Tubal insufflation is a tubal patency test, first described by Rubin, which is now rarely performed. The procedure uses an endocervical cannula connected, by rubber tubing, to a mercury manometer and a source of carbon dioxide (CO₂). The rate of gas flow through the system is gradually increased to approximately 30 to 60 mL per minute. Tubal patency is determined by one or more of the following: a written record of the rise and rapid fall of the gas pressure, auscultation of the lower abdomen for the gas passing through the tubes into the peritoneal cavity, or direct visualization of the pressure changes on a mercury manometer.

This historic tubal patency test has been replaced by hysterosalpingography (HSG) and/or salpingosonography. Both of these tests should be performed before ovulation, about the
tenth day of the cycle. Administration of one of the nonsteroidal anti-inflammatory medications is helpful to the patient as it reduces her discomfort due to uterine cramping and thus diminishes diagnostic errors.

Hysterosalpingography is a contrast study of the uterine cavity and fallopian tubes. It is a simple, inexpensive, safe, and rapid diagnostic procedure that, when performed properly, provides valuable information about the uterine cavity and tubal patency and architecture.

Contraindications to HSG include pregnancy, uterine bleeding, lower genital tract infection, PID, and allergy to the contrast material. In women with a history of recurrent PID, or with any suggestion of a recent exacerbation, there is a significant risk of reactivation of quiescent PID. This occurs in approximately 3% of such patients. To combat this risk, some centers prophylactically administer antibiotics. During the preliminary history and physical examination, the physician must search for possible contraindications and screen for and treat any lower genital tract infections, before performing an HSG. Prophylactic antibiotics prior to HSG are indicated in selected cases, particularly if hydrosalpinx is suspected.

Selective salpingography is the injection of a contrast medium directly into the uterine tubal ostium with the use of a special radiopaque cannula inserted through the cervix. The increased pressure generated by the direct injection helps to overcome obstructions associated with mucous plugs or minor synechiae. Data from Thurmond, Novy et al, and Papaioannou et al. indicate selective salpingography is technically possible in approximately 90% of available tubes.

Cannulation of the tube requires the use of a special flexible guide wire and narrow-gauge cannula. This cannulation system is introduced through the larger cannula, which is used for selective salpingography.

If HSG demonstrates a cornual or proximal tubal obstruction (Fig. 21.7), selective salpingography with or without tubal cannulation (Fig. 21.8) should be the next step; this is ideally performed in the same setting. These techniques are useful in differentiating true from false cornual occlusion. The benefits of this approach have been shown for apparent cornual spasm, obstructions caused by amorphous material (tubal plugs), and tubal synechiae. Indeed, half of the tubes that were proximally blocked at selective salpingography were found to be normal after tubal catheterization in the largest series reported to date. It is doubtful that these techniques have a real therapeutic effect on pathologic occlusions that are due to obliterative fibrosis, chronic follicular salpingitis, salpingitis isthmica nodosa, or endometriosis.

Salpingosonography is a sonographic technique to assess the uterine cavity and tubal patency. After the insertion of a Foley catheter into the cervix, transvaginal sonography is carried out to assess the pelvic structures. Then, a 20-mL syringe is filled with 10 mL of saline solution followed by 10 mL of air. Air is injected first slowly, and passage is followed through the tube; saline is then injected to cause the air bubbles to flow more visibly through the tube. Air-filled albumin microspheres have also been used for this purpose. Several authors (Chenia et al., Inki et al., Strandell et al.) found salpingosonography to have a concordance with laparoscopy of
approximately 80% and with HSG between 72% and 90%. Although the concordance with HSG with regard to passage of contrast into the peritoneal cavity appears high, it is important to remember that salpingosonography does not provide any information about the intratubal architecture. Yet, the pain scores associated with both of these techniques were comparable, as demonstrated in a prospective study by Cheong and Li in 2005.

