Tubal ligation

This should be the most common operation you do, and the most important one. It is chosen after careful consideration of the alternatives, so it must be as safe and as painless as it can be. Try not to keep a mother waiting too long for surgery, or she may become pregnant meanwhile!

Large numbers of mothers need their tubes tying, and if you take the trouble to encourage them, many will be willing to accept it. But however many ligations you do, you will probably be only able to satisfy a small fraction of the community's need. You can: (1) Tie a mother's tubes at the same time that you do a Caesarean section (18.9). (2) Do a ''minilap', which is a laparotomy through a very small incision. (3) Do a standard laparotomy[md]but this should seldom if ever be necessary. (4) Tie her tubes through a laparoscope, or a laprocator (15.4).

Tying a mother's tubes immediately after delivery has several advantages: (1) They are easier to get at when her uterus is still enlarged. (2) You already have her in hospital, whereas if you send her out and ask her to come back, she may never return. (3) Immediately after a normal delivery she will tolerate the minimal additional trauma of sterilization particularly well. (4) If you have already opened her abdomen for some other reason, such as Caesarean section, tying her tubes is easy. But there are some minor disadvantages in doing it at this time: (a) She is more likely to change her mind later. (b) You have little time to examine the baby and exclude any abnormality before you tie them.

Local anaesthesia has many advantages, and if you follow the methods described here carefully, complications should be few and easily managed. Finding a tube and bringing it painlessly up into a small incision needs gentleness, skill, and practice. Carefully trained theatre sisters and assistants can tie tubes, but you should examine all patients first, and be at hand in case there are difficulties. Tubes can also be tied on a large scale in special ''camps'.

OPERATING IN A HEALTH CENTRE. Grand multips with large families don't like going to a remote hospital to have their tubes tied, but they may be pleased to have this done at their local health centre, if you can visit it and do a list there. Operating in a health centre is not easy, but it extends the benefits of this most necessary operation to those who need it most[md]if the health centre has a theatre (2.2a).

Ask the staff to prepare a list of all the mothers in the district who want their tubes tying. Often only a few will come the first time, but more will come later. If you plan ahead, you can work without an autoclave on the site, or you can combine antiseptic methods (2.6) with aseptic ones. Bring sterile packs of drapes and gowns, and use the same gown for several patients; for gloves see Section 2.3. Use a single square drape with a 12[mu]12 cm opening for each patient. If necessary, this can be a plastic sheet sterilized between patients in an antiseptic fluid. Boil instruments between cases. Some workers give each patient a gram of chloramphenicol intravenously at the start of the operation (2.6). Barss P, ''Tuballigation with local anaesthesia', Tropical Doctor 1985;175[nd]178. Fig. 15-3 TUBAL LIGATION. A loop of tube has been tied with catgut and is being excised. The catgut will later be absorbed, and allow the ends of the tube to separate. This will make them less likely to recanalize.

MINILAP [em]CAUTION ! (1) Before you tie anyone's tubes, make sure you know what the local cultural attitudes to it are. (2) Always get consent from the patient and her husband, and if necessary her mother. (3) Don't try to press for consent during labour. (4) This operation has a mortality of the order of 5/100,000 from anaesthesia (the major risk), tetanus and haemorrhage, so take the appropriate precautions.

INDICATIONS. (1) Mothers who are sure they want no more babies. (2) Medical diseases contraindicating pregnancy, particularly severe heart disease, renal failure or severe diabetes.

CONTRAINDICATIONS. (1) Extreme obesity (see below). (2) Excessive anxiety. (3) A history of pelvic sepsis (PID) immobilizing the uterus of a non-postpartum patient make a minilap under local anaesthesia difficult. She needs subarachnoid or general anaesthesia, and she will probably be infertile anyway. Dense adhesions are unusual immediately postpartum in multips. (4) A chronic cough will increase the risk of an incisional hernia later. (5) Pregnancy. (6) Refusal of the patient or her husband to sign a consent form.

ARRANGEMENTS. You can do a minilap as a day case, but if you admit her the night before, she is more likely to be present when the list starts.

THE EQUIPMENT includes two long narrow, 13[mu]44 mm Langenbeck retractors, a scalpel, a needle-holder, ovum (ring) forceps, a circular cutting needle, chromic catgut, and monofilament.

A special manipulator is listed above, which you can use to press a patient's fundus against her abdominal wall, and bring it into a small minilap incision. This is unnecessary immediately postpartum, but if you are inexperienced, it makes the tubes easier to find in a non-postpartum patient.

