The microsurgical tubal (or “microtubal”) reanastomosis (MTR) can be performed via laparotomy, minilaparotomy, or laparoscopy (either direct or by robotics), although the principles and precepts of the procedure remain the same. Surgeons today also need to understand the impact the advent of advanced reproductive technologies, and in particular in vitro fertilization (IVF), has had on the care of patients with prior tubal ligation and the selection of patients for MTR.

First, these procedures have created a viable option to MTR for many patients who have undergone a prior tubal interruption, particularly for those women who are younger, are willing to undergo more than one IVF cycle if necessary, and do not want more than one additional child. Alternatively, for women who have undergone a tubal ligation and desire more than one child, are concerned about the maternal and pediatric risks of multiple pregnancies, or are older (˜38 years of age), MTR may prove to be a viable and useful alternative. Both types of procedures are expensive if the full cost is bore by the patients, and so finances are also a factor in the decision between MTR and IVF.

Second, we should note that as the number of patients who undergo IVF has increased, the number of MTR procedures performed has declined, decreasing the availability of skilled and experienced reproductive surgeons.

Factors affecting pregnancy success following MTR include: a) total tubal length remaining (>4 cm best); b) type of sterilization (Pomeroy, clip, and ring sterilization best); c) site of reanastomosis (isthmic—isthmic best); d) time from sterilization (the less time the better); e) techniques employed (microsurgical technique best); f) surgeon expertise (best if done more than 50 cases); g) patient’s age (younger the better); and h) presence or absence of other infertility factors. In well-selected patients, MTR results in 60% to 80% intrauterine pregnancy rates.

Thus, careful patient selection is critical prior to undertaking the procedure. Usually this should include a review of the prior tubal ligation (tubal interruption) operative note, and the associated pathology report if pertinent, along with a brief assessment of the couple’s fertility potential. The latter should include a semen analysis, ovulation monitoring, and ultrasonographic assessment of the uterine and pelvic anatomy. In women who are older, say over the age of 35 years, or who have begun to experience other concerning signs or symptoms, including irregularity in menstrual cycles, vasomotor flushing or hirsutism, intermittent or persistent pelvic pain, and dyspareunia, a more comprehensive evaluation may be required.

The presence of obesity should also be a consideration, as it not only impacts on the obstetrical outcome of any resulting pregnancy but also on the technical
ease and feasibility of the MTR itself, at least via laparotomy or minilaparotomy. Thus, many reproductive surgeons advise obese patients to lose weight prior to an MTR, if age is not an issue.

Of importance, and beyond the scope of the current discussion, is for the surgeon to recognize the various types of tubal ligation or interruption performed, as some are not amenable to reanastomosis. Only those anastomoses in which relatively healthy and sufficient tubal segments are left behind should be attempted, including those with a total tubal length of at least 4 cm and in which the intramural and fimbriated portions of the tube are preserved. For example, tubal ligation by fimbriectomy or sterilization using cornual occlusion (e.g., using the Essure^® and Adiana^® procedures) are not amenable to reanastomosis. Likewise, patients who have undergone a monopolar “triple-burn” tubal interruption often have so much destruction of the tube that MTR is not possible.

The condition of the intramural and proximate portions of the occluded tube can be assessed preoperatively using a hysterosalpingogram (HSG). Assessment of the proximate portion of the tube is particularly critical in patients who have undergone cauterization of the tubes, either as the primary interruption procedure or after the tubes have been severed. While the condition of the uterine cavity today can be easily and less invasively assessed using transvaginal ultrasonography and/or sonohysterography, these procedures are not helpful in visualizing the intramural/proximate portions of the occluded fallopian tube.

If no portion of the occluded tube is visualized by HSG, it is possible that most, or all, of the intramural portion of the fallopian tube has been destroyed, often by excessive use of electrosurgery at the time of the original tubal ligation. If this is the case, the prognosis for a successful MTR is significantly reduced. This information will help in guide the surgeon at the time of the procedure, allowing him/her to know how far back they may need to resect the proximal portion of the tube before a healthy lumen is identified; arrangements to have the HSG films available for intraoperative examination at the time of the MTR should be made. This information may also help in counseling the patient concerning the best method of approaching her secondary infertility.

