevertheless, much, if not most, of contemporary medical practice still lacks a scientific foundation.^7,8Recent reviews of emerging technologies suggest that little progress has been made in requiring rigorous evidence of efficacy or validity before adoption and dissemination of new technologies.^9-11 The road to medical progress has been littered with potholes—or, more accurately, craters. While some new technologies have clearly improved health and reduced costs, others have not. For example, the introduction of D immune globulin dramatically reduced hemolytic disease of the newborn in the United States, as did the use of vaccines for several infectious diseases. Similarly, the advent of laparoscopic tubal sterilization improved the safety of this operation and made

Comparison of silastic rings and electrocoagulation for laparoscopic tubal ligation under local anesthesia

To compare objectively the pain associated with tubal occlusion by Silastic rings versus electrocoagulation during laparoscopic tubal ligation under local anesthesia.Consecutive patients scheduled for laparoscopic tubal ligation under local anesthesia were randomized to Silastic rings (N = 50) or electrocoagulation (N = 52) as the method of tubal occlusion. Sterilization was performed under local anesthesia in a standard fashion. Bupivacaine 0.5% was used as the local anesthetic agent. Operative pain was measured based on intraoperative anesthesia requirements and a modified McGill pain questionnaire. This questionnaire was used to assess pain at 15 minutes, 1 hour, and 24 hours postoperatively.Demographics were similar for the two groups. Operative time was shorter in the Silastic-ring group (16.7 versus 21.8 minutes; P = .001), and this group also required less intraoperative anesthesia (P = .004). There were no statistical differences between the groups in self-reported pain intraoperatively or postoperatively. No patient in either group required antiemetics or pain medication in the recovery room.Silastic rings appear preferable to bipolar electrocoagulation for laparoscopic tubal sterilization under local anesthesia when long-acting local agents are used for tubal anesthesia.

Breaking new ground or just digging a hole? An evaluation of gynecologic operative laparoscopy.

The gynecological surgical procedures that may be accomplished via operative laparoscopy have dramatically increased in the past decade. Ideally, strong evidence of advantages over traditional surgical approaches should be presented for each surgical procedure before widespread use occurs. Such evidence is generally lacking. This review of recent publications concludes that laparoscopic operations for tubal ectopic pregnancy have been demonstrated generally to be preferable to laparotomy. Although evidence is very suggestive, clear superiority of laparoscopy has not been proven for endometriosis, ovarian cystectomy, oophorectomy, distal salpingostomy, or adhesiolysis for infertility. There is not adequate evidence to reach a conclusion on the use of laparoscopic myomectomy for fertility. When appropriately indicated, vaginal hysterectomy seems preferable to abdominal or laparoscopic hysterectomy, and preliminary evidence suggests that laparoscopic hysterectomy may have some advantages over abdominal hysterectomy. There is no evidence that laparoscopic tubal sterilization is better than minilaparotomy tubal sterilization. Much more scientific study of operative laparoscopic procedures is needed before universal change to these procedures can be fully endorsed.

Effects of sera from patients given various anesthetics on preimplantation mouse embryo development in vitro

This study compared the effects of sera from patients given various anesthetics on in vitro mouse preimplantation embryo development. Patients electing bilateral laparoscopic tubal sterilization were subjected to general anesthesia with nitrous oxide (N2O) that included either isofluorane (ISO/N2O) as an inhalant or fentanyl or morphine (FEN/MOR/N2O). The addition of sera collected 1 hr after anesthetic induction significantly reduced the numbers of two-cell mouse embryos that developed to blastocyst in the ISO/N2O group as compared to that of preanesthesia sera. In contrast, no detrimental effects were revealed from sera of patients given FEN/MOR/N2O. Comparison of sera from patients given ISO/N2O and FEN/MOR/N2O for laparoscopic oocyte retrieval and from patients given spinal anesthesia and/or i.v. sedation for ultrasonic retrieval also revealed a decrease in mouse embryo development in the ISO/N2O group, but no differences were seen in the other anesthetic regimens. ISO/N2O anesthesia was also associated with a significantly decreased fertilization rate of mature oocytes retrieved. However, no significant effect of ISO/N2O anesthesia on IVF pregnancy rates could be demonstrated. These studies indicate that embryo toxic effects can be detected in sera from patients given ISO/N2O and that this anesthetic may be detrimental to the success of in vitro fertilization and embryo transfer.

