TUBECTOMY AND

VASECTOMY
Dr. Maimuna Tabassum
STERILISATION
Definition
Sterilisation is a procedure which destroys the
procreative function, and the effect is usually
permanent.
The term sterilisation is generally restricted to those
cases in which destruction of reproductive function is
the primary purpose of the treatment.

Ref:Jeffcoate’s Gynecology
Indications
Population Control
Family limitation
Medical indications : Permanent Ill Health of the
Potential Mother.
Permanent Ill Health of the Potential Father
Diseases and Genetic Faults Transmissible to the Foetus
Previous Obstetrical Complications and Operations
High parity
Nonspecific methods which cause sterilisation are:

Hysterectomy.
Bilateral salpingectomy.
Oophorectomy.

All these have an incidental sterilising effect, but the term

sterilisation is generally restricted to those cases in which
destruction of reproductive function is the primary purpose
of the treatment.
FEMALE STERILISATION BY TUBAL
LIGATION/OCCLUSION
Types :
Puerperal sterilisation/ postabortal
Non puerperal / Interval sterilisation

Puerperal sterilisation: sterilisation process performed in

conjunction with cesarean delivery or soon after vaginal
delivery.

Interval sterilisation: Done at times unrelated to pregnancy

William’s Gynaecology
Methods of sterilisation
1.Abdominal - 1.Laparotomy
2.Minilaparotomy
3.Laparoscopic – Mostly used during
interval sterilisation.

2. Vaginal - via anterior/posterior pouch/culdoscopic.

3.Transcervical - occlusion by chemicals.
Timing of sterilisation:
Ref: NFP, MoHFW India
Eligibility of Providers to Perform
Sterilization procedure
Eligibility Criteria for Case Selection
Clients should be ever married.
Female - 22 - 49 years.
Male – 22- 60 years.
The couple should have at least one child, whose age is above
one year unless the sterilization is medically indicated.
Clients or their spouses/partners must not have undergone
sterilization in the past.
Sound state of mind so as to understand the full implications
of sterilization.
Mentally challenged clients must be certified by a psychiatrist.
Preoperative evaluation:

HISTORY –
Menstrual History – especially date of last menstrual
period (LMP)
Obstetric history
Contraceptive History - when and what was the last
contraceptive used. If discontinued, when and why.
Medical History
PHYSICAL EXAMINATION
General Examination
Abdominal Examination
Pelvic Examination
Speculum Examination
Bimanual Pelvic Examination–Rule out PID
Laboratory Examination
Haemoglobin
Urine examination for sugar and albumin
Pregnancy test
“Haemoglobin <7 gm/ dl should not be accepted for
sterilization and referred to higher centres for
management.”

Ref: NFP, MoHFW India

Consent/Risk counselling:
1. Consent of Patient. In practice, in the case of a
married couple it is wise but not essential to obtain
the consent of the spouse also.
2. Possibility of failure of operation.
3. Counsel her that the operation is intended to be
permanent & may not be reversible.
4. The existence of alternatives like LARC, vasectomy are
to be explained.
5. Risk of ectopic pregnancy.
6. All risks of surgery however remote they are.
7. No effect on sexual activity.
8. No protection against RTI/STI
9. Reversal is possible but not sure.

“Documented consent is necessary.”

Anaesthesia
Mini laparotomy - local / regional anaesthesia.
Vaginal route – regional anaesthesia.
Laparoscopic route – general anaesthesia.
SURGICAL APPROACH
Minilaparotomy
 Interval :
• 2-3 cm midline vertical or transverse suprapubic incision.
• Small handheld retractors & Trendelenburg position
enhances the exposure.
• Uterine elevators are used to bring fallopian tubes in the
field.
 Postpartum:
• 2-3 cm subumbilical vertical or semicircular incision made
in the midline.
Techniques of sterilisation:
MODIFIED POMEROY’S TECHNIQUE:
Tube grasped at the midportion with Babcock & loop of
tube is elevated.

It is important to follow the tube distally to its fimbriated

end to ensure that it is the fallopian tube and not the
round ligament.

Base of the loop is ligated with no.1 plain catgut.

2-3 cm of the tube in the ligated loop is resected.

