Acta Obstet Gynecol Scand 55: 34%353, 1976

TUBAL STERILIZATION W i t h Special Reference t o Electrocoagulation through the L a p a r o s c o p e

Per Agnar Nilsen and Fridtjof Jerve From the Department of Obstetrics and Gynecology (Head: Per Agnar Nilsen), Aker Hospital, Oslo 5, Norway

Abstract. In the past 5 years 1 168 tubal sterilizations have been performed. One thousand and twelve of these were performed by dividing the tube by diathermy through the laparoscope. Since the first cases, and with increasing experience, complications have been infrequent, at the most a slight bleeding from the mesosalpinx. So far we have had ten failures, probably due to lack of experience. In every failure it was found at re-examination that the tube had not been divided-at least at one side. The method is quick and simple. The patient suffers little inconvenience, has a very small scar and is in hospital only a short time. It has been used in post-partum cases, but is not suitable for patients who have had several abdominal operations.

The frequency of legal abortions has increased in most countries in recent years. Unwanted pregnancies appear to be more common than before, in spite of improved methods of contraception. Many couples feel that older methods of contraception are no longer acceptable, once they have experienced the simplicity of the pill. On the other hand, many women are able to take the pill only for a limited time, and others have been scared by reports of various complications. The intra-uterine contraceptive devices also produce side effects, and still have a relatively low acceptability rate. A practical alternative for many couples will then be sterilization of one partner. When they have all the children they want, and have decided on permanent contraception, sterilization may be considered. Many methods have been employed in the past for the purpose of tubal sterilization. The Madlener operation (7), or the modification of Pomeroy, is possibly the most frequently accepted method. Other possibilities are: total salpingectomy, Al-

drige’s temporary procedure, and cornual excision of the uterus. Post-partum sterilization has been the method of choice in many hospitals. A small incision gives ready access to the tube 2-3 days post partum. As early as 1932, Skajaa (1 1) reported the first series of 126 cases of post-partum sterilization from Oslo University Hospital. In 1939 Amundsen (1) presented an additional 150 cases. Blom Hartvigsen (4) carried out a survey of 267 new cases from the same hospital in 195 1. The combined series of 543 cases were complicated by 18 cases of thrombosis and 1 severe infection. The mortality rate was 0.18%. No failures were mentioned. In 1957 Jensen & Lester (5) published a series of 734 cases of sterilization by the Madlener operation from Denmark. There were two deaths but no other major complications. A sterilization method should be easy, with minimal risk to the patient. It should be as effective as possible and should not carry any side effects. In 1937 Anderson (2) suggested the possibility of tubal cauterization during peritoneoscopy . Power & Barnes (10) in Michigan had the same idea, but none of them have published reports of patients treated in this way. With improved equipment and the fiberoptic light, laparoscopy has gained in popularity in recent years. Palmer (8) and Steptoe (12) introduced a new, improved laparoscope with fiberoptic light and surgical equipment for different procedures. A simple method of tubal electrocoagulation under laparoscopic control was presented. Following the initial presentations by Palmer and by Steptoe, many investigators have used their methods, unaltered or partly modified, and several Acta Obstct Gynccol Scund 55 (1976)