Operating Room Setup and Instrumentation

The emphasis of this chapter has been on the organization of an operating room for pelviscopic surgery--the major equipment and instrument components; their basic requirements for effective, safe function; and their logical arrangement and integration during surgery. Instrumentation for laparoscopic tubal sterilization has been omitted, having been widely discussed in the past. There are undoubtedly alternate plans to accomplish the same task. This is but one approach, based on the experience of a particular pelviscopy team. The important thing is that the room works, that the basic components are in place and in order, and that the individual members of the surgical team have a thorough understanding of the technical capabilities and limitation of each and every instrument they use.

Endometriosis in pregnant and non-pregnant women at tubal sterilization

The prevalence of endometriosis was investigated in 208 women at the time of laparoscopic tubal sterilization. In 101 women who were in the first trimester of pregnancy, 16% endometriosis was found. In 107 non-pregnant women, 22% endometriosis was detected. Endometriosis in the pregnant women showed more superficial, non-pigmented, gland-like lesions than in the non-pregnant group. In 23% of the endometriotic lesions from pregnant women, no decidualization was found. No special risk factors for developing endometriosis were found.

Pharmacokinetics of Propofol in Women Undergoing Elective Caesarean Section

In order to compare the pharmacokinetic properties of propofol in pregnant and nonpregnant females, the authors undertook to study 10 women with singleton pregnancies scheduled for elective cesarean section and 6 nonpregnant females undergoing elective laparoscopic tubal sterilization. All patients were free of significant systemic diseases or complications of pregnancy. General anesthesia for cesarean section patients was carried out with all generally recognized precautions. Anesthesia for both groups was induced with a propofol dose of 2.0 mg/kg injected over 20 seconds, neuromuscular blockade was maintained with atracurium after intubation, and anesthesia was produced with nitrous oxide-enflurane. Venous blood samples were obtained before induction and then periodically for 480 minutes after propofol injection. Samples were chromatographically analyzed for propofol concentrations and the data employed to derive pharmacokinetic parameters: distribution and elimination half-lives, apparent central volume of distribution, apparent volume of distribution at steady state, and clearance.

Laparoscopic Tubal Sterilization Under Local Anesthesia

Laparoscopic tubal sterilization has been performed under local anesthesia in the United States since 1971. Pilot studies suggested that local anesthesia was as adequate and as safe as general anesthesia. Since 1980, the senior author has performed more than 3000 outpatient laparoscopic tubal sterilizations with the silastic ring under local anesthesia. A retrospective descriptive study was conducted on 2827 cases. The technical failure rate was 0.14%. There were no unintended laparotomies due to complications. The mean operative time was 10.0 +/- 5.1 minutes. The mean anesthesia time was 23.3 +/- 6.9 minutes. The hospital cost for the patient was reduced by 68-85%. This study demonstrates that laparoscopic tubal sterilization can be performed adequately, safely, and quickly under local anesthesia.

10 Laparoscopic female sterilization

An overview of laparoscopic sterilization techniques from a historical and practical viewpoint includes instrumentation, operative techniques, mechanical occlusive devices, anesthesia, failure rates, morbidity and mortality. Laparoscope was first reported in 1893, but was developed simultaneously in France, Great Britain, Canada and the US in the 1960s. There are smaller laparoscopes for double-puncture procedures, and larger, single-puncture laparoscopes. To use a ring or clip, a much larger operating channel, up to 8 mm is needed. Insufflating gas may be CO2, which does not support combustion, but is more uncomfortable, NO2, which is also an anesthetic, and room air often used in developing countries. Unipolar electrocautery is now rarely used, in fact most third party payers do not allow it. Bipolar cautery, thermal coagulation and laser photocoagulation are safer methods. Falope rings, Hulka-Clemens, Filshie, Bleier, Weck and Tupla clips are described and illustrated. General anesthesia, usually a short acting agent with a muscle relaxant, causes 33% of the mortality of laparoscope, often due to cardiac arrest and arrhythmias, preventable with atropine. Local anesthesia is safer and cheaper and often used in developing countries. Failure rates of the various laparoscopic tubal sterilization methods are reviewed: most result from fistula formation. Mortality and morbidity can be caused by bowel damage, injury or infection, pre- existing pelvic infection, hemorrhage, gas embolism (avoidable by the saline drip test), and other rare events.

