Vaginal Tubal Ligation: The Ultimate Minimally Invasive Procedure and a Literature Review

Introduction

The first sterilization was reported by Lungren in 1880 (described in Burch), and was done during a cesarean section procedure. ¹ Sterilization though a vaginal incision was first reported by Burch in 1934. ¹ This then became a more popular method of sterilization in the 1940s through the 1970s, to be replaced later by laparoscopic procedures. The past decade has seen a movement to change gynecologic surgical procedures toward more minimally invasive operations. Vaginal sterilization is consistent with the concept of minimally invasive tubal sterilization.

Method

Women who desire interval sterilization are selected for this procedure if they have had good uterine vaginal mobility with cervical traction and no histories of vaginal reconstruction procedures with extensive surgical repairs. The uterus should be of a normal size and mobile, and there should be no cul de sac diseases or adhesions. The patient receives a broad-spectrum antibiotic, such as Keflex, intravenously before the surgery begins. The patient is generally given general anesthesia, and the perineum and vagina are prepared and draped for vaginal surgery. The posterior lip of the cervix is grasped with a tenaculum and elevated, and a Kocher forceps is used to clamp the vagina below the cervix. A rectal examination is done to be certain the rectum has not been inadvertently clamped. A posterior colpotomy incision is then cut on the clamped tissue with a Mayo Scissors, and the cul de sac is entered. The incision is extended on each side to develop a 3–4-cm entry hole. The cervix is then pushed anteriorly under the synphysis with the tenaculum. The posterior side of the uterus is then visualized and is lifted up to the fundus with towel clips. The fundus is then brought through the colpotomy incision, so that the Fallopian tubes become visible. Each tube is then individually grasped with a Babcock clamp and moved to where the fimbriated end is visible (Fig. 1). The ovary may also be visualized during this step. The tube is then grasped in the middle and pulled so a loop is formed and an excision is then done. Possible tubal procedures that have been reported include the Pomeroy, Madelener, and Kroener. ² The excised tube section is then sent for pathologic analysis.

OPEN IN VIEWER

FIG. 1.

In this vaginal sterilization the top Babcock forcep is pulling the tube into the vagina, where a Pomeroy tubal sterilization can be done.

The uterus is inspected for hemostasis and pushed back through the colpotomy incision into the abdomen. The two layers of the colpotomy incision (vaginal mucosa rectovaginal fascia and peritoneum) are secured with a running locked 2-0 Vicryl suture and hemostasis results.

Patients who undergo this procedure, in the author's experience, usually have minimal discomfort postoperatively. They go home on the same day with mild oral analgesia and are told to have pelvic rest for 3 weeks, when they are then seen postoperatively.

Results

The chronology of reports of vaginal sterilization procedures are listed in Table 1.^3–18 These many reports demonstrate a low morbidity rate and a low failure rate. As seen by the current author, the women usually go home the day of surgery and need minimal analgesic medication. The results of the current author are also shown in Table 1; they are consistent with the literature experience, except that 2 women were kept overnight with nausea and ileus (morbidity 6.6%). The mean operating time was 38.5 minutes.

Discussion

The use of the vaginal approach for interval female sterilization has a long history. In 1934 Burch reported his experience with this operation done through the posterior cul de sac. ¹ Subsequently, many reports^3–18 have appeared, with data to support this operative approach for female interval sterilization. The advantages are no visible abdominal scars; short periods of anesthesia; short operating, hospital, and recovery times; low morbidity; and high success rates. This procedure can be considered with other minimally invasive procedures for tubal sterilization, such as laparoscopy and hysteroscopy.

Conclusions

Currently “minimally invasive surgery” is emphasized in gynecology. Vaginal interval sterilization should be considered as an ideal type of procedure that fits into this paradigm.