The condition of the distal portion of the occluded/interrupted fallopian tube may be guessed at preoperatively based on the description provided in the tubal ligation procedure note. This report should optimally note whether or not periadnexal or peritubal adhesions or endometriosis were observed and the condition of the tubal ostia and fimbria. In addition, particularly in those procedures where a portion of the tube is resected (e.g., Pomeroy’s tubal ligation), a description of what tubal length was removed and confirmation of the same by the pathologic report is also helpful. Unfortunately, because the original operator is often focused primarily on destroying the fallopian tubes, not considering that the patient may change her mind and desire later fertility, often little useful description is available in the tubal ligation operative note beyond the type of procedure performed.

In patients scheduled to undergo a laparoscopic MTR, the absence of such information is offset by the fact that at the time of surgery the operator will be able to inspect the pelvis in a minimally invasive fashion. Alternatively, for those surgeons who are planning to perform the MTR via laparotomy, consideration should be given to performing a concomitant initial laparoscopy if the condition of the distal segment of the tubes is unclear (e.g., in “triple-burn” procedures). In these circumstances, only if the tubal condition appears to be favorable at laparoscopy should the surgeon proceed with the laparotomy and MTR or laparoscopic MTR.

For this the patient may be placed supine on the operating table, an insufflating needle placed through the umbilicus and a laparoscope placed as per routine. Manipulation of the uterus and adjacent structures through a vaginally placed sponge on a grasper, or via a suprapubically placed probe, is usually sufficient to expose the tubal ligation sites. Performing the diagnostic laparoscopy on a day separate from the MTR is not recommended, due to the added costs and risks, except when a more thorough discussion of the pelvic findings with the patient may alter the decision for surgery.

The MTR is a microsurgical procedure, in other words a reproductive surgery that utilizes sutures best viewed with magnification, that is, equal to or smaller than 8-0G. These procedures usually call for the use of magnification of some type, either using magnifying loupes (1.7× to 6×) or an operating microscope (2× to 40×), although the need for magnification obviously varies according to the surgeon’s visual acuity. Some of us even use loupes when performing macroscopic surgical procedures, a response more to failing eyesight than the need for microsurgical technique.

However, the true basis of microsurgery, as discussed in Chapter 22, is not the size of the sutures used or the degree of magnification utilized. The success of reproductive microsurgery principally lies in the ability of the surgeon to intimately understand the tissues
that she/he is operating upon, thus minimizing the degree of tissue damage. Reproductive surgeons should be well acquainted with what is commonly called the microsurgical technique, as its principles are applicable to surgery in general, and to reproductive organ surgery in particular. Following we will review the surgical technique of MTR step by step, initially describing the procedure when performed by laparotomy (see also video: Microsurgical Tubal Reanastomosis).

However, during the entire procedure surgeons should be fully aware and use all principals related to micro or peritoneal surgery.

1. Ensuring all necessary instruments are available and ready: In addition to the standard laparotomy instruments, specialized instruments for microsurgery should be available. The microsurgeon should have intimate knowledge of the surgical instruments used during an MTR (see Box 23.1 and Figure 23.1) and should check them immediately before surgery to ensure they are available on the surgical table and are in good working condition, as these delicate instruments are easily damaged during sterilization and storage.

A needle or wire-tip monopolar electrosurgery tip (0.3 mm or less) should be available and should be set to 10 W cutting current or less, depending on the electrosurgical unit, and the patient appropriately grounded. The tip should not become red hot or melt when the current is turned on; otherwise the wattage should be reduced. Likewise, if the instrument does not cut through fine adhesions, cauterizing them instead, the wattage should be increased slightly. In addition a fine bipolar forceps (e.g., McPherson curved bipolar uncoated forceps, 3½ inch in length with 5-mm tips) should be available.

Continuous irrigation of the surgical site to minimize the risk of desiccation is critical to the success of the procedure. This surgeon prefers the use of Lactate Ringer’s as there is some evidence to indicate that this isotonic crystalloid solution causes less peritoneal swelling than other solutions. To the extent possible the fluid should be warmed to body temperature, but no more, to avoiding freezing or scalding the peritoneal surfaces. Various filled syringes with 20-18G IV catheter (e.g., Angiocath®) tips should be available for this purpose.

