Indications and Contraindications

Indications

The primary indication is the woman′s well-considered wishes, following appropriate counseling. There are no compelling medical indications. Implantable progesterone systems such as Norplant (active substance: levonorgestrel) or Implanon are suitable long-term alternatives to tubal ligation techniques for practically all patients, especially patients with severe cardiovascular disease, and probably also for those with known thrombophilia. Contraindications to laparoscopy provide specific indications for an open abdominal procedure. The main indication for postpartum partial salpingectomy through an infraumbilical minilaparotomy is a wish for sterilization immediately after delivery, which was formulated and documented during pregnancy.

Contraindications

Every permanent form of sterilization is contraindicated in a patient who is ambivalent or under external pressure. The treating doctor must react to the situation with particular sensitivity. Another contraindication is when the patient is unable to decide or give informed consent, for example, women with more or less severe intellectual disability. In cases of doubt, an ethics committee decision or ruling by a competent family court may be required.

Operation Risks and Informed Consent

Besides the usual risks such as infection, pain, hemorrhage, and injury of internal organs, the patient must be clear about three facts before the procedure:

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  “Forever”: sterilization is permanent and is practically irreversible.

  
  
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  “Not 100%”: sterilization is the safest method of contraception long-term, but pregnancy can occur at any time.

  
  
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  “Increased risk of tubal pregnancy”: if pregnancy occurs, it is an EUP in almost 40% of cases.

Beyond these three facts, the most important risk of sterilization is that the patient will regret the procedure later. This regret should be addressed specifically, especially in women aged less than 30 years. As nearly every sterilization is an elective procedure, the informed consent must be especially careful. Sterilizations performed just after the end of pregnancy (delivery or abortion) have a somewhat higher failure rate. Patients must therefore be informed of this.

Operation Planning

1. 
   

   Detailed history of the family status, information about the procedure and its consequences, and counseling with regard to alternatives

   
   
2. 
   

   Documentation of this information and counseling

   
   
3. 
   

   Exclusion of gynecologic problems and pathology

   
   
4. 
   

   Decision on and discussion of the technique

   
   
5. 
   

   Consent to the procedure

   
   
6. 
   

   Anesthesiologic preoperative investigations according to the local practice

   
   
7. 
   

   If appropriate, the procedure is planned in the first half of the cycle so that undiagnosed pregnancy can be ruled out with certainty

   
   
8. 
   

   Easy surgery; takes < 1 hour; surgeon and possibly one assistant

Anesthesia and Positioning

Special Instruments

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  Small laparotomy set

  
  
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  Small retractors for infraumbilical minilaparotomy