M. Chantel Long, M.D.July 22, 2011

Tubal LigationSurgical sterilization is the most popular

form of contraception in the U.S. (includes tubal ligation and vasectomies)

Female sterilization is chosen by about 28% of couples

Can be performed at any time, but half of them are performed in conjunction with a cesarean or vaginal delivery

Puerperal Tubal SterilizationSince oviducts are easily accessible

at the umbilicus for days after delivery, is considered technically simple and doesn’t prolong hospitalization

Some physicians prefer to wait 12-24 hours after delivery

Tie the TubesThe first tubal was performed over 120

years agoConsisted of a silk suture placed around

the tubes one inch distal from the uterine attachment at the time of a C-Section

This led to many different techniques to disrupt tubal patency

Irving ProcedureMost difficultLeast likely to failThe cut oviduct is separated from the

mesosalpinx to free a medial segment.Then, the medial cut end is buried in the

myometrium posteriorly and the distal cut end is buried in the mesosalpinx

Pomeroy ProcedureSimplest methodPlain catgut is used to ligate the knuckle of

the tubeThis ensures prompt absorption and

separation of the severed tubal endsEctopic pregnancy can occur in the distal

segmentSuture slippage is a concern

Parkland ProcedureSimilar to the Pomeroy but avoids the

intimate approximation of the cut ends of the oviduct

The avascular mesosalpinx is opened with blunt dissection

A 2cm segment is ligated with O-Chromic and excised between the sutures

Risks and BenefitsFailure rate is less than 1/400 for the last 4

decades and is now close to 3-12/1000Electrocautery destroys more tissue and makes

reversal less possiblePuerperal sterilization fails for two major reasons:

Surgical Error: ligation of the round ligament or only partial transection of the oviduct

Formation of a fistulous tract between the severed stumps or spontaneous reanastomosis

RisksAnesthesia ComplicationsInjury to adjacent structuresFailure (with subsequent intrauterine or

ectopic pregnancy)Case Fatality rate is 1.5/100,000Complication rate is 1/100

Failure RatesSurgical error accounts for 30-50% of casesFailures after one year are not likely due to

technical errorsFistula formation (peurperal), faulty clips

(interval)Luteal Phase Pregnancy – With interval

tubals, woman is already pregnant at the time of surgery

EctopicHalf of pregnancies that follow a failed tubal

with electrocautery are ectopic versus 10% with ring, clip, or resection

ANY symptom of pregnancy in a woman after a tubal sterilization must be investigated and an ectopic must be ruled out

Posttubal Ligation SyndromeIncreased incidence of menorrhagia and

intermenstrual bleedingCurrent studies lean toward decreased

duration and volume of menstrual flow, less dysmenorrhea, yet increased irregularity

Talk to patients about their prior contraception

Factoids?Protects against ovarian cancerIncrease in functional ovarian cysts80% no change in sexual interestOf the 20% with a change, positive effects

were 10-15 times more likelyAt 5 years, 6-7% of women express regret

(same as women whose husbands had vasectomies)

ReversalNo woman should undergo sterilization

believing it can be reversedDifficult, expensive, and unsuccessfulRates vary based on method, tube length,

age, fimbriectomy, etcAlmost 10% of women who undergo reversal

have an ectopic pregnancy

Nonpuerperal (Interval) TubalLigation and resection at laparotomy Application of permanent rings, clips, or

electrocautery to the fallopian tubes via laparoscopy with or without transection

Electrocoagulation of a segment of the tubes, usually through a laparascope or via vagina (hysteroscopy)

DisadvantagesLaparascopic tubal ligation is under general

anesthesia with endotracheal intubationDisrupts breastfeedingTechnically more difficult

IntratubalChemicals – silicone, erythromycin,

quinacrineDevices – Essure microinsert (stainless steel

inner coil with expandable outer coil of nitinol; outer coil expands after placement, tissue grows, occlusion occurs) is costly; requires HSG at 3 months to ensure tubal blockage

Consent and RestrictionsFemale (male)Insurance Guidelines (Medical Card)