Salpingoscopy is the endoscopic examination of the ampullary portion of the tubal lumen. This can be accomplished with a small-gauge rigid or flexible endoscope during either laparoscopy or laparotomy. If the distal tube is totally occluded (hydrosalpinx), it is necessary to make a small opening at the fimbriated end to permit the introduction of the scope. The tubal lumen is visualized while distended with physiologic solution injected through the outer sheath of the rigid endoscope or the channel of the flexible scope. The distal end of the tube must be appropriately manipulated to bring it into the axis of the scope. Salpingoscopy permits direct assessment of the tubal epithelium. The findings have been classified into five grades. Grade 1 refers to normal mucosal architecture. Grade 2 refers to tubes that demonstrate variable degrees of flattening of both major and minor mucosal folds, which are largely preserved. Grade 3 refers to tubes that demonstrate focal adhesions between mucosal folds. Grade 4 refers to tubes with extensive intraluminal adhesions or disseminated flattened epithelial areas. Grade 5 refers to tubes that are rigid and hollow with a complete loss of epithelial folds. Findings at salpingoscopy appear to be predictive and prognostic of pregnancy outcome.

Microsalpingoscopy has been used to examine the integrity of the tubal mucosa more closely. Microsalpingoscopy uses an endoscope that has magnification capability enabling visualization of individual cells of the tubal epithelium. The epithelium is stained with concentrated methylene blue solution injected through the cervical cannula. It is then assessed under magnification. The level of staining of the nuclei of the tubal cells is inversely proportional to functional integrity of the mucosa. This technique is at present investigational; thus, its value remains to be determined.

Falloposcopy is a transvaginal microendoscopic technique aimed at exploring the entire length of the tube, especially the intramural and isthmic segments. A linear eversion catheter system has been used to perform falloposcopy without the need for preliminary hysteroscopy and anesthesia. The patient requires premedication to decrease the discomfort associated with the procedure.

The system includes a linear eversion catheter with an outer plastic polymer body 2.8 mm in diameter and a sliding stainless steel inner body 0.8 mm in diameter, containing a 0.48-mm fiberoptic endoscope. The tip of the outer catheter is angulated so it can be directed toward the uterotubal junction. Once the tubal ostium is identified, the tip of the catheter is held against the ostium. The pressure within the eversion catheter is increased, and the membrane of the eversion catheter is introduced into the fallopian tube for a short distance. The endoscope is pushed down the lumen to the tip of the introduced catheter. The image obtained is displayed on a high-resolution color monitor. The eversion catheter and the endoscope it houses are advanced in the described manner, slowly and gradually, with the endoscope always maintained within the inverting membrane to prevent the tip of the endoscope from piercing the tubal wall.

Falloposcopy may be used as a means of tubal catheterization and has the added benefit of permitting assessment of the lumen of the tube, especially its intramural and isthmic segments. Kerin et al. proposed a classification based on a scoring system that takes into account the degree of tubal patency, tubal dilatation, epithelial and vascular changes, intratubal adhesions, and other abnormal findings.

This technique, which requires expensive disposable equipment, did not gain clinical acceptance.

Salpingography, salpingoscopy, and falloposcopy are designed to assess tubal patency and morphology. Many procedures designed to assess tubal function have been proposed but did not attain clinical acceptance.

Early attempts at using radioactive microspheres as oocyte surrogates to evaluate egg transport did not appear to be clinically valuable. Uher et al. have introduced biodegradable microspheres into the pouch of Douglas by either cul-de-sac puncture or laparoscopy. These microspheres, which
were recognizable by fluorescence, were collected in a cervical cup 24 hours later. Microspheres were present in the cup in 66% of 69 patients with unexplained infertility and in 100% of 20 patients with male factor infertility.