Management of tubal pregnancy with methotrexate

Ten women with tubal ectopic pregnancy were treated by the injection of methotrexate into the gestational sac under direct laparoscopic vision followed by a course of intramuscular therapy including folinic acid rescue. One course of treatment induced resolution of the extrauterine pregnancy in eight women. Complete resolution (beta-hCG less than 10 miu/ml) was achieved within 6-47 days (mean 14.5 days). Serum beta-hCG levels started to decline 3.4 days from the beginning of therapy. Length of hospital stay was 5-11 days (mean 6.4 days). Treatment failed in two patients. One woman had a laparoscopic tubal clip sterilization concomitantly with methotrexate treatment. Tubal patency was demonstrated in all the other seven women (100%) tested subsequently. There is a need to establish criteria for patient selection before methotrexate becomes a routine treatment for tubal pregnancy.

A comparison of recovery in outpatients receiving fentanyl versus those receiving butorphanol

The frequency of postanesthesia side effects and times to reach “benchmarks” in the recovery process for IV preinduction doses of 20 μg/kg butorphanol, 40 μg/kg butorphanol, or a 2 μg/kg dose of fentanyl were compared in a double-blinded study involving ambulatory surgical patients. The authors hypothesized that all drugs would perform equally well in all study areas. Sixty ASA physical status I and II women undergoing laparoscopic tubal sterilization were randomly assigned to one of three groups: Group I (n = 20) received 20 μg/kg butorphanol as a preinduction agent; Group II (n = 20) received 40 μg/kg butorphanol; Group III (n = 20) received 2 μg/kg fentanyl. Anesthesia management for allgroups was the same. Statistically significant variance was found in time to discharge-ready status and duration of nausea ( p < 0.05) between 40 μg/kg butorphanol and 2 μg/kg fentanyl, but no significant difference was found between 20 μg/kg butorphanol and 2 μg/kg fentanyl in these areas. Statistically significant variance was found in duration of dizziness and time to obtain a 10 on the Aldrete Post Anesthesia Recovery Score (APARS) between 40 μg/kg butorphanol and 20 μg/kg butorphanol and 40 μg/kg butorphanol and 2 μg/kg fentanyl. From the study, 20 μg/kg butorphanol appears to be as suitable as 2 μg/kg fentanyl for use as a preinduction narcotic analgesic, whereas 40 μg/kg butorphanol appears to be unsuitable due to increased duration of nausea, dizziness, and time to score 10 on APARS and reach discharge-ready status.

Unintended laparotomy associated with laparoscopic tubal sterilization

Although the complication rate for laparoscopic tubal sterilization is generally low, laparotomy is sometimes necessary to complete the sterilization or manage complications. To better characterize factors that predispose women to unintended laparotomy, we analyzed data from the Collaborative Review of Sterilization. Of the 5027 women undergoing laparoscopic tubal sterilization, 12 had unintended laparotomies to manage complications, whereas 39 women had unintended laparotomies because of technical inability to complete the laparoscopic procedure. Women with prior abdominal or pelvic surgery had an increased risk of unintended laparotomy (relative risk = 10.2, 95% confidence interval = 5.3 to 19.7). Women with a history of intrauterine device use or pelvic inflammatory disease had elevated risks that were not statistically significant (relative risk = 2.2 and 1.5, respectively). Comparative studies of alternative surgical approaches for tubal sterilization are needed to formulate recommendations for women who may be at increased risk of unintended laparotomy associated with the laparoscopic approach.