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Falope Ring tubal ligation
Falope Ring* tubal ligation ANDRE
B. LALONDE,
Montreal,
Quebec,
M.D.,
F.R.C.S.(C.)
Canada
By minilaparotomy or through the laparoscope, Falope Ring sterilization is accompMed applying silicone rubber bands to the Fallopian tubes. The applicator and its use are de&bed and 383 cases without any major complication are reported. The major advantage is elimination of thermocoagulation. The occlusion is complete in a short segment and offers theoretical possibilities of tubal reconstruction. (AM. J. OBSTET. GYNECOL.
130: 567,1978.)
IN THE LAST few years, new methods of therapeutic sterilization in women are being researched.’ Ideally, tubal ligation should be wholly secure, 100 per cent effective, without major complications, and easily adaptable to a day-care center. The latest techniques in therapeutic sterilization have progressed to the use of different endoscopes through which the tubes can be cauterized or blocked by the application of clipszW5 A method of sterilization is proposed, without the useof electrocoagulation, technically simple, with general or local anesthesia,through minilaparotomy or a conventional laparoscope,and permitting tubal reconstruction. The method described in this paper is a modification of the one presented by Yoon.s A dilatation and curettage in all patients except those post parturn is used asa modification of the Yoon technique.
and method After intubation of 1 to 2 L. of CO2 through a subumbilical incision utilizing a laparoscopeor through an abdominal incision, the tubal ligation applicator is introduced through the laparoscopeor through a second incision. The tubal ligation applicator consistsof two cylinders: in the interior cylinder is a grasping forceps to seizethe Fallopian tube; on the exterior cylinder, in its distal portion, the silicone rubber band is applied in M8tefi8l
the Department of Obstetrics and Gynaecology, McGill University, Royal Victoria and LaSalle General Hos$tal. Presented at the Thirty-third Annual Meeting of the Society of Obstetricians and Gynaecologists of Canada, Montreal, Quebec, Canada, June 14-l 8, 1977.
From
Reprint H$&zl Qtibec,
requests: And& B. L&o&e, Universitk McGill, Royal Victoria, 687 0. ave. des Pins, Montrkal, Canada H3A 1Al.
*K. L. I., Inc., Philudelphia,
0002-9378/78/05130-0567$00.20/O
by
Pennsylvania.
@ 1978
The C. V. Mosby
Co.
a stretched state. A segment of the Fallopian tube is grasped, preferably 3 to 4 cm. from the cornual area, and drawn up into the cylinder until the mechanism releasesthe Fallope Ring on the exterior cylinder, thus occluding a portion of the tube. The applicator can be inserted through a minilaparotomy or through a subumbilicalincision for the postpartum patients. Although local anesthesiahas been described,’ all our patients were operated on under general anesthesia, with endottacheal intubation and cardiac monitoring. Most of the patients received premed&&on consisting of atropine, meperidine, and prochlorperazine. POptMiOfl Of our 383 patients, 34 per cent were in day-care centersand 66 per cent were hospitalized. Of the latter, 5 per cent were in the postpartum period and 2 per cent were having a general surgery procedure suchasa cholecystectomy. Eighty-five per cent of our caseswere managed by laparoscopy. The agesvaried from 1 patient lessthan 20 years of age to 54 per cent in the 30-to 40-year-old bracket. Parity wasdistributed quite evenly between gravida 1, 3, and 4, but 48 per cent were gravida 2 patients.
During 1 year (from February, 1976, to February, 1977), in three McGill University-affiliated hospitals (Royal Victoria Hospital, Queen Elizabeth Hospital, and LaSalle General Hospital), 383 patients who had signed up for voluntary sterilization underwent a tubal ligation by silicone rubber ring without any major complication. Eighteen months after the first tubal ligation, no 567
568
Lalonde
March Am. J. Obstet.