Laparoscopy permits direct visualization of the peritoneal cavity, pelvis, and internal reproductive organs. It can also test tubal patency with the use of concomitant chromopertubation. It is the most accurate way to identify periadnexal adhesive disease and endometriosis. Laparoscopy also provides the necessary surgical access to perform surgical procedures. Hysteroscopy and salpingoscopy, when indicated, may be performed during the same setting. Laparoscopy is an invasive procedure that usually requires a general anesthetic. It is important to be reminded that most of the major vascular and bowel injuries occur with the initiation of laparoscopy, during the introduction of the Veress needle, principal trocar, and ancillary trocars.

There are those who argue in favor of an immediate laparoscopy bypassing HSG. An analysis of 18 published series demonstrates good congruence between laparoscopic and HSG findings. These collected data indicate that the sensitivity and specificity of HSG are approximately 76% and 83%, respectively. These studies represent a selected population of patients in whom the prevalence of tubal occlusion was 38%. This prevalence figure falls to 10% in studies of large numbers of unselected patients, which reflects more accurately the general population. If the sensitivity and specificity figures reported above are applied to a hypothetical group of patients with a 10% rate of tubal occlusion, only 3% of those with a normal HSG will have an abnormal laparoscopy. Thus, the laparoscopy will be normal in approximately 97% of patients. These data support delaying endoscopy for 4 to 6 months in those with an apparently normal HSG, except in women of older reproductive age.

Based on the preceding information, a well-performed HSG should be the preliminary investigation for tubal factor infertility. This approach permits the identification of (a) uterine anomalies and lesions; (b) cornual occlusion or lesions, even in the presence of cornual patency; (c) distal tubal occlusion; and (d) assessment of intratubal architecture. This information is of paramount importance to the surgeon at the time of laparoscopy, especially if the condition is amenable to laparoscopic surgery, which should be performed in the same setting. Indeed, with the advanced imaging techniques and newer therapeutic modalities available today, laparoscopy, solely for the purpose of diagnosis, should be rarely required.

Hydroculdoscopy was introduced to visualize the fallopian tubes, ovaries, and the cul-de-sac of Douglas. The technique is a modification of the traditional “culdoscopy,” which has been largely abandoned. It was introduced as a diagnostic technique to replace laparoscopy in the investigation of infertile women, hence the name “fertiloscopy.”

With the patient properly positioned, a bimanual examination is carried to examine the pelvic organs and confirm that the pouch of Douglas is free. The posterior fornix of the vagina is exposed, and the pouch of Douglas is entered using a Veress-type needle. Once the needle is appropriately placed, 200 to 250 mL of saline solution is introduced into the pouch of Douglas through the Veress needle. A trocar/cannula that permits the introduction of a small-caliber endoscope or a “fertiloscope” is then inserted.

The procedure permits the visualization of the pouch of Douglas, the posterior surface of the uterus, the fallopian tubes, and ovaries. Tubal patency can be ascertained by the introduction of a dilute methylene blue solution into the uterine cavity, through an appropriate cannula. If tubal damage is suspected, a salpingoscopy may be performed during the same procedure.

Initially introduced as a diagnostic tool, the technique has also provided surgical access for certain therapeutic procedures including minor adhesiolysis and ablation of minor endometriotic lesions; it also permits performance of ovarian drilling.

The first ovarian drilling by hydroculdoscopy was performed in France in 1999 at the Antoine Beclère Hospital by Hervé Fernandez, introducing a bipolar Versapoint probe into the pouch of Douglas through a site lateral to that of the endoscope. The patient was markedly obese and was found to have polycystic ovaries as reported by Fernandez in 2001 (Fig. 21.11). Ovarian drilling using this access has since been performed in many centers; the reported results appear similar to those performed by laparoscopy.

It is evident that the procedure cannot be undertaken if the cul-de-sac of Douglas is occluded. The view obtained with hydroculdoscopy is localized and very different from the panoramic view obtained by laparoscopy; furthermore, it does not offer the wide surgical applications that laparoscopic surgical access offers. However, it does have a role in replacing a laparoscopy in appropriately selected patients.