The excised tube should be appropriately labelled and sent to
the pathology laboratory for histological documentation.
Advantages:
Simple to perform, and is highly-effective.
Minimises the bleeding by compressing & sealing the
mesosalpinx before tubal resection.
It can be performed abdominally, vaginally, or
laparoscopically.
Complications are minimal.
PARKLAND
1. Identify an avascular section of the mesosalpinx.
2.A window is created in this region , below the tube,
with Metzenbaum scissors or a hemostat while elevating
the tube with Babcock clamps.
3.By opening the hemostat or scissors within the window
it can be stretched in parallel with the tubal lumen.
4.Rapidly absorbable (0 chromic or plain gut) sutures
placed proximally and distally.

5.The segment between the suture ligatures is then

excised.
THE MADLENER TECHNIQUE

A loop of the ampullary portion of the A strand of nonabsorbable suture

tube is elevated and then both segments material is used to ligate the tube over
are crushed with a hemostat. the crushed area. No tissue is excised.
The devascularized loop of tube undergoes aseptic
necrosis.
This technique is abandoned due to high failure rates.
IRVING TECHNIQUE

The tube is divided in the region of Using blunt dissection, a tunnel is made
the ampullary–isthmic junction, within the substance of the uterine
and the ends of the suture are kept myometrium and the proximal tube is
long for traction and for use in the pulled into this chamber and sutured in
subsequent steps of the procedure. place.
The distal tube is then buried within the
substance of the broad ligament.
THE UCHIDA TECHNIQUE

The serosa is then incised with the

A subserosal injection of a scissors, exposing the muscular layer of
saline-epinephrine solution the tube. A segment of the muscular layer
is made in the region of the is elevated while the serosa is
tubal ampulla. simultaneously stripped back over the
proximal and distal segments.
The proximal portion of the A purse-string suture is placed
muscular tube is ligated and around the distal tube and tied.
excised. The proximal ligated
segment then drops back beneath
the serosa
THE ALDRIDGE TECHNIQUE

• The fimbrial end of the

fallopian tube is drawn into
a pocket beneath the
peritoneum of the broad
ligament.

• The buried fimbrial end is

then secured in place by
several sutures of
nonabsorbable suture
material.
THE KROENER FIMBRIECTOMY

• Described by Kroener.

• Ligation of the distal ampulla of the

tube with two permanent sutures
and then division and removal of
the infundibulum of the tube
Laparoscopic Sterilisation ( GA)
Pneumoperitoneum should be
created with veress needle.

Insufflation of abdomen
should be done preferably
with carbon dioxide

Intraabdominal
pressure should not exceed 15
mm of mercury.
The uterus and tubes are manipulated into
convenient positions by a uterine elevator
through the cervix or by a probe from above.

A portion of each tube, with its inner margin 1-

2 cm from the cornu of the uterus, is
coagulated with diathermy and divided, or clips
or rings applied

After applying the second ring, systematically

inspect the pelvis to verify that both tubes are
occluded, there is no unusual bleeding and that
there is no visceral injury.
 Silicone rubber
bands
Isthmic portion
of the tube is held
with grasping tong
about 3cm from
the uterus.
Hulka /Spring clip
Advantage :
Only 3mm of the
tube is
compressed by
the clip.
Filshie clip
It has titanium jaws
with silicone rubber.

It has a hinge on one

end & a small curve
on the other.
The precautions to be taken while applying Falope rings:

• Draw the tube slowly and smoothly into the sleeve of the
laparoscope after proper identification.

• To prevent injury to the mesosalpinx/tube, avoid pulling

up or back on the laparocator.

• Do not apply the rings in case of thick, oedematous or

fixed tubes.

• In such cases, tubectomy should be done with

laparotomy under GA by conventional method.
Other methods of tubal occlusion:

Unipolar coagulation:
3-5 cm of the tube can be destroyed with a single burn.

Disadvantage: Thermal injuries to abdominal viscera –

capacitive coupling.
Delayed necrosis.
Peritonitis.
Bipolar coagulation
Current flows from one jaw of the grasper to the
other.
Advantages:
Capacitive coupling doesn’t occur.
Reduced risk of tuboperitoneal fistula.
Chemical occlusion
 Obstructing the lumina of the tubes along their length
by liquid non-irritant materials or injecting chemical
irritants to produce aseptic endosalpingitis.

 Chemicals like methyl cyanoacrylate and quinine have

been used to destroy the cornual end.

