Simulation

Laparoscopic Sterilization and Salpingectomy

Module

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Female Sterilization

Highly utilized method
- ~11 million women in United States undergo female sterilization
- 30% of all contraceptive users undergo female sterilization •
Mortality rate is:
- 1-4 per 100,000 procedures
- Less than the rate related to pregnancy and childbirth
- Mostly related to anesthesia
Complication rate is from 0.4 to 1%
- Wound infection, bleeding, or perforation of internal organs
- Obesity, diabetes, or previous abdominal or pelvic surgery are risk factors

Indications

Desire for and understanding of permanent sterilization
Contraindication to nonpermanent options in a woman done who has completed childbearing, i.e., uterine anomalies that prohibit use of intrauterine contraception

Contraindications and Cautions

Absolute contraindication: Desire for more children
Cautions: Conditions that increase risk
- Multiple previous abdominal surgeries
- Morbid obesity o Medical co-morbidities

**Must counsel that there are nonpermanent options that work as well for contraception without surgery and nonabdominal permanent surgical options (hysteroscopic), as well as male vasectomy

Benefits of Laparoscopic Sterilization

Opportunity to inspect abdominal and pelvic organs
Small incisions
Immediately effective
Enables rapid return to full activity

Equipment Needed for Laparoscopic Sterilization

Stirrups
Speculum/tenaculum/uterine manipulator (or sponge stick)
Urinary catheter (for either pre-op drainage or to be left in through the procedure)
Laparoscope
Light source
Monitor(s)
Trocars
Basic L/S instruments
- Most hospitals and surgery centers have a minor L/S “tray” with all necessary equipment
- Become familiar with your center’s equipment

Preevaluation

Informed consent
- Inform patient regarding risks, benefits, and alternatives
- Medicaid 30-day consent form for any woman with government-funded coverage
Anesthesia pre-op consult if indicated
- Medical co-morbidities
- Per your hospital or clinic policy

Early Steps of Laparoscopic Sterilization

Confirm all necessary equipment is present
Conduct a “time-out” per institution protocol
Once patient is under anesthesia and asleep, place her in stirrups and perform an exam
Prep and place a uterine manipulator through the cervix
Place and leave a catheter in the bladder **there is some variation to this by institution and program**

Laparoscopic Sterilization Options

Determining which method to use is surgeon and hospital dependent
The number of trocars and ports are determined by equipment and technique chosen
It is best to have experience with more than one technique in case equipment fails or the woman’s anatomy limits the use of a technique (short or thick tubes)

Bipolar Electrocoagulation

Can be done with one, two, or three ports depending on equipment and anatomy
Device requires a 5-mm port and a foot pedal to activate
3 cm of tube is destroyed by passing current through the tissue
- Typically takes three sequential burns to destroy 3 cm
Can use resistance meter to demonstrate there is no flow through the tube

Silastic (Falope) Ring

Can be done with one, two, or three ports depending on equipment and anatomy
Applicator requires 8-mm port
2-3 cm segment of fallopian tube is drawn inside a narrow coneshaped applicator and a silicone rubber band is released onto the tubal loop
The silicone rubber band constricts the base of the loop and blocks the fallopian tube
Deprived of its blood supply, the constricted loop is replaced with scar tissue, and the remaining healthy tubal segments often separate

Placement of the Falope Ring

Filshie Clip

Can be done with one, two, or three ports depending on equipment and anatomy
Applicator requires 8-mm port
Titanium clip lined with silicone rubber is placed 3 cm from the cornua perpendicular to the tube
Complete blockage is ensured by viewing the front and back of the tube
The tube in the clip is occluded

United States Collaborative Review of Sterilization (CREST) Study

A prospective cohort study in U.S. academic medical centers (teaching hospitals)
12,138 women who underwent tubal sterilization
- Nine centers
- Enrollment 1978-86
- Followed patients for up to 10 years
Over 25 publications reporting risks, failures, and regret

Female Sterilization Failures per 1,000 Procedures

Method	Failure Year 1	Failure Year 10
Postpartum partial salpingectomy	0.6	7.5
Monopolar coagulation	0.7	7.5
Bipolar coagulation	2.3	24.8
Silicone bands	5.9	17.7
Interval partial salpingectomy	7.3	20.5
Spring (Hulka) clips	18.2	36.5
All methods	5.5	18.5

Filshie clip: 1.7/1000 at Year 1; 9.7/1000 at 2 Years

Nonlaparoscopic Permanent Sterilization

Hysteroscopic sterilization (ESSURE) developed as an alternative to abdominal surgery for permanent female sterilization; available since 2002 in the United States
Coils are placed in the tubal ostia
The body scars and occludes the tubes over a period of 3 months
Requires hysterosalpingogram (HSG) to confirm tubal occlusion 3 months after the procedure. Patient must use reliable contraception during this time
Can be performed in the office setting with local anesthesia

Risk of Ectopic Pregnancy

1 out of 3 of pregnancies poststerilization were ectopic
10-year cumulative probability 7.3 per 1,000 procedures
- Bipolar coagulation highest probability: 17.1/1,000
- Postpartum partial salpingectomy lowest probability: 1.5/1,000
- Age less than 30 years is an increased risk factor for ectopic pregnancy
Risk of ectopic pregnancy does not diminish over time

Source: N Engl J Med. 1997;336:762-7

Tubal Sterilization Regret

Cumulative probability of expressing regret during a follow-up interview within 14 years after tubal sterilization
- 20.3% for women who were 30 years or younger at the time of sterilization
- 5.9% for women were older than 30 years at the time of sterilization

Source: Obstet Gynecol. 1999;93:889-95

Summary

Several options for L/S sterilization
Not technically difficult and very safe
Women should be aware of risks/benefits/alternatives and fully understand the permanence of the procedure
Increasing interest in salpingectomy for increased success as well as decreased risk of ovarian cancer and tubal cancer

References

Hillis SD, Marchbanks PA, Tylor LR, Peterson HB. Poststerilization regret: findings from the United States Collaborative Review of Sterilization. Obstet Gynecol 1999;93:889-95 2.
Jamieson DJ, Hillis SD, Duerr A, Marchbanks PA, Costello C, Peterson HB. Complications of interval laparoscopic tubal sterilization: findings from the United States Collaborative Review of Sterilization.
Obstet Gynecol 2000;96:997-1002.
Nardin JM, Kulier R, Boulvain M, Peterson HB. Techniques for the interruption of tubal patency for female sterilisation. Cochrane Database Syst Rev 2002;(4):CD003034.
Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. The risk of ectopic pregnancy after tubal sterilization. U.S. Collaborative Review of Sterilization Working Group. N Engl J Med 1997;336:762-7.
Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996;174:1161-8; discussion 1168-70.
Peterson HB, Xia Z, Wilcox LS, Tylor LR, Trussell J. Pregnancy after tubal sterilization with bipolar electrocoagulation. U.S. Collaborative Review of Sterilization Working Group. Obstet Gynecol 1999;94:163-7.
UpToDate Surgical Sterilization of Women available at: http://www.uptodate.com/contents/ surgical-sterilization-ofwomen?source=search_result&search=female+sterilization& selectedTitle=1%7E150.

Contributing Authors

Elizabeth Britton Chahine, MD, Associate Professor, Department of Gynecology & Obstetrics, Emory School of Medicine, Atlanta, Georgia
Tamika C. Auguste, MD, FACOG Director of OB/GYN Simulation MedStar Washington Hospital Center Associate Professor, Obstetrics and Gynecology Georgetown University School of Medicine

Developed in association with the Society of Family Planning.

Reaffirmed February 2021