Reconstructive tubal surgery was the only treatment option for infertile women with damaged fallopian tubes, until the recent past. This is no longer the case due to significant improvement in outcomes and much wider availability of IVF and ART that provide such couples with a realistic therapeutic alternative.

Data collected prospectively for ART treatments during the year 2009, the last year for which there was a detailed analysis available at the time of writing, from 441 clinics in the United States provided the following outcome data, which were tabulated by the Centers for Disease Control and Prevention (CDC) in 2011. There were 146,244 cycles of ART in 2009. Of these 102,478 (70.1%) were fresh nondonor and 26,069 (17.8%) were frozen nondonor cycles; 11,038 (7.5%) were fresh donor and 6,659 (4.6%) were frozen donor cycles. The majority of the women treated (61.1%) were 35 years of age and more, and only 38.9% were under 35. The overall live birth rate per cycle started in the fresh nondonor group was 30% and in the frozen nondonor group was also 30%. The birth rate was the same in 2010. In cycles that resulted in a clinical pregnancy, 81.3% resulted in live births. Of live births, 69.5% were singleton births and 28.9% were twins and 1.6% triplets or greater multiples.

Of note, a 2013 report from the CDC indicates the number of ART cycles performed in the United States has more than doubled from 64,036 cycles in 1996 to 147,260 in 2010. More important is the improvement in the overall live birth rate per cycle started from 12.3% in 1990 to 30% in 2010.

Intracytoplasmic sperm injection represents a very important progress in ART; it has proven to be a panacea in the treatment of male infertility. As early as 2003, it was demonstrated that in male factor infertility, the use of ICSI is associated with a success rate that almost equals that of standard IVF in the absence of male factor (Table 21.2). Furthermore, since the same time there has been an increasing use of ICSI for fertilization of oocytes even in couples without a male factor. In the United States in 2010, ICSI was used in 66% of IVF cases.

The outcome of both standard IVF and ICSI is adversely affected by the age of the female partner. There is a linear decline after age 35 in both the overall live birth rates and the implantation rate of embryos as clearly evident in Table 21.3 that summarizes the US IVF results for the year 2010.

There has been an increase in the use of frozen nondonor embryos and improvement in outcomes. Frozen nondonor embryos were used in approximately 18% of all ART cycles performed in 2009, compared to 14% in 2003. The rate of thawed embryos resulting in live births is 30.3%, similar to the overall rate with fresh nondonor cycles, which is quite impressive. Although replacement of frozen thawed embryos improves the cumulative success rate for a couple, the overall net effect remains limited because not all of the cycles provide spare embryos and not all of the frozen embryos withstand the thawing process.

In vitro fertilization and embryo transfer is not risk free, especially in stimulated cycles. Although uncommon, ovarian hyperstimulation, bleeding, and infection can occur. Pregnancies resulting from IVF have an abortion rate of approximately 17%. The overall tubal pregnancy rate is approximately 1% to 2% of ART cycles. A 1991 study from our center by Zouves et al. demonstrated a tubal pregnancy rate of 2.6% (of clinical pregnancies) among IVF patients without tubal factor infertility. However, this rate was 12% in patients with prior tubal disease and tubal surgery.

Assisted reproductive technology procedures are associated with a significant increase in the rate of multiple pregnancies (relative risk [RR] >20). The Centers for Disease Control (CDC) Assisted Reproductive Technology report for 2009 indicated that of the resulting live births, only 69.5% were singletons, 28.9% twins, and 1.6% triplets or higher order. These results show a modest improvement compared to those of 2003, which were 65.8%, 31.0%, and 3.2%, respectively. The high rate of multiple pregnancies is due to the number of embryos transferred. Since transfer of more embryos improves the overall pregnancy rate, there is a temptation to do so. In Europe, where in many jurisdictions the number of embryos to be transferred is limited, both the live birth outcomes and the multiple pregnancy rates are lower (Table 21.4).