 Quinacrine , 252 mg pellet is inserted postmenstrually

through a modified intrauterine contraceptive device
inserter and the insertion is usually repeated in the next
cycle.
 ESSURE:

The device is inserted transcervically via hysteroscopy .

It is available as a part of disposable system which includes;
Microinsert 4cm length;0.8 mm diameter.
Delivery system
Split introducer
Microinsert contains stainless steel inner coil, nickel titanium
alloy outer coil & a layer of PET fibres
(polyethylene terephthalate)
Inflammatory
& fibrotic
response to
the PET fibres.

A HSG must be
performed 3
months
postinsertion
to assure
complete
bilateral tubal
occlusion.
Post-operative and Follow-up
Instructions
In the case of interval sterilization she may have
intercourse one week after surgery or whenever she
feels comfortable thereafter.

In case of post partum sterilization (after caesarean

or normal delivery) she may have intercourse 2 weeks
after sterilization or whenever she feels comfortable.

Report to clinic in case of missed periods.

COMPLICATIONS
Intra-operative complications Post-operative Complications

Injury to round ligament /faulty Wound sepsis

application

Anaesthesia complications Haematoma in the abdominal wall

Gas/ Air Embolism/Mortality Intestinal obstruction

Uterine perforation due to manipulator Paralytic ileus /Peritonitis

Bleeding from the meso-salpinx Tetanus/Incisional hernia

Injury to the urinary bladder/viscera Failure of procedure- pregnancy

Post tubal ligation syndrome
 Perception that menstrual disturbances could result
from tubal sterilisation.
Failure rate
• The incidence of failure is less than one pregnancy per
100 women over the first year after having the
sterilization procedure (5 per 1000).
MALE STERILISATION
Conventional Vasectomy
Two or with one incision on the midline.
The length of each incision should not be more than 2
cm.
The mid-scrotal part of the vas should be removed.
Not more than 1.0 cm in length of vas is removed.
Removal of the excess vas may make a subsequent re-
canalization operation difficult.
Ligate at two points about 1.5 cm apart using 2-0 silk.
Fascial interposition is recommended (optional).
The skin incision should be closed with non-absorbable
sutures after ensuring complete haemostasis.
 No-Scalpel Vasectomy (NSV)

The basic difference between the NSV procedure and the

conventional technique is in the surgical approach to the
vas, which is through a small puncture in the scrotum
rather than by a cut with a scalpel.
Advantages
NSV is less invasive than the conventional
technique, causes fewer complications and takes
much less time.
NSV is to be performed under local anaesthesia.
Procedure
Fixation, Puncture and
Delivery of Vas:
The vas is fixed in the midline
at the junction of its upper
one-third and lower two-
third by a vas fixation forceps.

The skin of the scrotum, is

then punctured at this site
and vas is then delivered out
of wound in one motion.
Excision and Ligation of Vas:
 About 1 cm length of the bare vas should be excised
and ligated with 2-0 black silk
Delivery of the Opposite Vas:
 The opposite vas must be fixed, delivered, excised
and ligated through the same puncture hole.
Fascial Interposition:
 Places a tissue barrier between the two cut ends of
the vas.
 It should be performed on both the sides.
 This step may reduce the failure rates.
Dressing the Wounds
Scrotal Support

Follow up :

• He should report to the clinic for

semen examination three months
after the surgery.

• Barrier contraceptives are used for

3 months.
 “VISION FP
• In 2012 the2020”
‘London Summit on Family Planning’ was
held to bring back the focus on family planning globally.

• India committed to spend $2 billion by 2020 for

family planning program.
• In 2014,India has renewed its commitment and now
promises that it will invest $3 billion by 2020.
• The goal is to Ensure access to family planning
services to 48 million (4.8 Crore)
additional women by 2020.
Goals
Increasing access to contraceptives through
distribution of contraceptives at the doorstep of
beneficiary through community health workers
Ensuring healthy birth spacing by augmenting the
focus on spacing methods.
Strengthening the sterilization services through
quality service delivery and demand generation

Ref: NHM,FP 2020

Under the ‘Vision FP2020’, The government has
encouraged the districts to ensure the availability of NSV
services in their facilities on fixed day basis.

FP2020 initiatives emphasize on providing minilap

sterilization services in high delivery case load facilities.