Acta Obstet Gynecol Scand 57: 169-171, 1978
BIPOLAR CAUTERY FOR LAPAROSCOPIC STERILIZATION Erik Gregersen and Jens Jsrgen Kjer From the Department of Obsretrics and Gynecology, Gentofte Hospital, Copenhagen, Denmark
Abstract. Laparoscopic sterilization with a bipolar electrode was performed in 62 patients. The sterilization failed in one patient and was questionable in another. The effectiveness was assessed by hysterosalpingography (HSG) in 51 patients. No complications due to laparoscopy occurred. The method is considered to be advantageous because of the low risk of complications. The effectiveness of the method seems to be acceptable.
Laparoscopic sterilization is usually performed by coagulation with a single electrode placed in a clamp and with a ground-plate placed on the buttock of the patient, causing the current to pass through the patient as described in Fig. 1 A . However, the method is associated with a certain risk of burning unplanned sites, especially bowel and abdominal wall ( 2 , 14). If the contact between patient and groundplate is inadequate, the current becomes erratic and may pass through the operator or the anaesthetic equipment. However, intimate knowledge of the instruments and routine in the operation can reduce the frequency of complications (5, 6, 8, 10). Nevertheless, despite all precautions, complications do occur. The use of a bipolar electrode (4,12, 13) can also serve to reduce the complications rate, on account of the short circuit (Fig. 1 B). We have tested the method and the results are shown below. MATERIAL AND METHOD During the period 17.10.1975-25.2.1976 laparoscopic sterilization was performed in 62 unselected patients. For the operation Karl Storz's laparoscope and accessory equipment were used. Double incision technique was used (one incision along the lower border of the umbilicus and another a few centimetres above the symphysis). Cauterization was performed with the bipolar electrode 2 and 4 cm from the uterine comu. There was no transec-
tion of the fallopian tubes. An Erbotom F2 was used as current source. When legal abortion was to be performed this procedure was done first. In the puerperium, sterilization was performed between the 3rd and the 5th day post partum. Shortly before the operation 1 ml of oxytocin was administered intravenously to obtain maximum contraction of the uterus. Because of the large uterus the lower incision was placed a few centimetres below the umbilicus. For the same reason the patients were not placed in the head-down position and special care was taken. Curettage was performed if the sterilization took place in the secretory phase of the endometrium, in order to exclude pregnancy. The patients were advised to use contraceptives until control hysterosalpingography was performed at least 3 months after the operation. The period of observation varied between 9 and 12 months. To allow for possible change of mind, a waiting time of at least 3 months from receiving the admission papers to the admission was endeavoured; however, the waiting time was often prolonged because of the number of admissions. An endeavour was made to avoid sterilization and legal abortion simultaneously, as an unwanted pregnancy can influence the decision concerning sterilization. The patients were fully informed about the method and were told that the resulting tubal occlusion was considered to be irreversible.
RESULTS The age distribution of the 62 patients is shown in Table I. The youngest was 25 and the oldest 43 years. The mean age was 33.3. The average number of pregnancies was 3.5 (0.9 abortions and 2.6 births). Maximum was 9 pregnancies in the same patient (5 births and 4 abortions). The operation was usually performed in less than 30 minutes. The patients were without symptoms shortly afterwards and usually they were disActa Obstet Gynecol Scand 57 (1978)
170
E. Gregersen and J . J . Kjer
A
Table I. Age ofpatients
UNIPOLAR CAUTERV CLAMP
'\:\rWAY
0
OF CURRENT
,-F-C
BIPOLAR CAUTERY
Fig. 1 . The two types of cautery.
charged the following day so that the average hospital admission was 3.1 days. Four of our patients had another simultaneous operation (3 conizations and one vaginal repair). No immediate complications occurred. In one case the uterus was accidentally perforated at curettage. No bleeding was seen through the laparoscope. She stayed one extra day in the department and no further problems were observed. Another patient had fever (38°C) for one day without focal symptoms. No antibiotic treatment was given and the cause remained obscure. Four patients were sterilized on the 3rd and 4th day of the puerperium. Legal abortion was simultaneously performed in 2 patients. Both of them were 35 years old. One had used various contraceptives without success, resulting in 7 pregnancies. The other patient had been waiting for a long time for the operation. Postoperative hysterosalpingography was performed in 51 patients (82.3%). 50 had occluded fallopian tubes. In a 37-year-old patient a small fistula at the site of the cauterization on the right side was revealed by HSG performed 16 weeks after the operation. HSG repeated 7 months later showed a larger spillage into the peritoneum. This patient was offered a new sterilization but because of lack of ability to metabolise curare she refused to undergo a further procedure. As an alternative she was recommended to use conventional contraception. As she had not used contraception in the interval between the hysterosalpingographies the risk of pregnancy was supposedly low. In one patient legal abortion was performed in the Actu O h ~ t e Cynecol t ScundS7 (1978)
BIPOLAR CAUTERY FOR LAPAROSCOPIC STERILIZATION Erik Gregersen and Jens Jsrgen Kjer From the Department of Obsretrics and Gynecology, Gentofte Hospital, Copenhagen, Denmark
Abstract. Laparoscopic sterilization with a bipolar electrode was performed in 62 patients. The sterilization failed in one patient and was questionable in another. The effectiveness was assessed by hysterosalpingography (HSG) in 51 patients. No complications due to laparoscopy occurred. The method is considered to be advantageous because of the low risk of complications. The effectiveness of the method seems to be acceptable.