SurgerySmall infraumbilical incision is made through

the skin (between two alices pulled taut)Bluntly dissect with a kelly to the fasciaLift and open the fascia with mayo scissors

between two kellys (I keep the kelly on the fascia)Open the peritoneum, again between two

kellys; check for bowelPlace army/navyRotate/tilt the patient and identify the oviduct

Surgery Cont’dCan put a kelly on a mini-lap and push into

abdominal cavity and upward with pick-ups for better visualization

Grasp with a babcock and “walk” to the distal end to visualize the fimbriae and ovary (to be sure you don’t have the round ligament, which is smoother, less vascular, and more taut)

If you drop the oviduct, start overSuture is placed times two (with one tagged), the

oviduct resected, and segments are sent for pathology

Surgery Cont’dElectrocauteryInspect each end for hemostasisClose fascia and skin

ConclusionsA thorough discussion of the risks, benefits,

and alternatives to permanent sterilization should take place for informed consent

Is safe (complication rate <1% and failure rate approx. 5/1000)

Pregnancy after tubal ligation is more likely to be ectopic

Procedure should be considered permanent

Conclusions, Cont’dLaparoscopic and minilaparotomy have

comparable safety and efficacySexual desire and menses overall not affectedLess likely to develop ovarian cancer and PIDWomen with preexisting gyn conditions

(menorrhagia, irregularity) may be better served by hormonal contraception

LEEP

DefinitionLoop Electrosurgical Excision ProcedureThe electric arc does the cutting not the loop itselfThe high density current vaporized the tissue,

exploding cell releases steam which forms a steam envelope that prevents contact between the electrode and the tissue, ionization of the steam in the electric field forms an arc which cuts the tissue

Since the arc does the cutting, placing the electrode in direct contact with the tissue reduces the power density and causes dessication

DessicationDessication interrupts the continuous

current, which collapses the steam envelopeYou can also cause this to happen by forcing

the loop to move faster than the arc can cut (the loop drags through the tissue, bends, changes shape of the specimen and can get “stuck”)

Dessication damages the specimen causing cautery artifact that makes pathological interpretation more difficult

Treatment OptionsAblation = Cryotherapy or Laser with

Destruction of the transformation zoneExcision = LEEP or Cold Knife Conization

with Removal of the transformation zoneObservation:

CIN1CIN2,3 in adolescents and youngCytology/Histology Discrepancy

LEEPAdult Women

CIN 2,3HSIL

Adolescent/Young WomenCIN 3CIN 2,3 that persists for > 2 years CIN 2 with unsatisfactory colposcopy

CIN 3 Any Age

CIN 2 in women >30 usually persists or worsens

CIN 2 in women <25 usually regressesCryotherapy can lead to cervical stenosis and

secondary unsatisfactory colposcopies

LEEPTwo classes of Loop Electrosurgical Excision

ProcedureRoutine

7-8 mm in depth Single Pass For lesions confined to ectocervix

LOOP Conization LEEP with Top Hat (Second pass into endocervical

canal) Used when lesions extend into the canal 1x1 cm loop

Indications for Routine LEEPCIN 2,3 (Biopsy Confirmed)Satisfactory ColposcopyPatient prefers over ablative therapiesRecurrent CIN after prior therapy (because

they automatically have an unsatisfactory colposcopy)

Can not treat the entire lesion with the cryo gun (size, geographic)

When “see and treat” is advantageous

Indications for LEEP ConeCIN 2,3 with unsatisfactory colposcopyHSIL Pap with unsatisfactory colposcopy CIN 2,3 with positive ECC (neoplasia of any grade

present) Some observe if felt the positive ECC is contamination

from ectocervical lesion Some observe if CIN1 on ECC and pap is only ASCUS

or LSIL

Once they have had cryotherapy or an unsatisfactory coloposcopy with an abnormal pap they need to proceed to LEEP

Advantages of LEEPOffice ProcedureMinimal Pain (from local anesthetic and

reflexive cramping)Easy to learn and performEquipment is simple to maintainEntire TZ is assessed histologically to rule

out cancer!