pregnancy has been reported. A survey of all the cases treated prior to publication of the paper has revealed no pregnancy in the 383 cases. Immediately after the tubal ligation, a mild to moderate lower abdominal pain is felt which is relieved by a single injection of 50 mg. of meperidine. Within 4 to 6 hours after the tubal ligation, an abdominal pain can be caused by the insufflation of COz or by the incision itself; the pain is easily relieved by a simple oral nonnarcotic analgesic. Two cases of abdominal pain required a readmission on the day after the tubal ligation, observation for 48 hours, and discharge without any further treatment. One case of laceration of the mesosalpinx during the application of the ring required a laparotomy for hemostasis. One case of ectopic pregnancy occurred; the patient was readmitted 17 days after the tubal ligation for lower abdominal pain; on day 22 after the tubal ligation, a laparotomy was performed with a diagnosis of intraperitoneal bleeding, which revealed an ectopic pregnancy in the distal portion of the tube that was ligated with a ring. In 60 per cent of our cases, the sterilization procedure was accompanied by a diagnostic dilatation and curettage. In one asymptomatic patient cancer of the endometrium was found. Total abdominal hysterectomy and bilateral salpingo-ovariectomy 27 days after the tubal ligation permitted us to study the tubes. The segment of the “loop,” formed by the ring, was studied and was completely occluded. The tube was opened on each side, 5 mm. from the ring edges. Tubal occlusion had occurred by a process of hyalinization and thrombosis of the small vessels.
1, 1978 Gynecol.
Comment This method does not require electrocoagulation and thus eliminates the problem of burns. It is rapid and safe and presents a low pregnancy rate. The method is also simple technically and can be done on an outpatient basis. McCann and KesseP studied three routine techniques of laparoscopic sterilization: cauterization, clip, and ring. They found that the ring technique offered maximum security, a minimum pregnancy rate, and a minimum of complications. This tubal ligation does not damage the fimbriae of the proximal portion of the tube, thus theoretically permitting an easier reconstruction or reanastomosis of the tube. Most of the pregnancies occurred as a result of technical fault or were due to luteal phase pregnancy, when the patient did not have a diagnostic dilatation and curettage during the tubal ligation. The other failures were due to the application to a single tube, or to ovarian ligaments, the incomplete occlusion of the tube, application to the mesosalpinx, and tuboperitoneal fistula. Yoon’s collaborators reported 11,268 ring applications
with
a pregnancy
more
than
30 per
time
of tubal
ligation
to inadequate Our
ported
revealed and
thrombosis
occlusion
of 0.23
were
and
per
already
another
occlusion
histologic
ligation, tion
rate cent
cent;
30 per
cent
or misapplications
study
of
the
occlusion
tube,
by
of the
by infarction
at the were
of the 28
days
a process
small
of these,
pregnant
vessels.
due ring.
after
the
of hyalinizaTingeyO
with obliteration
re-
of the
lumen.
With other techniques, the hospital stay has been on an average 3 days. With this one, there is no hospital stay;
sterilization
is now
a day-care
procedure.
REFERENCES
Kessel, E., and McCann, F.: Laparoscopic tubal occlusion by electrocoagulation, spring-loaded clip, and tubal ring, in Proceedings of the First Inter-Congress, Asian Federation of Obstetrics and Gynecology, Singapore, April 27-30, 1976. Phillips, J., and Keith, L.: The evolution of laparoscopic sterilization, Int. J. Gynaecol. Obstet. 14: 59, 1976. Wheeless, C. R.: The past, present, and future use of the
laparoscope
in female
sterilization,
in Sciarra, J. J.,
Droegemueller, W., and Speidel, J. J., editors: Advances in Female Sterilization Techniques, Hagerstown, Md., 1976, Harper & Row, Publishers, pp. 30-36. McCann, M. F.: International experience with laparoscopic sterilization: A review of 8500 cases, In Proceedings of the IGCC Contributors Conference, Kuala Lumpur, Malaysia, Jan. 12-13. 1976.
5. Wortman, J. S.: Tubal sterilization-Review of methods, Population Rep. Ser. C, No. 7, 1976. 6. Yoon, I. B., Wheeless, C. R., and King, T. M.: A preliminary report on a new laparoscopic sterilization approach: The silicone rubber band technique, AM. J. OBSTET. GYNECOL. 120: 132, 1974. Yoon, I. B., and King, T. M.: A preliminary and intermediate report of a new laparoscopic tubal ring procedure, J. Reprod. Med. 15: 54, 1976. McCann, M. F., and Kessel, E.: International fertility research program conference paper: International experience with laparoscopic sterilization; follow-up of 8500 women, Florida, Nov. 1976. Tingey, W. R.: A study of laparoscopic sterilization using Yoon’s silicone Fallope Rings, Proc. R. Sot. Med. 69: 8, 1976.