The high rate of multiple births has a tremendous personal and social impact. Perinatal morbidity and mortality are markedly increased in pregnancies complicated by multiple gestations. The cost, both emotionally and financially, of caring for premature or abnormal children is great. It was demonstrated that monofetal pregnancies also are associated with elevated risk as compared with non-ART singleton pregnancies; more than 10% of monofetal births are preterm, and the perinatal mortality rate (approximately 19 per 1,000) is higher than non-ART singleton pregnancies. This has not changed; the 2009 US outcomes for fresh nondonor ART cycles indicate preterm birth rates of 11.6% for singletons from single-fetus pregnancy, 19.0% for singletons from multiple-fetus pregnancy, 60% for twins, and 97.5% for triplets or more. The percentages of low-birth-weight infants for the same group were 8.7%, 16.7%, 56.1%, and 92.1%, respectively.

A 1994 study by Rufat et al. from France that analyzed a total of 1,637 IVF pregnancies resulting in 1,263 deliveries and 1,669 live born or stillborn children demonstrated a preterm birth rate of 22.7% of all deliveries and 12.2% of singleton deliveries compared with 5.6% among all deliveries in France, and 34.7% of babies weighed less than 2,500 g compared with 5.2% among all deliveries in France. The rates of perinatal, neonatal, and infant mortality were higher than the national
average. Another important study by Bergh et al. from Sweden compared the obstetric outcomes of babies conceived with IVF (n = 5,856) to all babies born in the general population during a span of 13 years (1982-1995) demonstrated that children resulting from IVF conception had increased rates of low birth weight (RR = 5), major malformations (RR = 1.4), cerebral palsy (RR = 4), and death (RR = 2). Such elevated personal and societal costs must be considered when embarking on any ART procedure.

Microsurgery has been defined as “surgery under magnification.” In fact, magnification is only a single facet of microsurgery, which embraces a broad concept of tissue care designed to minimize tissue damage and the use of measures that prevent and/or decrease an acute inflammatory reaction in the peritoneal cavity. These are measures applicable to both open and laparoscopic access; they include the following:

Additional measures help to decrease acute inflammatory reaction. Specifically before the close of the procedure, we leave 300 to 500 mL of lactated Ringer solution with 500 mg
of hydrocortisone succinate in the peritoneal cavity. General measures assist in this regard: use of preoperative and postoperative antiinflammatory medications, for example, Voltaren suppository, infiltration of a local anesthetic before placing the incision, and the administration of a single dose of prednisone postsurgery.

Magnification, with an operating microscope or with an endoscope, provides many advantages; it permits prompt identification of abnormal morphologic changes, recognition and avoidance of surgical injury, and application of the preceding principles with the use of fine instruments and suture materials. Microsurgery is a surgical attitude as much as a technique.

In the late 1960s, Swolin used magnification with loops— electrosurgery with a fine electrode for the reconstruction of distal tubal occlusion. In addition, he strived to reduce peritoneal trauma by keeping the operative site moistened by frequent irrigation. In Vancouver, we expanded the microsurgical techniques; using an operating microscope, we applied them in the correction of pathologic cornual and midtubal occlusions (tubocornual anastomosis and tubotubal anastomosis) and in reversal of sterilization. This approach permitted us to perform tubocornual anastomosis as opposed to a tubouterine implantation—which was the standard procedure at the time—in cases of pathologic cornual occlusion. An anastomosis in such cases preserves tubal integrity and thus is a more physiologic approach of tubal reconstruction.

Microsurgery, in fact, finds its ultimate application in tubal anastomosis. The use of magnification, microsurgical instruments, and sutures enables the recognition of subtle abnormalities—even in the presence of tubal patency, excision of abnormal tissues, and correct alignment of the tubal segments and precise apposition of each layer. Indeed, the application of microsurgery has significantly improved the outcome of such procedures. However, in the treatment of distal tubal occlusion, any improvement attributable to the use of microsurgical techniques has been relatively modest, despite the reduction in postoperative adhesions and improved tubal patency rates.

