Tubectomy - Female Sterilization: Procedures

Approaches / Routes of Access

Surgical Techniques for Tubal Occlusion

1. Pomeroy Technique (most common)

• A loop of the midportion (ampullary) tube is elevated
• The base of the loop is ligated with an absorbable catgut suture
• The ligated loop is excised
• As the suture absorbs, the ends retract apart and are sealed by scarring
• Destroys 3-6 cm of tube
• Failure rate: 1-4 per 1,000 procedures

2. Modified Pomeroy / Parkland Technique

• A small length of tube (about 2 cm) is separated from the mesosalpinx
• Ligated at each end with separate sutures
• The free segment between the ligatures is removed
• Also called: partial salpingectomy, Parkland Hospital technique, separate sutures technique
• Similar failure rate to classic Pomeroy

3. Irving Technique (very low failure rate)

• The midportion of the tube is excised
• The proximal stump is turned back and buried into a small stab wound in the uterine wall (creating a blind loop)
• The distal stump is buried in the mesosalpinx
• Pregnancy is exceedingly rare after this technique
• Not easily reversible

4. Uchida Technique (very low failure rate)

• Saline-epinephrine solution (1:1,000) is injected beneath the mucosa of the midportion, separating mucosa from underlying tube
• Mucosa is incised along the antimesenteric border
• A tubal segment is excised under traction so the proximal stump retracts beneath the mucosa
• The mucosa is then closed, burying and separating the proximal stump from the distal stump
• In Uchida's personal series of >20,000 cases: zero pregnancies
• Technically demanding; becoming more popular in the USA

5. Fimbriectomy

• Complete removal of the fimbriated end of the tube
• Higher pregnancy failure rate than other techniques
• Reversal is not feasible

6. Madlener Technique (abandoned)

• A loop of tube was crushed by cross-clamping, ligated with permanent suture, and excised
• Now abandoned due to high failure rates

Laparoscopic Occlusion Techniques

Bipolar Electrocoagulation

• The midisthmic portion of the tube is grasped with bipolar forceps
• Radiofrequency current is applied to three adjacent areas, coagulating 3 cm of tube
• Generator must deliver at least 25 W into 100-Ω resistance to ensure full-thickness coagulation
• If inadequate energy is used, intrauterine pregnancy can occur through an intact inner lumen
• After bipolar failure, ectopic pregnancy results in >50% of cases (tuboperitoneal fistula)

Falope Ring (Silastic Band)

• A small Silastic ring is stretched and placed over a loop of the midisthmic tube, then released
• Tube is blocked by ischemic compression (2-3 cm segment involved)
• If the tube cannot be easily pulled into the applicator, change to electrical coagulation to avoid tube laceration
• More post-procedure pain than clips; can be reduced with bupivacaine bathing
• Better reversibility than electrocautery, Irving, or Uchida techniques

Hulka Spring Clip

• Placed at right angles across the midisthmus
• Applicator must be perpendicular to tube with the tube completely contained before closing
• Can only be used on non-thickened tubes (not after prior salpingitis)

Filshie Clip (titanium + silicone rubber liner)

• Hinged titanium device with a silicone rubber liner
• Placed at right angles across the midisthmus
• The posterior jaw anvil should be visible through the mesosalpinx to confirm full-thickness tube capture
• Lower pregnancy rate than Hulka clip - has largely supplanted it
• First introduced in the USA in 1996; extensively used in UK and Canada

Vaginal Approaches (Less Common)

• Both share higher complication and failure rates than abdominal approaches
• Not suitable as postpartum methods

Transcervical Approaches

Salpingectomy for Sterilization

• No increase in complication rates compared to occlusion methods
• Operative time increased by approximately 6-13 minutes
• Does not significantly affect ovarian reserve (AMH levels comparable)
• Recommended by ACOG when women undergo gynecologic surgery for other benign indications (opportunistic salpingectomy)
• Cost-effective: incremental cost-effectiveness ratio of ~$31,432 per QALY gained

Minilaparotomy vs. Laparoscopy - Comparison

Risks and Safety

• Overall complication rate: 1.7 per 100 procedures (CREST study, 9,475 cases)
• Risk factors for complications: general anesthesia, prior pelvic/abdominal surgery, PID history, obesity, diabetes
• Most common major complication: unintended laparotomy due to intra-abdominal adhesions
• Mortality: 1-2 per 100,000 sterilizations (national US data); nearly half from complications of general anesthesia
• International data: 4.7 deaths per 100,000 female sterilizations vs. 0.5 per 100,000 vasectomies
• When general anesthesia is used for laparoscopy, endotracheal intubation is mandatory (pneumoperitoneum increases aspiration risk)
• Prophylactic antibiotics are NOT indicated for laparoscopy or laparotomy sterilization (per ACOG/AHA guidelines)

Sterilization Failure

• Many apparent "failures" are pregnancies that began before surgery - a sensitive pregnancy test should be performed on the day of surgery
• Causes of true failure: misapplication of clip/ring, inadequate coagulation energy, anatomic abnormalities/adhesions
• 10-year cumulative failure rates (CREST study):
  • Bipolar coagulation: 36.5 per 1,000 procedures (if <3 sites coagulated)
  • Clip methods: lower when correctly applied
  • Pomeroy/partial salpingectomy: 1-4 per 1,000
  • Irving/Uchida: near zero

Noncontraceptive Benefits

• Reduced ovarian cancer risk: Tubal ligation associated with HR 0.76 (95% CI 0.64-0.90) for ovarian cancer (Nurses' Health Study, 29,340 women)
• Significant reduction in high-grade serous carcinomas (RR 0.77), endometrioid (RR 0.54), and clear cell tumors (RR 0.55)
• Complete salpingectomy is expected to offer even greater cancer risk reduction