B. LALONDE,
Montreal,
Quebec,
M.D.,
F.R.C.S.(C.)
Canada
By minilaparotomy or through the laparoscope, Falope Ring sterilization is accompMed applying silicone rubber bands to the Fallopian tubes. The applicator and its use are de&bed and 383 cases without any major complication are reported. The major advantage is elimination of thermocoagulation. The occlusion is complete in a short segment and offers theoretical possibilities of tubal reconstruction. (AM. J. OBSTET. GYNECOL.
130: 567,1978.)
IN THE LAST few years, new methods of therapeutic sterilization in women are being researched.’ Ideally, tubal ligation should be wholly secure, 100 per cent effective, without major complications, and easily adaptable to a day-care center. The latest techniques in therapeutic sterilization have progressed to the use of different endoscopes through which the tubes can be cauterized or blocked by the application of clipszW5 A method of sterilization is proposed, without the useof electrocoagulation, technically simple, with general or local anesthesia,through minilaparotomy or a conventional laparoscope,and permitting tubal reconstruction. The method described in this paper is a modification of the one presented by Yoon.s A dilatation and curettage in all patients except those post parturn is used asa modification of the Yoon technique.
and method After intubation of 1 to 2 L. of CO2 through a subumbilical incision utilizing a laparoscopeor through an abdominal incision, the tubal ligation applicator is introduced through the laparoscopeor through a second incision. The tubal ligation applicator consistsof two cylinders: in the interior cylinder is a grasping forceps to seizethe Fallopian tube; on the exterior cylinder, in its distal portion, the silicone rubber band is applied in M8tefi8l
the Department of Obstetrics and Gynaecology, McGill University, Royal Victoria and LaSalle General Hos$tal. Presented at the Thirty-third Annual Meeting of the Society of Obstetricians and Gynaecologists of Canada, Montreal, Quebec, Canada, June 14-l 8, 1977.
From
Reprint H$&zl Qtibec,
requests: And& B. L&o&e, Universitk McGill, Royal Victoria, 687 0. ave. des Pins, Montrkal, Canada H3A 1Al.
*K. L. I., Inc., Philudelphia,
0002-9378/78/05130-0567$00.20/O
by
Pennsylvania.
@ 1978
The C. V. Mosby
Co.
a stretched state. A segment of the Fallopian tube is grasped, preferably 3 to 4 cm. from the cornual area, and drawn up into the cylinder until the mechanism releasesthe Fallope Ring on the exterior cylinder, thus occluding a portion of the tube. The applicator can be inserted through a minilaparotomy or through a subumbilicalincision for the postpartum patients. Although local anesthesiahas been described,’ all our patients were operated on under general anesthesia, with endottacheal intubation and cardiac monitoring. Most of the patients received premed&&on consisting of atropine, meperidine, and prochlorperazine. POptMiOfl Of our 383 patients, 34 per cent were in day-care centersand 66 per cent were hospitalized. Of the latter, 5 per cent were in the postpartum period and 2 per cent were having a general surgery procedure suchasa cholecystectomy. Eighty-five per cent of our caseswere managed by laparoscopy. The agesvaried from 1 patient lessthan 20 years of age to 54 per cent in the 30-to 40-year-old bracket. Parity wasdistributed quite evenly between gravida 1, 3, and 4, but 48 per cent were gravida 2 patients.
During 1 year (from February, 1976, to February, 1977), in three McGill University-affiliated hospitals (Royal Victoria Hospital, Queen Elizabeth Hospital, and LaSalle General Hospital), 383 patients who had signed up for voluntary sterilization underwent a tubal ligation by silicone rubber ring without any major complication. Eighteen months after the first tubal ligation, no 567
568
Lalonde
March Am. J. Obstet.