350

P . A . Nilsen and F . Jerve

Table 1. Survey of rhe series

Table 111. Tuba1 sterilization. Time of operation

No. of patients 1970 1971 1972 1973 1974 Total

Resect. Pomeroy Palmer Total

73 40 19 14 10 156 76 175 186 258 317 1012 149 215 205 272 327 1 168

series have been published. Steptoe had one failure in 310 cases. No complications were described. Svennerud & h e d t (13) in Sweden presented a series of 42 cases in 1968. Listen et al. (6) published a series of 760 patients sterilized by laparoscopy . Nine became pregnant after the operation, but only 4 were found to be operative failures. Six patients required laparotomy to control bleeding. Cohen, Taylor & Kass (3) reported a series of 50 cases, treated with a slightly different technique which allowed histological verification of tubal tissue. They had no failures and no complications followed. Peterson & Behrman (9) recently published a series of 186 women sterilized by electrocoagulation and cutting of the tubes. One pregnancy occurred, while 5 patients required laparotomy to control bleeding. Perforation of the stomach occurred once and in 5 patients the uterus was perforated by the instrument inserted to manipulate the organ. Wheeless (14) from experience in 75 patients advocated the method as an excellent procedure for sterilization in the out-patient department. In his series hemorrhage occurred in 3 patients, one of whom required laparotomy. One patient had postoperative aspiration pneumonia. The observation time was too short to decide on failures. Pomeroy’s tubal resection has previously been the method of choice for sterilization in our department. During the last 5 years, however, this method Table 11. Age distribution Age 20-24 25-29 30-34 35-39 40-44 45-49 Total

Number 30 189 335 384 212 18 1 168

Acta Obstet Gynecol Scand SS (1976)

Resect. Pomeroy Palmer Total

At legal abortion

1.4. Interpost- val parturn operaday tion Total

63 487 550

59 113 172

34 412 446

156 1012 1 168

has gradually been replaced by tubal electrocoagulation under laparoscopic control. In patients who have had a number of laparotomies and where extensive adhesions can be expected, we still prefer laparotomy if we do not succeed at once. MATERIAL AND METHODS The present paper deals with a series of 1168 patients sterilized at the Department of Gynecology, Aker Hospital, from 1970 through 1974. Of these, 156 were treated by

Table IV. Medical indications for sterilization Psychoneurosis Sectio caesarea 2-4 times previously Pre-eclampsia Polyarthritis Osteochondrosis columnae Mb. Bechterew Ischias Pelvic relaxation Rhesus-immunization Tuberculosis Lupus erythem. Diss. Boeck’s sarcoid H yperthyreosis H ypothyreosis Diabetes mellitus Morbus renis Hypertension Asthma bronchiale Hemophilic carrier Ca. cerv. ut. st. 0 Chondrodystrophia Colitis ulcerosa Cephalalgia, atypical EEG Seq. Poliomyelitidis Subileus Hab. postpartum bleeding Cancer mammae op. Glaucoma Prolapsus gen. op. Hernia diaphragmatica Paresis Mb. cordis Epilepsia Abortus habitualis Hyperemesis Advanced age Earlier malformed children

19 13 6 4 2 1

4 4 5 1

1 1

2 2 3 5 4 1 1

2 1 2 2 3 1 1

4 2 1

1

3 2 1 5 1

3 1

Tuba1 sterilization Table V. Deliveries prior to sterilization Children None 1-2 3 4 5 or more Total

1970 1971 8 40

90 11 149

4 76 126 9 215

1972 1973 3 74 120 8 205

1974 Total

17 124 116

4 158

15

14 327

272

151

36 472 603 57 1 168

Pomeroy’s method, while 1012 were treated by electrocoagulation during laparoscopy (Table I). The table also shows the increasing tendency to prefer the laparoscopic method in recent years. Table I1 shows the distribution by age. The operation was performed most frequently on patients between 30 and 40 years, but not less than 219 patients were below the age of 30 years. Table I11 shows the circumstances under which the operations were done. About half of the operations were done in connection with legal abortions under the same anesthetic, while 113 patients underwent post-partum sterilization by the laparoscopic technique. More recently we have, with increasing experience, preferred the latter method also postpartum. The indications for the operation fell mainly into two groups. The medical indications for the operation are seen in Table IV. The other 1053 patients all had their applications approved by the Department of Public Health. It appears from Table V that most of the women had 3-4 children before they resorted to sterilization. Thirtysix of the patients had had no pregnancy at all and some of these operations were performed on psychiatric indications. About 30% of the patients had one or more spontaneous abortions before they were sterilized. This is more than double the rate expected in the population (Table VI). It is seen from Table VII that 20% of the patients had one or more therapeutic abortions before they were sterilized. As previously shown in Table I11 about half of the sterilizations are performed at the time of therapeutic abortion. These abortions are not included in Table VII. For laparoscopic sterilization the following items of equipment are used: (i) Wolf Operating Laparoscope, model Jacobs-Palmer with angled optics. (ii) Biopsy forceps and grasping forceps with blunt jaws and insulated

