FIGURE 39-2 Pomeroy method. During ligation of a tubal loop, plain catgut is used to ensure prompt absorption of the ligature and subsequent separation of the severed tubal ends. (Reproduced with permission from Hoffman BL, Corton MM: Surgeries for benign gynecologic conditions. In Hoffman BL, Schorge JO, Bradshaw KD, et al: Williams Gynecology, 3rd ed. New York, McGraw-Hili Education, 201o6.)
Steps of salpingectomy are shown in Figure 39-3. he umbilical incision generally will need to be larger to allow an adequate view of the tube and mesosalpinx and to place clamps. With total salpingectomy, the entire mesosalpinx must be divided to free the fallopian tube.
In two small cohorts undergoing salpingectomy ater vaginal birth, surgical times were longer than for tubal occlusion, and in one report, blood loss was increased (Danis, 2016; Powell, 2017).
With salpingectomy and cesarean delivery, total blood loss rates were not statistically higher (Powell, 2017; Shinar, 2017).
After surgery, diet is given as tolerated. Ileus is infrequent and should prompt concern for bowel injury, albeit rare. Most women have an uncomplicated course and are discharged on the first postoperative day.
These techniques and other modiications basically consist of (1) ligation and resection at laparotomy as described earlier for puerperal sterilization; (2) application of permanent rings, clips, or inserts to the fallopian tubes by laparoscopy or hysteroscopy; or (3) electrocoagulation of a tubal segment, usually through a laparoscope. A detailed description and illustration of these can be found in Wiliams Gynecoloy, 3rd edition (hompson, 2016).
In the United States, a laparoscopic approach to interval tubal sterilization is the most common. The procedure is frequently performed in an ambulatory surgical setting under general anesthesia. In almost all cases, the woman can be discharged within several hours. Minilaparotomy using a 3-cm suprapubic incision is also popular, especially in resource-poor countries. Major morbidity is rare with either minilaparotomy or laparoscopy. lthough not often used, the peritoneal cavity can be entered through the posterior vaginal fornix via colpotomy to perform tubal interruption.
Pregnancy following sterilization is infrequent. The Collaborative Review of Sterilization (CREST) study followed 10,863 women who had undergone tubal sterilization from 1978 through 1986 (Peterson, 1996). he cumulative failure rate for the various tubal procedures was 18.5 per 1000 or approximately
FIGURE 39-3 A. With salpingectomy, the mesosalpinx is sequentially clamped, cut, and ligated. B. At the cornu, clamps are placed across the fallopian tube and its adjacent mesosalpinx prior to tubal transection. (Reproduced with permission from Stuart GS: Puerperal sterilization. In Yeomans ER, Hoffman BL, Gilstrap, III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili, 201o7.) 0.5 percent. The study found puerperal sterilization to be highly efective. The 5-year failure rate was 5 per 1000, and for 12 years, it was 7 per 1000.
Puerperal sterilization fails for two major reasons. First, sur gical errors occur and include transection of the round ligament or only partial transection of the tube. For this reason, both tubal segments are submitted for pathological confirmation.
Second, a fistulous tract or spontaneous reanastomosis may form between the severed tubal stumps.