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Removal of deeply inserted, nonpalpable levonorgestrel (Norplant®) implants
ELSEVIER
Removal of Deeply Inserted, Nonpalpable Levonorgestrel (Norplant@) Implants Seshu P. Sarma,”
Jane G. Wamsher,t
and Susan W. Whitlockt
Deeply inserted, nonpalpable contraceptive implants can often be removed easily using 6-8 cm3 of 1% lidocaine and a single 1 cm incision. There is no need for suturing of the incision. The location of nonpalpable implants not retrieved by this procedure can be determined by a plain, soft tissue x-ray (standard AP and lateral and internal oblique; 45-55 kVP) of the area where the implants are inserted. Removal can then be accomplished several weeks later. CONTRACEPTION 1996;53:159-161 KEY WORDS:
nonpalpable implant
removal
Introduction implant device orplant@, the contraceptive (Wyeth-Ayerst, Philadelphia, PA, USA), has been used extensively in the US since it was approved by the Foad and Drug Administration in December 1990. Many clinicians were trained in the insertion of the implants in clinical workshops which included video presentation and limited “hands-on” training. Some contraceptive implant systems, however, have been inserted by clinicians who have no prior experience in this procedure. It is quite conceivable that many such !Norplant implants were not inserted properly. Although much was written in medical journals as well as lay press about the difficulty of removing contraceptive implants, it is not hard to retrieve implants that are properly placed. Several Norplant implants removal techniques, namely, the Population Council method, the Pop-Out method, the Emory method and the “U” technique, have been described by investigators in the US and abroad.’ These methods describe removal of implants Chat are properly inserted. How-
N
*Morehouse School Atlanta, GA 30303,
of Medicine, USA
*Family
Planning
Clinic,
Grady
Health
(404)616-5807 Revised Accepted Norplants
December 5, 1995 for publication De is a registered tra
mark
of the Population
0 1996 Elsevier Science Inc. A/I rights reserved. 655 Avenue of the Amerrcas, New York, NY 10010
Council,
Inc
System,
ever, at times, clinicians may encounter implants that, because of deep insertion, are not palpable. As we are nearing the end of the 5year period for initial Norplant implants insertions in the US, a simple method for removal of nonpalpable implants is needed. The methods presented in this article have not been studied scientifically or compared with any other methods previously published, but rather represent the authors’ wish to describe their experience with removal of nonpalpable implants.
Methods and Materials In addition to the routine surgical lowing equipment is used: One tissue Adson forceps, with Two mosquito Halstead forceps curved, 5” long); Butterfly bandages or other skin
supplies,
the fol-
1x2 teeth; (1 straight
and 1
closures.
Removal Procedure for Nonpalpable Implants-Key Points 1. Determine the area of the missing or nonpalpable implants by locating the palpable implants. Mark the area with a nonerasable marker. 2. Draw up 6-8 cm3 of 1% lidocaine. 3. Inject 1 cm3 at the original incision site and 3/4 cm3 underneath the lower (proximal) half of each implant. Inject 3/4 cm3 of 1% lidocaine along the track of the marked area. 4. Make a superficial, horizontal incision about 8 mm-l cm long close to the lower ends of the implants (preferably at the original incision site). 5. Remove the easily accessible implants first (using the method familiar to the clinician). 6. Introduce the curved mosquito (with the curvature facing upwards) in the area marked and advance it gently by dissecting the tissue. Gently probe the surrounding area with the curved mosquito as far as it allows. Often the implant can be ISSN 0010.7824/96/$15.00 PII SOOlO-7824(96)00004-X
160
7.
8. 9.
10.
11,
12.
Sarma et al.
Contraception 1996:53:159-161
felt with the mosquito even if it is not palpable. The mosquito can be advanced in all directions, to probe for the implant. Once the implant is felt with the mosquito, carefully open the jaws of the mosquito and grasp the implant and pull it gently towards the incision. If the white surface of the implant is visible, grasp the implant with the straight mosquito without grasping any surrounding tissue. Remove the curved mosquito and pull the implant with the straight mosquito. If tissue encapsulation is still present over the implant as it is pulled out, clear it either with a piece of gauze or the Adson’s forceps, before grasping it with the straight mosquito. Clean the incision site with an antiseptic and apply Steri-strips to close the incision and wrap it with a bandage. While probing for deeply placed implants in the area of the brachial groove (the groove that is located just medial to the biceps muscle), care must be taken not to injure the important vessels and nerves.’ If the attempt to retrieve the implant fails, a soft
Figure 1. Soft tissue x-ray films upper arm.
(AP and internal
oblique]
tissue plain x-ray (anteroposterior, lateral and internal oblique views) of the upper arm using 45 55 kVP should be performed to locate the implant (Figure 1). 13. Once the location of the implant is determined, removal may be attempted 2-3 weeks later, using the steps described above. Waiting for 2-3 weeks allows the swelling of the tissues to subside facilitating removal. 14. If removal could not be accomplished as outlined above, special fluoroscopy (low kVP) guidance should be used to retrieve the implant.