Table VI, Spontaneous abortions prior to sterilization Spontaneous abortions One Two Three or more Total 23-762864

1970 1971 1972 1973 1974 Total 22 7 11

40

36 10 7 53

47 13 6 66

55 14 5 74

79 239 17 61 13 42 109 342

351

Table VII. Therapeutic abortions prior to sterilization Therapeutic abortions

1970 1971 1972 1973 1974 Total

One Two Threeor more Total

19 6 0 25

26 4 1 31

31 6 1

38

51 55 8 1 9 4 1 63 75

182 43 7 232

shaft suitable for electrocoagulation. (iii) Verre’s needle for laparocentesis and insumation. Long Hegar dilator for manipulation of the uterus. Wolf C0,-PneuAutomatic chamber for CO, insumation with control of volume and pressure. (iv) Fiberoptic light source and cables. The anesthetic is chosen with regard to the risk of explosion, and all operations were done under intubation anesthesia. The patient is placed in 20-30 degrees Trendelenburg position and 2-3 litres of CO, are insufflated to make a pneumoperitoneum. The laparoscope is inserted through an incision in the lower edge of the umbilicus and with the grasping forceps the tubes are lifted away from other structures, especially the intestines. The tubes then are coagulated and divided 1-2 cm from the uterine cornu (Figs. 2-3).

Complications At the very beginning we had some difficulty in making the pneumoperitoneum, which is essential for this technique, and we had three times to resort to laparotomy due to this technical failure. Before we became familiar with the method, we also had some cases with bleeding from vessels in the mesosalpinx. Usually this bleeding can be stopped by electrocoagulation, but in 20 cases we had to undertake laparotomy to stop the bleeding, which, however, was not severe in any case. In our series we had three severe complications. A 26-year-old woman came to the hospital 10 days after laparoscopic sterilization with diffuse peritonitis due to a lesion in the rectum. This particular patient was at the time treated with corticosteroids for disseminated lupus erythematosus, and we think that either this disease or the treatment might have been contributary to the complication. Two other patients had a lesion of the intestine, one followed by peritonitis. These complications warned us to stay well away from other structures while doing the electrocoagulation.

RESULTS Despite the above-mentioned complications our experiences with the laparoscopic method for tuba1 sterilization are good. One of the greatest advantages of the operation is the short hospital stay (Table VIII). Most of the patients left the hospital on the first or second postoperative day and when discharge was postponed it usually was due to intervening holidays, the patients’ wishes or other Actu Obstet Gynecol S c w i d 55 (1976)

352

P . A . Nilsen and F . Jerve

Table VIII. Hospital stay after operation Days after operation

Laparoscopic sterilization (Palmer) Resectio tubarum A. M. Pomeroy

1

2

3

4

449

325

165

32 5

5

6

7 (or more)

14 7

5 12

22 132

Table IX. Failures

Year

Name

Pregnant after (months)