Laparoscopic sterilization is usually performed by coagulation with a single electrode placed in a clamp and with a ground-plate placed on the buttock of the patient, causing the current to pass through the patient as described in Fig. 1 A . However, the method is associated with a certain risk of burning unplanned sites, especially bowel and abdominal wall ( 2 , 14). If the contact between patient and groundplate is inadequate, the current becomes erratic and may pass through the operator or the anaesthetic equipment. However, intimate knowledge of the instruments and routine in the operation can reduce the frequency of complications (5, 6, 8, 10). Nevertheless, despite all precautions, complications do occur. The use of a bipolar electrode (4,12, 13) can also serve to reduce the complications rate, on account of the short circuit (Fig. 1 B). We have tested the method and the results are shown below. MATERIAL AND METHOD During the period 17.10.1975-25.2.1976 laparoscopic sterilization was performed in 62 unselected patients. For the operation Karl Storz's laparoscope and accessory equipment were used. Double incision technique was used (one incision along the lower border of the umbilicus and another a few centimetres above the symphysis). Cauterization was performed with the bipolar electrode 2 and 4 cm from the uterine comu. There was no transec-
tion of the fallopian tubes. An Erbotom F2 was used as current source. When legal abortion was to be performed this procedure was done first. In the puerperium, sterilization was performed between the 3rd and the 5th day post partum. Shortly before the operation 1 ml of oxytocin was administered intravenously to obtain maximum contraction of the uterus. Because of the large uterus the lower incision was placed a few centimetres below the umbilicus. For the same reason the patients were not placed in the head-down position and special care was taken. Curettage was performed if the sterilization took place in the secretory phase of the endometrium, in order to exclude pregnancy. The patients were advised to use contraceptives until control hysterosalpingography was performed at least 3 months after the operation. The period of observation varied between 9 and 12 months. To allow for possible change of mind, a waiting time of at least 3 months from receiving the admission papers to the admission was endeavoured; however, the waiting time was often prolonged because of the number of admissions. An endeavour was made to avoid sterilization and legal abortion simultaneously, as an unwanted pregnancy can influence the decision concerning sterilization. The patients were fully informed about the method and were told that the resulting tubal occlusion was considered to be irreversible.
RESULTS The age distribution of the 62 patients is shown in Table I. The youngest was 25 and the oldest 43 years. The mean age was 33.3. The average number of pregnancies was 3.5 (0.9 abortions and 2.6 births). Maximum was 9 pregnancies in the same patient (5 births and 4 abortions). The operation was usually performed in less than 30 minutes. The patients were without symptoms shortly afterwards and usually they were disActa Obstet Gynecol Scand 57 (1978)
170
E. Gregersen and J . J . Kjer
A
Table I. Age ofpatients
UNIPOLAR CAUTERV CLAMP
'\:\rWAY
0
OF CURRENT
,-F-C
BIPOLAR CAUTERY
Fig. 1 . The two types of cautery.
charged the following day so that the average hospital admission was 3.1 days. Four of our patients had another simultaneous operation (3 conizations and one vaginal repair). No immediate complications occurred. In one case the uterus was accidentally perforated at curettage. No bleeding was seen through the laparoscope. She stayed one extra day in the department and no further problems were observed. Another patient had fever (38°C) for one day without focal symptoms. No antibiotic treatment was given and the cause remained obscure. Four patients were sterilized on the 3rd and 4th day of the puerperium. Legal abortion was simultaneously performed in 2 patients. Both of them were 35 years old. One had used various contraceptives without success, resulting in 7 pregnancies. The other patient had been waiting for a long time for the operation. Postoperative hysterosalpingography was performed in 51 patients (82.3%). 50 had occluded fallopian tubes. In a 37-year-old patient a small fistula at the site of the cauterization on the right side was revealed by HSG performed 16 weeks after the operation. HSG repeated 7 months later showed a larger spillage into the peritoneum. This patient was offered a new sterilization but because of lack of ability to metabolise curare she refused to undergo a further procedure. As an alternative she was recommended to use conventional contraception. As she had not used contraception in the interval between the hysterosalpingographies the risk of pregnancy was supposedly low. In one patient legal abortion was performed in the Actu O h ~ t e Cynecol t ScundS7 (1978)
