For several days postpartum, the uterine fundus lies at the level of the umbilicus, and fallopian tubes are accessible directly beneath the abdominal wall. Moreover, abdominal laxity allows easy repositioning of the incision over each uterine cornu.
On our service, puerperal tubal ligation is performed by a surgical team dedicated to this role the morning after delivery. This timing minimizes hospital stay but lowers the likelihood that postpartum hemorrhage would complicate recovery following surgery. In addition, the status of the newborn can be better ascertained before surgery. In contrast, some prefer to perform sterilization immediately following delivery and use neuraxial analgesia already placed for labor. In this model, barriers to sterilization can be lessened by designating these postpartum surgeries as urgent, especially in high-volume labor and delivery units, which usually prioritize limited operating-room availability for intrapartum procedures (American College of Obstetricians and Gynecologists, 2016; Potter, 2013).
Various techniques are now used to disrupt tubal patency. In general, a midtubal segment of fallopian tube is excised, and the severed ends seal by fibrosis and peritoneal regrowth. Commonly used methods of puerperal sterilization include the Parkland, Pomeroy, and modified Pomeroy techniques (American College of Obstetricians and Gynecologists, 2017a). Less often, Filshie clips are used (Madari, 2011). Irving and Uchida techniques or Kroener fimbriectomy are rarely used because of their increased required dissection or unfavorably high failure rates. Also, in the absence of uterine or other pelvic disease, hysterectomy solely for sterilization at the time of cesarean delivery, early in the puerperium, or even remote from pregnancy is difficult to justify. It carries significantly increased surgical morbidity compared with tubal sterilization.
Evidence suggests that the fallopian tube may be the origin of pelvic serous carcinomas, especially those of the ovary. With this knowledge, the Society of Gynecologic Oncologists (2013) and American College of Obstetricians and Gynecologists (2017b) recommend consideration of salpingectomy to lower cancer risks. Specifically, for women at average risk of ovarian cancer, risk-reducing salpingectomy should be discussed and considered with patients at the time of abdominal or pelvic surgery, at hysterectomy, or in lieu of tubal ligation.
Spinal analgesia is typically selected for cases scheduled for the first postpartum day. If done more proximate to delivery, the same epidural catheter used for labor analgesia can be used for sterilization analgesia. Notably, for those with preeclampsia, HELLP (hemolysis, elevated liver enzyme levels, low platelet count) syndrome, or gestational thrombocytopenia, platelet levels should be >100,000 for spinal blockade (Chap. 25, Contraindications). General anesthesia may be less desirable due to residual pregnancy-related airway vulnerabilities (Bucklin, 2003). The bladder is emptied before surgery to avoid its laceration. A full bladder can also push the fundus above the umbilicus.
A small infraumbilical incision is ideal for several reasons. As noted, the fundus in most cases lies near the umbilicus. Second, the umbilicus usually remains the thinnest portion of the anterior abdominal wall and requires less subcutaneous dissection to reach the linea alba fascia. Third, an infraumbilical incision offers fascia with sufficient integrity to provide a closure that has minimal risk for later incisional hernia. Last, incisions that follow the natural curve of the lower umbilical skin fold yield suitable cosmesis. A 2- to 4-cm transverse or vertical skin incision is usually sufficient for normal-weight women. For obese women, a 4- to 6-cm incision may be needed for adequate abdominal access.
Beneath this incision, the subcutaneous tissue is bluntly separated to reach the linea alba fascia. For this, an Allis clamp can be opened and closed as downward pressure is exerted. Similarly, the blades of two army-navy retractors both pulling in downward yet opposite directions can part the subcutaneous layer. Clearing this fatty tissue away from the fascia isolates the fascia for incision and for later closure without intervening fat, which may impede wound healing.
The fascial incision may be transverse or vertical and follows the same orientation of the skin incision. For this, once the linea alba is reached, it is grasped with two Allis clamps—one placed on either side of the planned fascial incision. The purchase of tissue with each clamp should be substantial and creates a small roll of fascia to be incised. Often, the peritoneum is incorporated simultaneously and entered. If not, the peritoneum is grasped with two hemostats and sharply cut. Others may prefer to bluntly enter with a single index finger. Notably, if the initial fascial incision is too small, it can be extended with curved Mayo scissors.
Adequate exposure is critical, and army-navy or appendiceal retractors are suitable. For obese women, a slightly larger incision and narrow deeper retractors may be required. If bowel or omentum is obstructing, Trendelenburg position can help displace these cephalad. Digitally packing with a single, moist, fanned-out piece of surgical gauze can also be used, but a hemostat should always be attached to the distal end to avert its retention. At times, tilting the entire table to the opposite side of the tube being exposed assists tube isolation.
The fallopian tube is identified and grasped at its midportion with a Babcock clamp, and the distal fimbria confirmed. This prevents confusing the round ligament with the midportion of the tube. A common reason for sterilization failure is ligation of the wrong structure, typically the round ligament. Therefore, identification and isolation of the distal tube prior to ligation is necessary. Whenever the tube is inadvertently dropped, it is mandatory to repeat this identification process. Surgical steps for ligation are outlined in Figures 39-1 and 39-2.
Parkland method. A. An avascular site in the mesosalpinx adjacent to the fallopian tube is perforated with a small hemostat. The jaws are opened to separate the fallopian tube from the adjacent mesosalpinx for approximately 2.5 cm. B. The freed fallopian tube is ligated proximally and distally with 0‑chromic suture. The intervening segment of approximately 2 cm is excised, and the excision site is inspected for hemostasis. This method was designed to avoid the initial intimate proximity of the cut ends of the fallopian tube inherent with the Pomeroy procedure. (Reproduced with permission from Hoffman BL, Corton MM: Surgeries for benign gynecologic conditions. In Hoffman BL, Schorge JO, Bradshaw KD, et al: Williams Gynecology, 3rd ed. New York, McGraw-Hill Education, 2016.)
Pomeroy method. During ligation of a midsegment tubal loop, plain catgut is used to ensure prompt absorption of the ligature and subsequent separation of the severed tubal ends. (Reproduced with permission from Hoffman BL, Corton MM: Surgeries for benign gynecologic conditions. In Hoffman BL, Schorge JO, Bradshaw KD, et al: Williams Gynecology, 3rd ed. New York, McGraw-Hill Education, 2016.)
Steps of salpingectomy are shown in Figure 39-3. The umbilical incision generally will need to be larger to allow an adequate view of the tube and mesosalpinx and to place clamps. With total salpingectomy, the entire mesosalpinx must be divided to free the fallopian tube.In two small cohorts undergoing salpingectomy after vaginal birth, surgical times were longer than for tubal occlusion, and in one report, blood loss was increased (Danis, 2016; Powell, 2017). With salpingectomy and cesarean delivery, total blood loss rates were not statistically higher (Powell, 2017; Shinar, 2017).
A. With salpingectomy, the mesosalpinx is sequentially clamped, cut, and ligated. B. At the cornu, clamps are placed across the fallopian tube and its adjacent mesosalpinx prior to tubal transection. (Reproduced with permission from Stuart GS: Puerperal sterilization. In Yeomans ER, Hoffman BL, Gilstrap, III, et al (eds): Cunningham and Gilstrap’s Operative Obstetrics, 3rd ed. New York, McGraw-Hill, 2017.)
After surgery, diet is given as tolerated. Ileus is infrequent and should prompt concern for bowel injury, albeit rare. Most women have an uncomplicated course and are discharged on the first postoperative day.