pregnancy has been reported. A survey of all the cases treated prior to publication of the paper has revealed no pregnancy in the 383 cases. Immediately after the tubal ligation, a mild to moderate lower abdominal pain is felt which is relieved by a single injection of 50 mg. of meperidine. Within 4 to 6 hours after the tubal ligation, an abdominal pain can be caused by the insufflation of COz or by the incision itself; the pain is easily relieved by a simple oral nonnarcotic analgesic. Two cases of abdominal pain required a readmission on the day after the tubal ligation, observation for 48 hours, and discharge without any further treatment. One case of laceration of the mesosalpinx during the application of the ring required a laparotomy for hemostasis. One case of ectopic pregnancy occurred; the patient was readmitted 17 days after the tubal ligation for lower abdominal pain; on day 22 after the tubal ligation, a laparotomy was performed with a diagnosis of intraperitoneal bleeding, which revealed an ectopic pregnancy in the distal portion of the tube that was ligated with a ring. In 60 per cent of our cases, the sterilization procedure was accompanied by a diagnostic dilatation and curettage. In one asymptomatic patient cancer of the endometrium was found. Total abdominal hysterectomy and bilateral salpingo-ovariectomy 27 days after the tubal ligation permitted us to study the tubes. The segment of the “loop,” formed by the ring, was studied and was completely occluded. The tube was opened on each side, 5 mm. from the ring edges. Tubal occlusion had occurred by a process of hyalinization and thrombosis of the small vessels.
1, 1978 Gynecol.
Comment This method does not require electrocoagulation and thus eliminates the problem of burns. It is rapid and safe and presents a low pregnancy rate. The method is also simple technically and can be done on an outpatient basis. McCann and KesseP studied three routine techniques of laparoscopic sterilization: cauterization, clip, and ring. They found that the ring technique offered maximum security, a minimum pregnancy rate, and a minimum of complications. This tubal ligation does not damage the fimbriae of the proximal portion of the tube, thus theoretically permitting an easier reconstruction or reanastomosis of the tube. Most of the pregnancies occurred as a result of technical fault or were due to luteal phase pregnancy, when the patient did not have a diagnostic dilatation and curettage during the tubal ligation. The other failures were due to the application to a single tube, or to ovarian ligaments, the incomplete occlusion of the tube, application to the mesosalpinx, and tuboperitoneal fistula. Yoon’s collaborators reported 11,268 ring applications
with
a pregnancy
more
than
30 per
time
of tubal
ligation
to inadequate Our
ported
revealed and
thrombosis
occlusion
of 0.23
were
and
per
already
another
occlusion
histologic
ligation, tion
rate cent
cent;
30 per
cent
or misapplications
study
of
the
occlusion
tube,
by
of the
by infarction
at the were
of the 28
days
a process
small
of these,
pregnant
vessels.
due ring.
after
the
of hyalinizaTingeyO
with obliteration
re-
of the
lumen.
With other techniques, the hospital stay has been on an average 3 days. With this one, there is no hospital stay;
sterilization
is now
a day-care
procedure.
REFERENCES
Kessel, E., and McCann, F.: Laparoscopic tubal occlusion by electrocoagulation, spring-loaded clip, and tubal ring, in Proceedings of the First Inter-Congress, Asian Federation of Obstetrics and Gynecology, Singapore, April 27-30, 1976. Phillips, J., and Keith, L.: The evolution of laparoscopic sterilization, Int. J. Gynaecol. Obstet. 14: 59, 1976. Wheeless, C. R.: The past, present, and future use of the
laparoscope
in female
sterilization,
in Sciarra, J. J.,
Droegemueller, W., and Speidel, J. J., editors: Advances in Female Sterilization Techniques, Hagerstown, Md., 1976, Harper & Row, Publishers, pp. 30-36. McCann, M. F.: International experience with laparoscopic sterilization: A review of 8500 cases, In Proceedings of the IGCC Contributors Conference, Kuala Lumpur, Malaysia, Jan. 12-13. 1976.
5. Wortman, J. S.: Tubal sterilization-Review of methods, Population Rep. Ser. C, No. 7, 1976. 6. Yoon, I. B., Wheeless, C. R., and King, T. M.: A preliminary report on a new laparoscopic sterilization approach: The silicone rubber band technique, AM. J. OBSTET. GYNECOL. 120: 132, 1974. Yoon, I. B., and King, T. M.: A preliminary and intermediate report of a new laparoscopic tubal ring procedure, J. Reprod. Med. 15: 54, 1976. McCann, M. F., and Kessel, E.: International fertility research program conference paper: International experience with laparoscopic sterilization; follow-up of 8500 women, Florida, Nov. 1976. Tingey, W. R.: A study of laparoscopic sterilization using Yoon’s silicone Fallope Rings, Proc. R. Sot. Med. 69: 8, 1976.