Results At Grady Health System in Atlanta, the authors and other clinicians have removed 48 deeply placed implants using the above mentioned technique, between October 1992 and January 199.5. All removals were done using a single incision and 90% of them were done in 30 minutes or less. None of the patients had any complications. The scars were small and cosmetically acceptable to the patients. Using the same technique, 6-8 cm3 of 1% lidocaine and a single 8 mm-l
using 46 kVP show the implants
in the medial
aspect of the left
Removal
Contraception 1996;53:159-161
Figure
2. Sonogram
of the upper
arm showing
six shadows
several distorted (U-shaped, corkscrewshaped, etc.) implants, displaced implants, and broken fragments of implants were removed successfully. In order to determine the most cost-effective way of locating nonpalpable implants, a comparison of fluoroscopy, regular plain x-ray, low kVP plain x-ray (4555 LVP) and ultrasound using a 1 cm gel pad was made in a volunteer ‘with the Norplant system in her arm. Regular fluoroseopy and plain x-ray did not show the implants. Soft tissue plain x-ray using low kVP (451-55)~identified the implants clearly (Figure 1 J. Ultrasound examination also detected the implants in the transverse plane, but orientation of the implants was not as clear as the low KVP x-ray (Figure 2). Soft tissue, low kVP x-ray is less expensive than ultrasound examination. cm incision,
Discussion is an effective method of conpopularity in the US in 1991 removal of the contributed to a
of Nonpalpable
cast by the levonorgestrel
Norplant@
Implants
161
implants.
decline in the utilization of this contraceptive method in this country. Simple and cost-effective strategies for identification and removal of nonpalpable implants will benefit patients and clinicians alike. The methods described above should facilitate removal of nonpalpable implants in a safe and costeffective manner.
Acknowledgments We thank Gordon Carson, III, M.D., Chief of Emergency Radiology at Grady Health System, for his advice on imaging Norplant implants, and Ms. Tanya Arnold for volunteering to have imaging of her Norplant implants performed.
References 1. Contraception Report. 1994; Volume V, No. 5:7-12. 2. Sarma SP, Hatcher RA. Neuro-vascular injury during Norplant removal. Am J Obstet Gynecol 1995;172: 120-l. 3. Twickler DM, Schwarz BE. Imaging of the levonorgestrel implantable contraceptive device: Am J Obstet Gynecol 1992;167:572-3.
Removal of Deeply Inserted, Nonpalpable Levonorgestrel (Norplant@) Implants Seshu P. Sarma,”
Jane G. Wamsher,t
and Susan W. Whitlockt
Deeply inserted, nonpalpable contraceptive implants can often be removed easily using 6-8 cm3 of 1% lidocaine and a single 1 cm incision. There is no need for suturing of the incision. The location of nonpalpable implants not retrieved by this procedure can be determined by a plain, soft tissue x-ray (standard AP and lateral and internal oblique; 45-55 kVP) of the area where the implants are inserted. Removal can then be accomplished several weeks later. CONTRACEPTION 1996;53:159-161 KEY WORDS:
nonpalpable implant
removal
Introduction implant device orplant@, the contraceptive (Wyeth-Ayerst, Philadelphia, PA, USA), has been used extensively in the US since it was approved by the Foad and Drug Administration in December 1990. Many clinicians were trained in the insertion of the implants in clinical workshops which included video presentation and limited “hands-on” training. Some contraceptive implant systems, however, have been inserted by clinicians who have no prior experience in this procedure. It is quite conceivable that many such !Norplant implants were not inserted properly. Although much was written in medical journals as well as lay press about the difficulty of removing contraceptive implants, it is not hard to retrieve implants that are properly placed. Several Norplant implants removal techniques, namely, the Population Council method, the Pop-Out method, the Emory method and the “U” technique, have been described by investigators in the US and abroad.’ These methods describe removal of implants Chat are properly inserted. How-
N
*Morehouse School Atlanta, GA 30303,
of Medicine, USA
*Family
Planning
Clinic,
Grady
Health
(404)616-5807 Revised Accepted Norplants
December 5, 1995 for publication De is a registered tra
mark
of the Population
0 1996 Elsevier Science Inc. A/I rights reserved. 655 Avenue of the Amerrcas, New York, NY 10010
Council,
Inc
System,
ever, at times, clinicians may encounter implants that, because of deep insertion, are not palpable. As we are nearing the end of the 5year period for initial Norplant implants insertions in the US, a simple method for removal of nonpalpable implants is needed. The methods presented in this article have not been studied scientifically or compared with any other methods previously published, but rather represent the authors’ wish to describe their experience with removal of nonpalpable implants.
