Different types of tubectomies
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tubectomy types methods female sterilization tubal ligation
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fallopian tube occlusion techniques Pomeroy Fimbriectomy Parkland Irving Uchida
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Types of Tubectomy (Female Sterilization)
Tubectomy (tubal sterilization / tubal ligation) refers to any surgical procedure that occludes or removes the fallopian tubes to achieve permanent contraception. It has a failure rate of ~0.5 pregnancies per 100 women per year (Harrison's, p. 11117).
A. Classification by Timing
| Timing | Approach |
|---|---|
| Postpartum (within 48 hrs) | Mini-laparotomy via subumbilical incision (uterus still elevated) |
| Post-cesarean | Done at the time of LSCS through the same incision |
| Interval (≥6 weeks after delivery) | Laparoscopy or mini-laparotomy |
B. Classification by Surgical Approach
| Approach | Description |
|---|---|
| Laparoscopy | Minimally invasive; preferred for interval sterilization |
| Mini-laparotomy | Small suprapubic/subumbilical incision; preferred postpartum |
| Laparotomy | Done when sterilization is performed alongside another abdominal procedure |
| Colpotomy (posterior) | Vaginal approach; now largely obsolete |
| Hysteroscopy | For transcervical methods (e.g., Essure — now discontinued) |
C. Classification by Technique
1. Ligation and Excision Methods (Suture-based)
Pomeroy Method (Most common worldwide)
- A loop of tube is ligated at its base with an absorbable suture (plain catgut)
- The knuckle of tube above the ligature is excised
- As the suture absorbs, the cut ends separate — adds a physical gap
- Simple, safe, widely used for postpartum mini-laparotomy
Modified Pomeroy
- Uses chromic catgut instead of plain catgut; slightly slower absorption
Parkland Method
- A segment of the isthmic portion is isolated by creating a window in the mesosalpinx
- The segment is doubly ligated and excised
- No loop is created; ends are separated by the mesosalpinx
- Preferred by some for lower failure rates
Irving Method
- The proximal cut end is buried into the myometrium
- The distal cut end is buried into the mesosalpinx
- Very low failure rate; used mainly during cesarean section
- Technically more complex
Uchida Method
- Saline + adrenaline is injected under the serosa to create a bleb
- The muscularis is excised after stripping the serosa
- The proximal stump is buried under the serosa; distal end is left exposed
- Extremely low failure rate; good for postpartum and interval
Aldridge (Burial) Method
- The tube is inverted into the leaves of the broad ligament
- Rarely used today
2. Fimbriectomy
- Excision of the fimbriated end of the fallopian tube
- Prevents capture of the ovum at ovulation
- Higher failure rate than other methods
- May reduce ovarian reserve slightly
- Kroener's fimbriectomy: classic described technique
3. Salpingectomy (Removal of tube)
Partial Salpingectomy
- Removal of a segment of the tube (commonly the ampulla or isthmus)
- Effective; used during cesarean or laparoscopy
Total (Bilateral) Salpingectomy
- Complete removal of both fallopian tubes
- Currently preferred when sterilization is planned, especially in those with a family history of ovarian cancer
- Reduces risk of high-grade serous ovarian carcinoma (which originates in the fallopian tube fimbriae)
- Supported by guidelines: "Complete salpingectomy has the potential for greater ovarian cancer risk reduction and should be considered when laparoscopic sterilization is planned" (Contraceptive Considerations for Cancer, p. 3)
4. Electrocoagulation / Electrosurgical Methods
Used primarily via laparoscope:
| Type | Description |
|---|---|
| Unipolar coagulation | Burns a long segment of tube; high efficacy but risk of bowel burns; largely abandoned |
| Bipolar coagulation | Current passes only between the two forceps tips; destroys 2–3 cm of tube; safer than unipolar |
| Bipolar + transection | Coagulation followed by cutting — reduces recanalization risk |
5. Mechanical Occlusion Devices
Applied laparoscopically:
| Device | Mechanism | Notes |
|---|---|---|
| Falope ring (Yoon band) | Silicone band placed over a knuckle of tube, causing ischemic necrosis | Postoperative pain; failure rate ~0.5–1% |
| Filshie clip | Titanium clip lined with silicone; occludes ~4 mm of isthmus | Low failure rate; reversibility possible |
| Hulka-Clemens clip | Spring-loaded plastic clip | Higher failure rate than Filshie; less commonly used now |
6. Transcervical (Hysteroscopic) Methods (Largely obsolete)
- Essure (Bayer): Micro-insert placed in the tubal ostium causing fibrotic occlusion — withdrawn from most markets due to adverse events
- Adiana: Similar concept; also discontinued
D. Summary Comparison
| Method | Best Timing | Failure Rate | Key Advantage |
|---|---|---|---|
| Pomeroy | Postpartum / interval | ~0.4% | Simple, widely taught |
| Parkland | Postpartum | Very low | Separated ends, less recanalization |
| Irving | Cesarean | Very low | Buried stumps |
| Uchida | Any | Very low | Excellent results |
| Bilateral salpingectomy | Interval / cesarean | Near 0% | Ovarian cancer risk reduction |
| Bipolar coagulation | Interval (lap) | ~0.2–0.4% | Laparoscopic, minimal tissue destruction |
| Filshie clip | Interval (lap) | ~0.2–0.3% | Best reversibility potential |
| Falope ring | Interval (lap) | ~0.5–1% | Simple application |
Key Points
- Bilateral salpingectomy is increasingly preferred over older occlusion techniques because it nearly eliminates failure and reduces ovarian cancer risk.
- The Pomeroy and Parkland methods remain the most taught surgical techniques.
- Mechanical devices (clips, rings) are the easiest laparoscopic options but have slightly higher failure rates than excision methods.
- Electrocoagulation should always be bipolar when used; unipolar is considered unsafe.
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