The introduction of microsurgery into gynecology has yielded benefits much greater than simple improvement in the outcome of certain fertility operations. It created a great awareness of the effects of peritoneal trauma and the resulting postoperative adhesions. It also promoted the use of conservative approaches that are now considered standard of care for women undergoing surgical treatment for benign gynecologic disease. These are additional and important reasons to continue to teach reconstructive infertility surgery. Thus, microsurgery is a surgical philosophy, a delicate surgical approach designed to minimize peritoneal trauma and tissue disruption and prevent postoperative adhesions while increasing the accuracy of the procedure and improving the outcome.

Microsurgical techniques are equally applicable to both open and laparoscopic access. We demonstrated the applicability of microsurgical techniques by laparoscopy for adhesiolysis, salpingo-ovariolysis, fimbrioplasty, and salpingostomy as early as the mid-1970s. Microsurgical techniques must be used in all reproductive operations, irrespective of the mode of access. This is especially important today because most such procedures are performed by laparoscopy and minilaparotomy.

The laparoscope also provides a degree of magnification. Bringing the distal end of the laparoscope close to the area of interest, one achieves excellent visibility and illumination. There are microsurgical advantages inherent to laparoscopic access. Operating within a closed peritoneal cavity eliminates the need to use packs and prevents the introduction of foreign materials such as lint and talcum powder. The pressure effect of the pneumoperitoneum diminishes venous oozing and permits spontaneous coagulation of minor vessels. It is possible to perform intraoperative irrigation to expose any bleeding vessels and keep tissues moistened. Fine electrodes can also be used to achieve precise electrosurgical hemostasis. Like microsurgery, laparoscopic procedures are performed with few instruments. The instrument manufacturers have at last recognized the need for proper microsurgical instruments for laparoscopy; they are now readily available.

We must stress, however, that the large volume of gas insufflation necessary in operative laparoscopy causes desiccation of the mesothelial cells that line the peritoneum; furthermore, it has been recognized that CO₂ is toxic to mesothelial cells. This phenomenon may enhance the development of postoperative adhesions. Hypoxia causes retraction of the mesothelial cells exposing the extracellular matrix. This causes substances and cellular elements that enhance adhesion formation or decrease repair to enter the peritoneal cavity. Both animal and more recently human work demonstrated that the noxious effects of CO₂ pneumoperitoneum may largely be avoided by modifying the gas mixture by adding small percentages of O₂ and N₂O, keeping the gas mixture fully humidified and at a temperature of 31°C.

The major equipment includes an electrosurgical generator suitable for both general and microsurgical work and, depending on the access mode used, either an operating microscope or appropriate laparoscopic equipment. Most of the good modern electrosurgical generators can be used for both general work and microsurgical work. Such generators are now standard equipment in most operating rooms.

When access to the pelvis is achieved by laparotomy or minilaparotomy, magnification is obtained by the use of an operating microscope or loops. Loops provide low levels of fixed magnification. It is difficult to work with loops that provide a magnification greater than four times. They are suitable for use only in simple short procedures and are quite helpful when used to divide adhesions or excise endometriotic lesions located deep in the pelvis. Magnification is best obtained with an operating microscope that provides magnification ranges from 2 to 40 times; coaxial illumination of a constant visual field enables precise focusing and change of levels of magnification. In gynecologic microsurgery, an objective lens with a focal distance of 250 to 300 mm allows for a suitable working distance under the lens. The microscope can be mounted on the floor or ceiling. Focusing, varying the level of magnification, and other functions of the microscope can be manual or motorized. The latter version is preferable because changes can be readily accomplished through controls on a foot pedal while the surgeon’s hands remain in the operative field. Most modern operating microscopes are equipped with beam splitters, which permit the fitting of two pairs of binoculars so that both the surgeon and the assistant can simultaneously view the operative field. A miniature television camera can also be fitted to the same beam splitter, which enables the operating room personnel to follow the surgery on the monitor and allows video recordings of the procedure to be made.