Methods and Materials In addition to the routine surgical lowing equipment is used: One tissue Adson forceps, with Two mosquito Halstead forceps curved, 5” long); Butterfly bandages or other skin
supplies,
the fol-
1x2 teeth; (1 straight
and 1
closures.
Removal Procedure for Nonpalpable Implants-Key Points 1. Determine the area of the missing or nonpalpable implants by locating the palpable implants. Mark the area with a nonerasable marker. 2. Draw up 6-8 cm3 of 1% lidocaine. 3. Inject 1 cm3 at the original incision site and 3/4 cm3 underneath the lower (proximal) half of each implant. Inject 3/4 cm3 of 1% lidocaine along the track of the marked area. 4. Make a superficial, horizontal incision about 8 mm-l cm long close to the lower ends of the implants (preferably at the original incision site). 5. Remove the easily accessible implants first (using the method familiar to the clinician). 6. Introduce the curved mosquito (with the curvature facing upwards) in the area marked and advance it gently by dissecting the tissue. Gently probe the surrounding area with the curved mosquito as far as it allows. Often the implant can be ISSN 0010.7824/96/$15.00 PII SOOlO-7824(96)00004-X
160
7.
8. 9.
10.
11,
12.
Sarma et al.
Contraception 1996:53:159-161
felt with the mosquito even if it is not palpable. The mosquito can be advanced in all directions, to probe for the implant. Once the implant is felt with the mosquito, carefully open the jaws of the mosquito and grasp the implant and pull it gently towards the incision. If the white surface of the implant is visible, grasp the implant with the straight mosquito without grasping any surrounding tissue. Remove the curved mosquito and pull the implant with the straight mosquito. If tissue encapsulation is still present over the implant as it is pulled out, clear it either with a piece of gauze or the Adson’s forceps, before grasping it with the straight mosquito. Clean the incision site with an antiseptic and apply Steri-strips to close the incision and wrap it with a bandage. While probing for deeply placed implants in the area of the brachial groove (the groove that is located just medial to the biceps muscle), care must be taken not to injure the important vessels and nerves.’ If the attempt to retrieve the implant fails, a soft
Figure 1. Soft tissue x-ray films upper arm.
(AP and internal
oblique]
tissue plain x-ray (anteroposterior, lateral and internal oblique views) of the upper arm using 45 55 kVP should be performed to locate the implant (Figure 1). 13. Once the location of the implant is determined, removal may be attempted 2-3 weeks later, using the steps described above. Waiting for 2-3 weeks allows the swelling of the tissues to subside facilitating removal. 14. If removal could not be accomplished as outlined above, special fluoroscopy (low kVP) guidance should be used to retrieve the implant.
Results At Grady Health System in Atlanta, the authors and other clinicians have removed 48 deeply placed implants using the above mentioned technique, between October 1992 and January 199.5. All removals were done using a single incision and 90% of them were done in 30 minutes or less. None of the patients had any complications. The scars were small and cosmetically acceptable to the patients. Using the same technique, 6-8 cm3 of 1% lidocaine and a single 8 mm-l
using 46 kVP show the implants
in the medial
aspect of the left
Removal
Contraception 1996;53:159-161
Figure
2. Sonogram
of the upper
arm showing
six shadows
several distorted (U-shaped, corkscrewshaped, etc.) implants, displaced implants, and broken fragments of implants were removed successfully. In order to determine the most cost-effective way of locating nonpalpable implants, a comparison of fluoroscopy, regular plain x-ray, low kVP plain x-ray (4555 LVP) and ultrasound using a 1 cm gel pad was made in a volunteer ‘with the Norplant system in her arm. Regular fluoroseopy and plain x-ray did not show the implants. Soft tissue plain x-ray using low kVP (451-55)~identified the implants clearly (Figure 1 J. Ultrasound examination also detected the implants in the transverse plane, but orientation of the implants was not as clear as the low KVP x-ray (Figure 2). Soft tissue, low kVP x-ray is less expensive than ultrasound examination. cm incision,
Discussion is an effective method of conpopularity in the US in 1991 removal of the contributed to a
of Nonpalpable
cast by the levonorgestrel
Norplant@
Implants
161
implants.
decline in the utilization of this contraceptive method in this country. Simple and cost-effective strategies for identification and removal of nonpalpable implants will benefit patients and clinicians alike. The methods described above should facilitate removal of nonpalpable implants in a safe and costeffective manner.
Acknowledgments We thank Gordon Carson, III, M.D., Chief of Emergency Radiology at Grady Health System, for his advice on imaging Norplant implants, and Ms. Tanya Arnold for volunteering to have imaging of her Norplant implants performed.
References 1. Contraception Report. 1994; Volume V, No. 5:7-12. 2. Sarma SP, Hatcher RA. Neuro-vascular injury during Norplant removal. Am J Obstet Gynecol 1995;172: 120-l. 3. Twickler DM, Schwarz BE. Imaging of the levonorgestrel implantable contraceptive device: Am J Obstet Gynecol 1992;167:572-3.