female sterilisation

46
FEMALE STERILISATION Labeeb Pc

Upload: labeeb-pc

Post on 11-Jul-2015

119 views

Category:

Education


2 download

TRANSCRIPT

Page 1: Female sterilisation

FEMALE STERILISATION

Labeeb Pc

Page 2: Female sterilisation

Topics discussed

• Timing of sterilisation

• Guidelines

• Surgical -

• Minilaparotomy

• Laparoscopic Sterilisation

• Vaginal tubal ligation

• Hysteroscopic sterilisation

• Complications

• Failure

• Reversal

Page 3: Female sterilisation

TIMING OF STERILISATION

1. Postpartum sterilisation

• After 24 hrs to 7 days of delivery

2. Interval sterilisation

• Non preg , >6 weeks, within 7 days of menses

3. Postabortal sterilisation

4. Caesarean sterilisation

• Laparoscopic tubal ligation –not recommended? when?

*tubes are vascular & oedematous , may get torn easily

Page 4: Female sterilisation

CASE SELECTION

• Females – 22 to 45 yrs (male – below 60y)

• Married

• Atleast one child , above one yr

• Sound state of mind

• Mentally ill patients - psychiatrist & legal guardian

Page 5: Female sterilisation

Delay procedure….

• Suspected pregnancy

• 7-42 days postpartum

• Active pelvic infection/ peritonitis

• PID within 3M

• STD

• Active liver/gall b disease

• Cerebrovascular/ CAD

• Complicated heart diseases

• Severe anemia

• Psychiatric disorder

• Multiple scars of prev laporotomies

Page 6: Female sterilisation

• Pregnancy conditions-

• Puerperial sepsis

• PROM >24 hrs

• Postpartum Psychosis

• Severe trauma to genital tract

• Recent septic abortion

• Severe post abortal hemorrhage

• Pre ecclampsia/ ecclampsia

Page 7: Female sterilisation

Special precautions..

• Past Cardiovascular disease

• c/c resp disease

• Hyperthyroidism

• Diabetes with vascular disease

• c/c liver disease

• Pelvic TB, endometriosis

• Obesity

• Coagulation disorders

Page 8: Female sterilisation

COUNSELLING

1. Permanency

2. Surgical procedure

3. Possible failure

4. Complications

5. Not protect against STD or HIV

6. Reversal is available ??

Page 9: Female sterilisation

CONSENT

• Not under coercion, sedation

• Signed berfore surgery

• Consent of spouse not required

Page 10: Female sterilisation

Minilaparotomy

Laparoscopic sterilisation

Vaginal tubal ligation

Hysteroscopic sterilisation

SURGICAL APPROACH

Page 11: Female sterilisation

MINI LAPAROTOMY

• Post partum, post abortal, or interval period.

• Interval sterilisation –

• Empty stomach , void urine

• Local anaesthesia

• Premedication – meperidine, promethazine

• Uterine manipulator

• 2-3cm transverse suprapubic incision, 2.5cm above.

Page 12: Female sterilisation

Post partum sterilisation

• local anaesthesia

• 2-3 cm subumbilical incision, 2cm below the fundus

• Tube identified by the fimbrial end

• Tubal ligation done using modified Pomeroy’s method /

clips or rings

• Kept for observation for 4 hrs,discharged

• Antibiotics & analgesics are given

Page 13: Female sterilisation

1. Pomeroy method

2. Parkland procedure

3. Madlener procedure

4. Fimbriectomy

5. Irwing technique

6. Uchida technique

7. Aldridge method

8. Shirodkar’s method

Page 14: Female sterilisation

POMEROY METHOD

• Babcock’s forceps

• Catgut suture

• Difficult in tubal adhesion

Page 15: Female sterilisation

• Babcock’s forceps

Page 16: Female sterilisation

PARKLAND PROCEDURE

Page 17: Female sterilisation

MADLENER PROCEDURE

• Crushed at base

• Ligated with silk

• Failure rate high

Page 18: Female sterilisation

FIMBRIECTOMY ( Kroener )

Failure rate high

Page 19: Female sterilisation

IRWING TECHNIQUE

• Catgut

• Proximal tube buried within

substance of myometrium.