LEEP CounselingCervical Stenosis

Occurs in 1-6%Bleeding

Immediate post-procedure bleeding Ball Cautery (Avoid cauterizing near the os) Monsel’s Suture

Premature Delivery

LEEP CounselingVaginal Wall Burns and Lacerations

Risk lessened with insulated vaginal sidewall retractors

Recurrence or Persistence of Disease5-15%

6 year risk of CIN 2 or 3 after LEEP with clear marginsCIN 2: 3.6-4.3%CIN 3: 8.6-13.6%

Obstetric Outcomes after LEEPIncrease in:

Late preterm births (>32 weeks)pPROMLow birth weight infants

No increase in:Preterm births <32 weeksC/SNICU admissionsPerinatal Mortality

ContraindicationsSuspected Invasive CancerAIS or Squamous Cell Cancer (can have skip

lesions; need excisional procedure that shows clear margins without thermal artifact to exclude invasion and to determine if she needs simple or radical hysterectomy)

Cervicitis (Treat it first, because they bleed with procedures; check wet mount, KOH, GC testing for causes of trich, yeast, GC)

PregnancyPermanent PacemakerAllergy to local anestheticOral Anticoagulants or Hemorrhagic Disorder

Follow-UpWait 6 months after a LEEP to get pregnantPap at 6 and 12 months then yearly (can add HPV

testing if desired; because a negative HPV is highly predictive for treatment success, but note that testing is not type-specific so a positive could be new infection and not persistant/recurrence)

Annual paps for 20 yearsIf any paps are abnormal or positive HPV, then

colposcopy (to rule out persistence or progression)

Most recurrences are found within 24 months

General Principles of TreatmentTreat the entire Transformation Zone

CIN almost always starts in the TZCIN is almost always in contact with the

original squamous epitheliumMost advanced area of lesion usually is most

centralMultifocal or “skip” CIN lesions very rare

Exception is glandular lesionsNormal mature squamous epithelium is

resistant to the development of CIN

CIN: Endocervical Gland InvolvementAll grades of CIN may invade endocervical

glandsDeep involvement more likely in higher grade

Depth of crypt involvement in CIN3<3mm in 95.9%<4mm in 98.2%<5mm in 99.1%<6mm in 100%

Treat at least 5-7 mm in depth throughout

CryotherapyIndication is CIN2,3 with satisfactory colpo and

LEEP unavailableExcision preferred because identifies

unsuspected cancersRepeat diagnosis of CIN2,3 in first 6 years after

treatmentIs higher after cryotherapy than other modalities

of treatmentRisk of invasive cancer within 10 years after

treatmentHigher after cryotherapy

LEEP ProcedurePotocky NeedleInsulated SpeculumInsulated Vaginal Wall RetractorSmoke EvacuatorRemove jewelry and underwire bras

Day BeforeHistory and PhysicalFavors the OR

Co-morbidities needing anesthesia monitoringPacemaker or DefibrillatorAnatomical limitations

Narrow Vagina, Vaginismus, Cervix flush with vault

Favors the OfficeAlmost Everyone

Patient PreparationRisks and BenefitsNSAIDSTime it one week after menses (avoid menses

to decrease cramping and pain)No lifting (children), exercise and NPV for

one monthDiscourage travel

Informed ConsentAlternativesBleeding (2-8% first week post-op)CervicitisInjury to adjacent organs (vagina)Cervical Stenosis

Multiple LEEPsAmenorrheic Women

Minor Consent (Parental Consent)Expect malodorous discharge

Set UpDispersive PadLoop ElectrodesBall Electrodes (control bleeding, reduce residual

disease by destroying edge)Speculum with smoke evacuatorColposcopeAcetic Acid and Lugol’sTexas SwabsLocal Anesthetic (6-8cc)Syringe and Needle (25-30 gauge to decrease

bleeding)Monsel’sNeedle Holder and Suture

Remove all jewelry and wireThicker, larger loops require more current,

which is harder to containLess resistance with closer padPad needs to be flat and evenly dispersedInspect your Speculum!Try not to dessicate with ball electrode