1971 1971 1971 1972 1972 1972 1972 1972 1973 1973

M. S . L. G . H. K. E. L. R. A. L. E. K. J. L. H. A . M. L. B. B. B. H.

14 12 21 18 9 3 8 12 18 12

diseases being treated at the same time. The time in hospital is now seldom more than 48 hours, and can still be reduced if necessary. Another great advantage of the operation is the almost complete absence of postoperative trouble often seen after laparotomy. The patients usually feel only a dull ache in the back or on top of the shoulders, due to some CO, that has not been evacuated. The unsightly scar both outside and inside the abdomen resulting from laparoscopy places diathermy in a favourable light. In order to assess the efficiency of the method fully our observation time is rather short but our patients have been observed from 6 months to 5 years. So far we have had ten failures, probably due to lack of experience (Table IX). In 2 cases the mesosalpinx had been burned on one side only, while in 4 other cases one tube had not been completely divided, but partly coagulated, leaving a narrow communication between the two ends. In 2 cases the round ligament on one side had been burned, and in 2 cases the tube appeared normal, and no sign could be seen of the sterilization procedure. Initially we planned to carry out an X-ray control of the patients, or at least Levin’s test postoperatively, but we changed this decision because of the risk of reopening the tubal stump. Acto Obster Gynecol Scand 55 (1976)

At laparoscopic

Right tube not coagulated Right tube not coagulated Right tube not coagulated Right ligamentum rotundum divided Left tube not divided Right tube not divided Left tube not divided Left tube appeared normal Right tube not divided Right ligamentum rotundum divided

re-sterilizationfound

CONCLUSION With the laparoscopic method of tubal sterilization we have a relatively easy and rapid technique. The contra-indications to the operation are few, mainly previously laparotomies where adhesions may be suspected. In some cases we have done laparoscopies in spite of previous scars, but never when extensive adhesions have been observed during earlier operations. With increasing experience the operation is safe and secure, and for the patient the inconvenience is the least possible. One advantage, not mentioned in previous papers on the subject may be the relatively long and normal distal end of the tube. This lateral end with its normal fimbriae might be a better tube to implant in the uterus than the usually short end after Pomeroy sterilization, and with better hope of successful reversal of the sterilization. REFERENCES 1 . Amundsen, E.: Is sterilization during the puerperium contraindicated? Acta Obstet Gynecol Scand 20: 295, 1940. 2. Anderson, E. T.: Peritoneoscopy.Am J Surg35: 136, 1937. 3. Cohen, M. R., Taylor, M . B. & Kass, M. B.: Interval tubal sterilization via laparoscopy.Am J Obstet Gynecol108:458. 1970.

Tuba1 sterilization 4. Hartvigsen, F. B.: Sterilization post partum. Acta Obstet Gynecol Scand31:53, 1951. 5. Jensen, F. & Lester, J.: Ten years of tubal sterilization by the Madlener method. Acta Obstet Gynecol Scand 36: 324, 1957. 6. Liston, W. A., Bradford, W., Downie, J. & Kerr, M. G.: Female sterilization by tubal electrocoagulation under laparoscopic control. Lancet I : 382, 1970. 7. Madlener, M.: Uber steriliserende Operationen an den Tuben. Zbl Gynakol43: 380, 1919. 8. Palmer, R.: Trials of celioscopic tubal sterilization by isthmic electrocoagulation. Bull Fed Gynecol Obstet Franc 14: 298, 1962. 9. Peterson, E. P. & Behrman, S. J.: Laparoscopic tubal sterilization. Am J Obstet Gynecol110: 23, 1971. 10. Power, F. H. &Barnes, A. C.: Sterilization by means of peritoneoscopic tubal fulguration. Am J Obstet Gynecolll: 1038, 1941.

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11. Skaji, K.: Sterilization of women in the puerperium. Acta Obstet Gynecol Scand 12: 114, 1932. 12. Steptoe, Patrick C.: Laparoscopy in Gynaecology. E. & H. Livingstone, Ltd., Edinburgh, 1967. 13. Svennerud, S. & Astedt, B.: Sterilization during laparoscopy. Acta Obstet Gynecol Scand 48: 64,

Suppl. 3. 14. Wheeless, C. R.: Outpatient tubal sterilization. Obstet Gynecol36: 208, 1970.

Submitted for publication July 24, 1975 Per Agnar Nilsen Department of Obstetrics and Gynecology Aker Hospital Oslo 5 Norway

Acta Obsrer Gynecol Scand 55 (1976)