Surgical Techniques: Abdominal 18.104.22.168 Open Sterilization Operations
Aims and Methods
Reliable and definitive contraception is an important function of gynecology from the medical and sociocultural point of view. Of the many methods of contraception, surgical and permanent techniques will be described below. The decision not to have any (more) children is always a highly personal one. Medical indications for sterilization are extremely rare and must always be discussed precisely with the patient. Long-term but not final alternatives, which are almost as reliable, are now available. The importance of the “psychologic” or “theoretical” possibility of pregnancy should not be underestimated even in the presence of serious underlying disease or an objective physiologic near-impossibility of successful pregnancy. Although the patient′s wishes are crucial, this does not mean that her doctor should not advise her. It is known that very young women in particular regret sterilization relatively often after supposedly completing their families. The aim of each technique is permanent and safe prevention of further pregnancies with few side effects. The standard procedure is laparoscopic tubal ligation. Open techniques can also be employed as part of cesarean section. Besides laparoscopic sterilization techniques, immediate postpartum partial salpingectomy through an infraumbilical minilaparotomy has also become an accepted technique.
Indications and Contraindications
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.
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:
“Forever”: sterilization is permanent and is practically irreversible.
“Not 100%”: sterilization is the safest method of contraception long-term, but pregnancy can occur at any time.
“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.
Detailed history of the family status, information about the procedure and its consequences, and counseling with regard to alternatives
Documentation of this information and counseling
Exclusion of gynecologic problems and pathology
Decision on and discussion of the technique
Consent to the procedure
Anesthesiologic preoperative investigations according to the local practice
If appropriate, the procedure is planned in the first half of the cycle so that undiagnosed pregnancy can be ruled out with certainty
Easy surgery; takes < 1 hour; surgeon and possibly one assistant
Anesthesia and Positioning
Small laparotomy set
Small retractors for infraumbilical minilaparotomy