When laparoscopic access is used, a good laparoscope equipped with a high-resolution mini TV camera and a highresolution monitor is required. The laparoscope does not offer the stereoscopic vision and the excellent depth of field that the operating microscope provides. Nonetheless, first generations
of three-dimensional laparoscopic equipment and magnification devices have been produced. Progress is under way.

Good microsurgical instruments for open access have been present since the 1970s. Microsurgical instrument for laparoscopic access became available in the last two decades. Although their shapes are obviously different, their functions are similar. The basic microsurgical instruments are few and include plain and toothed platform microforceps, microscissors, microneedle holder, and straight scissors and/or a microblade to transect the tube (Fig. 21.12). The forceps have rounded tips with a shaft designed so that they, like the scissors and needle holder, have good ergonomics and can be used comfortably. Teflon-coated probes with variable rounded tips are used for retraction.

Electromicrosurgery requires the use of a true insulated microelectrode of 100 or 150 µm in diameter with a free pointed conical tip. The microelectrode is connected to the handle of the electrosurgical unit with an adaptor. A rocker switch mounted on the handle allows delivery of current in cutting, coagulating, or blend modes. Irrigation can be performed with an appropriate laparoscopic irrigator. For open procedures, a device with a fingertip control (Gomel irrigator) (Fig. 21.13) is commercially available and enables accurate irrigation.

Before the induction of anesthesia, the surgeon must ensure that all necessary equipment and instruments are present and in working order. After the induction of anesthesia, the patient’s bladder is catheterized with a Foley catheter, which is connected to continuous drainage. If intraoperative chromopertubation is required, either a pediatric Foley catheter or an appropriate uterine cannula is introduced through the cervix and fixed in place. The catheter or cannula is connected either directly or by means of an extension tube to a syringe filled with dilute dye solution.

When open surgical access is used, anteversion and elevation of the uterus can be achieved either by selecting a suitable uterine cannula or by packing the vagina. With the latter option, a pediatric Foley catheter should first be placed in the uterine cavity if intraoperative chromopertubation is desired.

As indicated earlier in the text, many reconstructive tubal operations can be performed by laparotomy, minilaparotomy, or laparoscopic access. The selection of the specific access route depends on the nature of the lesion, the type of procedure required, and the skill of the surgeon. The aim is to select the access route that will yield the best outcome for the patient.

Many reconstructive operations, especially those for distal tubal disease, can be efficiently performed by laparoscopic access. Because of the advantages inherent in undertaking such a procedure at the time of the initial diagnostic laparoscopy, it is preferable that a surgeon trained in this type of surgery perform the initial laparoscopy.

Once a proper pneumoperitoneum is obtained, the principal trocar and cannula are inserted (usually intraumbilically), the trocar is removed, and the laparoscope is introduced through the cannula. The details of performing a laparoscopy will not be described in this chapter. A thorough laparoscopic survey is performed as described earlier in this text, and the nature and extent of the tubal and pelvic lesions is assessed. The information yielded by the prior complemented by the laparoscopic findings and the status of the other fertility parameters, permits the surgeon to select the therapeutic approach that is best for the patient.

The laparoscopic survey requires the establishment of a secondary portal for the introduction of a probe or other appropriate instrument. This ancillary portal is placed suprapubically in the midline or in one of the lower abdominal quadrants. The undertaking of reconstructive surgery will necessitate the establishment of additional portals of entry. These are placed, depending on the clinical findings and the procedure to be performed, at sites that permit easy access to the operative field.

