Surgery: Postpartum Sterilization Techniques

What is a postpartum tubal?

Usually done within 1-2 days after vaginal delivery
Highly effective: risk of pregnancy is <1% (though if you want to look at the actual rates depending on type of surgery, please check out the CREST study!
Increased access: patients are already in the healthcare setting after delivery of their baby; don’t have to come back to the hospital/healthcare setting for a different procedure
Mostly minimally invasive: not laparoscopy, but can be done through a single, mini-lap incision below the belly button as the fundus of the uterus is still high

Today we will focus on the surgical steps

Review the way the procedure is done and discuss the different methods that you can provide.
Discuss the risks, benefits, and alternatives

Benefits: stated above, quick recovery usually
Risks: as with all surgeries, there are risks of bleeding, infection, injury to organs around the uterus and fallopian tubes

Another big risk I tell people: we can’t perform the surgery that they want after delivery
A few major reasons: significant anemia after delivery, infection (ie. chorio/endometritis), inability to palpate the fundus after delivery

Lastly, it is possible that we enter the abdomen but cannot perform the surgery because we can’t find the tubes, usually due to adhesions

Alternatives: no sterilization procedure or use a different form of birth control until 6 weeks postpartum for a laparoscopic procedure
MA-31 - 30 day consent! For those with state insurance

Ask specifically about history of abdominal surgeries and pelvic infections (ie. Chlamydia/Gonorrhea)
This can help determine if there will be significant intrabdominal adhesions that may prevent surgery
Not a strict contraindication for surgery, but should go into counseling of patients

No additional work up usually beyond prenatal care and delivery
Sometimes, if there is significant blood loss with delivery, providers may want to get a CBC
Usually, will have a type and screen on file already as patients are admitted for delivery (but should have this definitely)

Patient will not need to necessarily stay longer than for delivery
May need a small amount of narcotic medication for incisional pain, but usually, I do not prescribe more than 5 tabs of 5 mg oxycodone, and only if needed

Dorsal supine
Though during surgery, we can ask the anesthesiologist to airplane the patient to the left or right in order for the uterus to fall to one way or the other and bring the fimbria of the tube into view

After prepping the abdomen, mark approximately 3-4 cm on the inferior edge of the umbilicus
Some people will inject 1% lidocaine at this time, but I find that it distorts the anatomy
Incise along edge and continue downward dissection until the fascia is reached. Can use Army-Navy or other retractors to hold back the skin
Pick up the fascia with either Kelly, Kocher, or Allis and make a small incision with the Metzenbaum scissors after ensuring no bowel is adhered to the fascia
Incise the fascia after protecting with a finger, and place a Kocher on either end. Some people will also throw a stitch on either end with an 0-vicryl and hold these with hemostats to be able to find your fascia later
Retract the fascia (again, can use army-navies or some people like the small Alexis-O retractor) and pop into peritoneum, then use a finger to feel for the cornua and tube
Can airplane the patient right or left for either tube
Once the tube is found, use a Babcock to hold it up and follow it out to the fimbria. Make sure it is a tube and not a round ligament!
Salpingectomy

Use a Ligasure to clamp, seal, and cut the tube along the mesosalpinx
Make sure to hug the tube
Clamp, seal, and cut where the tube meets the cornua to remove the tube
Inspect area of sealing and cutting to ensure no bleeding
Allow the tube to fall back into the abdomen, and proceed with the next tube
If you don’t have a Ligasure, can use a kelly clamp to clamp along the mesosalpinx below the tube. Cut above the Kelly clamp until the end of the clamp is reached
Use a 3-0 synthetic absorbable suture and take a bite with the needle just beneath the level of the clamp and tie this portion down
Do this several more times until the cornua is reached
Use the Kelly clamp to clamp off the end of the tube, cut off the tube, and again, use the 3-0 synthetic absorbable suture to ligate the end of the tube
Send tube to pathology for confirmation of cross section

Place the babcock in the middle of the tube so that a small, 1-2 cm portion of tube is elevated
Tie a 3-0 synthetic absorbable around the base of this elevated section. Can tie two for a modified pomeroy
Hold the suture with a hemostat and then excise the knuckle of tube for pathologic confirmation
Use the hemostat to keep the tube out of the abdomen to inspect the area that you have incised for any bleeding. Use a bovie to coagulate any areas of bleeding
Once the area is dry, can take off the hemostat and let the tube drop back into the abdomen

Place the babcock in the middle of the tube so that a small, 1-2 cm portion of tube is elevated
Using the Metzenbaum scissors, incise a small, avascular portion of the mesosalpinx beneath the babcock
Pass two ligatures of 3-0 synthetic absorbable suture through the area that was incised and tie down on either end of the tube

Hold one end with a hemostat
Use the scissors to incise the knuckle of tube above the ligatures and send to pathology
Inspect the incised portions and ensure no bleeding
Allow the tube to fall back into the abdomen

Once you have completed both sides and achieved hemostasis, close the fascia with 0-Vicryl or similar suture
Then close the skin with 4-0 Biosyn/Monocryl
Can inject lidocaine at this time if desired
Bandage the area with small pressure dressing

Weekly Notes