Tubal Surgery Sterilization Laparoscopic sterilization has been used extensively since the late 1960s, and while it can be performed with local anesthetics, it is usually accomplished under general anesthesia. The fallopian tubes can be occluded by suture, clips, silastic rings, or with radiofrequency electrocoagulation, most commonly with a bipolar electrocoagulation instrument (see Chapter 10). When an “operative laparoscope” is used, only one incision is required because the sheath in such a system contains an instrument channel. Otherwise, a second port is needed for the introduction of the occluding instrument. Patients generally remain in the hospital only for a few hours; even when general anesthesia is used. Postoperative pain is usually minor and related to gas that remains in the peritoneal cavity (shoulder pain, dyspnea), and in the case of occlusive devices, pain at the surgical site. These effects normally disappear within a few days. The failure rate is about 5.4 per 1,000 woman-years (5,6). The use of laparoscopic tubal sterilization was impacted by the availability of office vasectomy, effective intrauterine contraception, and the development of office-based hysteroscopic sterilization techniques, discussed later in this chapter.
Ectopic Gestation Medical therapy with methotrexate is considered first-line therapy for tubal pregnancies that meet criteria that may include the following: no cardiac activity, tubal mass smaller than 4 cm as determined by ultrasonography, and β-hCG level less than 10,000 (7,8).
When surgical therapy is required, ectopic gestation can usually be managed successfully by using laparoscopic salpingotomy, salpingectomy, or segmental resection of a portion of the oviduct (see Chapter 20) (9,10). Salpingotomy is performed with scissors, a laser, or an electrosurgical electrode after carefully injecting the mesosalpinx with a dilute vasopressincontaining solution (20 U in 100 mL of normal saline). For salpingectomy, the vascular pedicles are usually secured with electrosurgical desiccation or coagulation, but it is possible using ligatures or clips. Tissue is usually removed from the peritoneal cavity through one of the laparoscopic cannulas.
When salpingotomy is performed, regardless of the route, there is about a 5% chance that trophoblastic tissue remains. In such instances, medical treatment with methotrexate is appropriate (see Chapter 20). Consequently, β-hCG levels should be measured weekly until there is confidence that complete excision occurred (11–13).