• Distal end buried in

mesosalpinx

• Very low failure rate

Page 20: Female sterilisation

UCHIDA TECHNIQUE

• Saline with epinephrine

injected into subserosal

area of tube

• Medial stump buried in

mesosalpinx

• Lateral stump ligated , kept

outside mesosalpinx –

purse string suture

• Failure rate very low.

Page 21: Female sterilisation

ALDRIDGE METHOD

• Hole in ant leaf of broad ligament

• Fimbrial end buried into this.

• High failure rate

Page 22: Female sterilisation

SHIRODKAR’S METHOD

• Cut ends are turned in opposite directions,

so that spontaneous recanalisation does not occur

Page 23: Female sterilisation

COMPLICATIONS

• Anaesthetic hazards

• Bowel & bladder injury

• Broad ligament hematomas

• Infection

• Wound sepsis

• Peritonitis

Page 24: Female sterilisation

LAPAROSCOPIC STERILISATION

Advantages

• Direct visualisation & manipulation

• Associated pelvic & abdominal abnormality detected

• Hospitalisation not needed

• Cosmetic advantage

• Min postop pain & discomfort

• Reversibility more after clip application.

Page 25: Female sterilisation

Veress needle

Trocar & canula

Page 26: Female sterilisation

• Lithotomy position

• Local anaesthesia

• Bladder catheterised, uterine manipulator applied

• Trendendeleburg position ( head down 15o ) after placing

first trocar

• Entering abdominal cavity –

1. Veress needle

2. Direct trocar

3. Open laparoscopy

Page 27: Female sterilisation

VERESS NEEDLE

Page 28: Female sterilisation

OPEN LAPAROSCOPY

Page 29: Female sterilisation

METHODS

1. Rings

2. Clips

3. Electrocoagulation

Page 30: Female sterilisation

RINGS

• Falope ring – silicone

rubber with barium

sulphate

Page 31: Female sterilisation
Page 32: Female sterilisation
Page 33: Female sterilisation

CLIPS

• Filshie clip

• Silicone

• Better

• Hulka Clemens clip

• Spring loaded

Page 34: Female sterilisation
Page 35: Female sterilisation
Page 36: Female sterilisation

ELECTRO COAGULATION

• Unipolar& Bipolar cautery

• Reversal difficult

Page 37: Female sterilisation

COMPLICATIONS

• Anaesthetic complications

• Injury of large vessels

• Bleeding from epigastric vessels – trocar

• Tearing of mesosalpinx & hemorrhage

• Bowel injury

• Thermal burns

• Surgical & Mediastinal emphysema

Page 38: Female sterilisation

CONTRA INDICATIONS

• Severe cardio pulmonary disease

• Prior abdominal surgery

• Postpartum sterilisation

• Extreme obesity, umbilical hernia

Laparoscopy best used for interval sterilisation or following abortion of less than 12 weeks.

Page 39: Female sterilisation

VAGINAL TUBAL LIGATION

• Colpotomy performed

• Complications – bowel injury, pelvic abscess

Page 40: Female sterilisation

HYSTEROSCOPIC STERILISATION

• Essure

• Buscopan & NSAID to prevent tubal spasm

• Fibrotic tissue reaction

• Backup contraception – 3M

• Then hysterosalpingogram to confirm occlusion

Page 41: Female sterilisation

SEQUELAE OF STERILISATION

1. Ectopic pregnancy

• Partial recanalisation, tuboperitoneal fistula

• More likely after 3 yrs

2. Post tubal ligation syndrome

• Abnormal bleeding, isolated ovarian syndrome

• Pain, cystic ovaries

3. Regret & Depression

Page 42: Female sterilisation

FAILURE

• Typical failure rate – 0.3%

Procedure Failure rate %

Irwing 0.1

Parkland 0.25

Laparoscopic rings & clips 0.2 - 0.3

Pomeroy’s 0.3

Madlener’s 2

Fimbriectomy 2 - 3

Page 43: Female sterilisation

• Due to –

• Recanalisation

• Incomplete division

• Incomplete occlusion

• Ligation of round ligaments in place of tubes

• Presence of early pregnancy

Page 44: Female sterilisation

REVERSAL

• Micro surgical anastomosis

• Depends upon –

• Type of procedure

• Length of tube remaining

• Associated conditions like endometriosis, post op adhesions

affecting infertility

Page 45: Female sterilisation
Page 46: Female sterilisation