Before beginning, the surgeon should also examine and set up the operating microscope, if one is available and to be used, fixing the height and separation of the ocular pieces. The microscope should also be sterilely draped at this time. In addition, if magnifying loupes are to be used, they should be put on.

2. Preparation of the surgical field: Before proceeding further the surgeon should wash his/her gloves off with irrigating fluid, which is then discarded, to remove any potential contaminating talc or, more commonly, corn starch.

a. Ensuring access: Ensuring adequate access to and exposure of the surgical site is critical, and greatly depends on the patient’s body mass. In thinner patients access to the surgical site can be achieved easily through
a small Pfannenstiel or minilaparotomy incision. Alternatively, access to the pelvic cavity of an obese patient is more difficult, and may require a more extensive abdominal port, including a Mallard incision. And even in this setting, it may be difficult to operate on a very obese patient due to the short length of most microsurgical instruments. Thus, many surgeons consider marked obesity to be a relative contraindication to MTR via laparotomy, and either suggest weight loss, if time and patient inclination permits, or performing the procedure via laparoscopy. Once an incision has been made, the sides of the wound are often wrapped in lap packs to minimize bleeding into the surgical site.

b. Examining the anastomosis sites and surroundings: At this point the surgeon should examine the surgical site, determine the status of the tubes and adjacent pelvic organs, ensure adequate exposure of the surgical field, and arrange the surgical field. In most circumstances, the surgeon should have determined the adequacy of the tubes for reanastomosis preoperatively, or at least before performing the laparotomy (see above). However, the surgeon should verify his/her preoperative assessment directly.

c. Exposing the anastomosis site and ensuring a surgical platform for the microsurgical reanastomosis: The bowel is gently packed away from the pelvis, over the pelvic brim, a procedure assisted by placing the patient in moderate Trendelenburg. This surgeon prefers to use laparotomy packs placed inside sterile plastic sandwich bags, one per bag, thus protecting the peritoneum from abrasion by this material. It also allows the bagged laparotomy packs to be used as the surgical platform upon which the anastomosis is performed (see below).

d. Establishing an avenue for intraoperative chromotubation: Next, a method for intraoperatively insufflating the tubes with a dilute solution of saline and indigo carmine (chromopertubation) is readied. One method is to place a small pediatric Foley bulb into the uterine cavity vaginally once the patient is draped, and then chromotubating with indigo carmine as needed via a syringe held by an assistant. While this is a simple method, this surgeon prefers to chromotubate through the uterine fundus, in order to minimize the risk of tubal contamination by vaginal organisms.

First, a Buxton uterine manipulator is placed abdominally, which not only allows for atraumatic manipulation of the uterus during surgery but also can be used to clamp the cervical os closed (Figure 23.2), allowing for transfundal chromotubation. Grasping the uterus at its base, a 20G needle and IV catheter is then placed through the fundus of the uterus, at a point midway between each tubal insertion and in the direction of the uterine cavity, until a gentle pop is felt when entering the cavity.

A syringe containing indigo carmine is connected via an IV connector to the IV catheter, after all air has been expressed from the line and the IV catheter needle has been removed. Proper placement of the IV catheter into the uterine cavity can be verified when symmetric distention of the uterus is palpated (and often seen) as insufflation of dye via the syringe is pulsated. A moderate amount of skill is necessary
to place the IV catheter transfundally correctly into the uterine cavity and, of course, a relatively normal uterus is necessary. Only at this point is the surgeon ready to proceed with the actual tubal reanastomosis.

3. Preparation of tubal stumps and anastomosis site anchoring: Microsurgery of the tubes, including dissection, preparation, and reanastomosis, is best performed over a stable platform of uniform height (to facilitate manipulation of the tubes while keeping tissues in within the focal length of the microscope. We use bagged laparotomy packs placed into the cul-de-sac as a suitable and stable platform.

The preparation of the tubal stumps varies according to the type of anastomosis to be performed, whether it is isthmic-isthmic, ampullary-ampullary, or isthmic-ampullary, and reference to these types will be made below (Figure 23.3). Different types of anastomosis may be necessary for each side. Less frequently performed anastomoses, such as the cornual-isthmic or cornual-ampullary (i.e., anastomosing the intramural portion of the tubal lumen to the distal isthmic or ampullary lumen) will not be discussed further, as these patients should preferably be treated by IVF.