In reconstructive tubal surgery, a transverse suprapubic incision is the type used most often. Since 1985, we have used a small, minilaparotomy, suprapubic transverse or vertical (if a midline or paramedian scar is present) incision to gain access to the pelvis. The length of this minilaparotomy incision is usually 4.5 to 6 cm. The prior pelvic findings and especially the depth of the patient’s subcutaneous adipose layer determine the length of the incision. The site of the proposed incision is infiltrated with a long-acting anesthetic agent, such as
0.25% bupivacaine (Marcaine) solution. A transverse suprapubic incision is made and extended down to the fascia. The subcutaneous fat is dissected over the fascia, in the midline upward and downward. The fascia is then incised vertically in the midline. The recti muscles are separated in the midline, and the peritoneum is incised vertically, with the incision curbed laterally at the lower end to avoid the bladder. The subcutaneous tissues are reinfiltrated with the same solution before closure of the skin incision. Thereafter, a bilateral ilioinguinal nerve block is established. The small size of the incision; the lack of bowel manipulation, along with gentle handling of tissues during the procedure; and the use of local anesthesia reduce postoperative discomfort and analgesia requirements. This approach permits prompt mobilization of the patient and discharge from the hospital or surgical center usually on the same day. These patients return to normal activity almost as rapidly as those who have had their procedures performed laparoscopically.

It is essential that the surgical personnel thoroughly wash their gloves after they have been put on and again before making the peritoneal incision. Once the peritoneal cavity is entered, retraction is obtained with a disposable device that provides both wound protection and circumferential retraction with maximal exposure for the incision size. Varying sizes of such devices are available from many manufacturers and are preferable to standard retractors. Pads soaked in heparinized (5,000 U/L) lactated Ringer solution can be introduced into the pouch of Douglas to further elevate the uterus and isolate the bowel already displaced by a mild (10- to 15-degree) Trendelenburg tilt.

Once the surgical site is well exposed, the operating microscope is positioned. Although the operating microscope can be draped, we have not found this to be necessary, particularly if foot pedals control the microscope. Intraoperative irrigation is performed with heparinized lactated Ringer solution in an intravenous bag that is elevated and connected with intravenous tubing to a Gomel microsurgical irrigator (Fig. 21.12). This enables periodic irrigation of the exposed peritoneal surfaces and ovaries to prevent desiccation and to visualize individual bleeders.

At the close of a reconstructive procedure, irrespective of the type and the mode of access, the operative site is inspected to ensure that complete hemostasis has been achieved. Any bleeding vessels are electrodesiccated. A thorough pelvic lavage is then performed with the irrigation solution until the fluid remains clear. Pelvic lavage serves to remove from the peritoneal cavity any blood clots or other debris that may be present.

When laparoscopic access is used for the procedure, underwater examination of the operative site may be performed. When the irrigation fluid remains clear, the pneumoperitoneum pressure is reduced and the region inspected with the distal end of the laparoscope under the surface of the fluid. This permits prompt recognition of any small bleeding vessels, which can be desiccated with the use of a microelectrode or microbipolar forceps.

Once the irrigation fluid is completely suctioned out of the pelvis, some investigators leave varying amounts of physiologic solution in the peritoneal cavity to reduce postoperative adhesions. We use 300 to 500 mL of lactated Ringer solution to which 500 mg of hydrocortisone succinate is added. There are promising new products designed to prevent adhesion formation that are easy to apply by both open and laparoscopic access; these are currently undergoing clinical trials. The topic of ancillary measures for adhesion prevention is outside the purview of this chapter and will not be discussed further.

Pelvic and periadnexal adhesions usually are the sequel of PID. These adhesions may be broad or shallow; they are usually not too vascular and extend from one structure to another. In so doing, they tend to leave a space or potential space between the involved structures, an aspect that facilitates adhesiolysis (Fig. 21.14). Dense cohesive adhesions often result from prior surgery. In this case, adjacent structures are intimately conglutinated. The adherent surface is devoid of the superficial mesothelial layer of the peritoneum. In other words, the underlying stromal layers of the two structures coalesce. The lysis of such an adhesive process is technically difficult and is associated with a very high percentage of recurrence.