AnestheticSubmucosal Injection, not a paracervical

blockPotocky needle – ensures anesthesia will not

be infiltrated too deeply, more expensive, infiltrates at 6mm

Infiltrate 1cc at 3,6,9,12 o’clockInfiltrate 1/2cc at 2,4,8,10 o’clockRaise a wheel, don’t let it spray back, you’ll

see blanchingInject slowly

Anesthetic Cont’dCrampingAvoid intravascular injectionInject, then let it sit until it is completely dryThen apply lugol’sCan get more bleeding from the block than

the LEEP itself

Monsel’s vs. Ball CauteryMonsel’s

Shorter duration of bleedingPersistent bleeding risk is lowerEBL no different

BallTreats residual atypiaMore technicalAvoid Os and Dessication

PearlsKeep vagina out of the way!IUD?Activate blend mode prior to touching tissue

to “cut”Go slowly (take 5-10 seconds); to prevent

dessication and getting “stuck”Orient specimen for the pathologistSee them back in 2 weeks

Post-Procedure InstructionsCramping for several hoursHeavy, brown, malodorous discharge and

spotting for 2-6 weeksNPV 4 weeksAvoid strenuous activity (even though they

will feel fine)Report fever >101, severe pain, bleeding

heavier than a period

Case 122 y.o. G0 HSIL, Satis. Colpo, CIN 2 = Pap

and colpo again in 6 months (vs. cryotherapy, laser ablation, LEEP, conization). Treatment is acceptable, but observation is preferred, which requires a satisfactory colposcopy, pap and colpo every 6 months up to 24 months, return to annual when two normals; treatment required if CIN2 persists past 24 months, unsatisfactory colpo, or CIN 3 develops

Examples If margin positive, re-excise OR paps every 6-

12 monthsLEEP Cone with positive endocervical

margin, recheck pap with ECC in 4-6 months and if positive, repeat excision or offer cone/hysterectomy

HPV Positive, ASCUS pap = Colpo = CIN3 then LEEP (or cryo)Can only cryo if satisfactory colpo (i.e. the SCJ

is easily visualized and ECC is negative)

Case 233 yo G2P2 ASC-H, s/p tubal, satisfactory

colpo, CIN2, ECC (-)Tx = Cryo, laser, LEEP, or Cone

Management of CIN2 with observation is limited to young women when fertility is a concern.

Case 2 Cont’dGot cryo6 months later, pap WNL6 months later, pap ASCUS, unsatisfactory

colposcopy and CIN3, ECC insufficient and/or lesion extends into the canal = LOOP ConizationCancer within the canal can not be excluded

Case 338 yo HSIL, satisfactory colpo, AW lesion

extends to vagina, ECC (-), CIN3 = Laser Ablation (for vaginal extension or VaIN)

Case 427 yo G0 AGC-NOS pap; ECC and biopsy

show AIS = Conization

Hyst: For persistent or recurrent CIN2,3 and

excision is not possibleFor adenoCAFor AIS if fertility not an issue

Puerperal Tubal SterilizationSince oviducts are easily accessible at the

umbilicus for days after delivery, is considered technically simple and doesn’t prolong hospitalization

Some physicians prefer to wait 12-24 hours after delivery to be assured of no postpartum hemorrhage concerns and because the status of the newborn is better ascertained

Tie the TubesThe first tubal was performed over 120 years

agoConsisted of a silk suture placed around the

tubes one inch distal from the uterine attachment at the time of a C-Section

Ligation without tubal resection has a high failure rate

This led to many different techniques to disrupt tubal patency

Posttubal Ligation SyndromeIncreased incidence of menorrhagia and

intermenstrual bleedingHowever, a similar incidence has been

reported in women whose husbands had undergone vasectomy

Current studies lean toward decreased duration and volume of menstrual flow, less dysmenorrhea, yet increased irregularity

Talk to patients about their prior contraception