ANAESTHESIA. Take all the precautions for an abdominal operation (9.1), and be sure to starve her. There are several alternatives:

(1) A method of local anaesthesia is described below with the surgery. Use 100 ml of 0.5% lignocaine with adrenalin. This is the maximum dose (A 5-1). Premedicate her with pethidine 25 mg and diazepam 5 mg intravenously. Double this premedication if she is large or anxious. The minimum intravenous premedication will enable her to get up and walk away immediately afterwards.

(2) Local infiltration as in A 6.7, with a paracervical block (A 6.14) for the dilatation and curettage, if you do one (see below). (3) Ketamine (A 8.1). (4) Pethidine with diazepam (A 8.8). (5) Subarachnoid or epidural anaesthesia are convenient. (6) If she is obese, you may need general anaesthesia with muscle relaxation.

CAUTION ! (1) Local anaesthesia, properly used, is the only safe anaesthetic for a national sterilization programme. (2) Avoid large intramuscular doses of pethidine. Instead, use small intravenous doses, followed by intravenous diazepam as in A 8.8.

METHOD. Immediately before the operation ask her to pass her urine, or catheterize her, to prevent you cutting into her distended bladder. Do a careful bimanual examination to make sure that she is not already pregnant. Put her into the semilithotomy position, with her thighs flexed to 45[de] and moderately abducted, her knees flexed, and her lower legs horizontal. Use Lloyd Davis stirrups, or, cheaper, ''Chogoria supports' (15-4).

Clean her abdomen, perineum, and vagina, empty her bladder with a catheter, and cover her with an abdominal sheet. Pass a Sims' or Auvard's speculum.

If more than 10 days have elapsed since the first day of her last period, consider doing a ''D and C' (20.3), to prevent implantation in this cycle. If you are operating under local anaesthesia, you will have to do this under a paracervical block (A 6.14). Many surgeons consider this unnecessary interference, and point out that it is not sure to prevent implantation.

THE INCISION depends on the position of her fundus.

If she has delivered within the last few days, and her uterus is at her umbilicus or can easily be pushed there, make a 2 cm horizontal incision in its inferior fold. This is good cosmetically, and avoids the need to shave her.

If her uterus has involuted, or she is not postpartum, make a short transverse incision just above her pubic hair. One contributor always makes a suprapubic incision, even if her uterus is enlarged; you can always find her tubes down beside it.

If you are using a uterine manipulator, insert it and move to her abdomen. Ask your assistant to raise her fundus against her abdominal wall until you see and feel a bulge. Make a 5 cm midline incision over this.

Tilt the table moderately head down to let her gut fall away from her uterus. Prepare her skin widely with iodine. Drape her abdomen, leaving a large area exposed. Use a 0.4 mm needle to raise bilateral skin wheals, just lateral to her rectus sheath and about 4 cm above the proposed incision. Push a long 1 mm subarachnoid (spinal) needle through the wheal, and inject a track of anaesthetic along either side of the proposed incision, extending well above and below it. Inject 10 ml on each side. These injections just lateral to the rectus sheath block a wide area.

Use a shorter 0.7 mm needle to inject another 10[nd]15 ml into her skin and subcutaneous tissue at the site of the incision.

Inject each rectus muscle through its anterior sheath about 2 cm from the midline. Inject 5 ml at three levels on each side, above, at the level of, and below the planned incision. Expect to find the rectus muscles further apart in multips. A total of 30 ml gives good muscle relaxation.

If you are going through her umbilicus, inject above and below it on both sides so as to infiltrate it completely. Stretch it and make a 2 cm horizontal incision in its inferior fold. Spread the subcutaneous tissue vertically with scissors until you see the fascia. Insert two small narrow right-angled retractors, one towards her head and the other towards her feet, and pull them apart. Pick up the fascia between two haemostats, and inject another 10 ml of lignocaine at a few points just beneath the fascia to anaesthetize her peritoneum. Open the fascia vertically with a knife. You will find it and and her peritoneum almost fused, and will enter her peritoneal cavity bloodlessly. Enlarge the incision in the fascia to admit your index finger. Her skin will stretch, so you can make the skin incision shorter than the fascial one.

If you go through her suprapubic area, do so in the exact midline between her rectus muscles. Spread them carefully to avoid bleeding. Spread the fat with scissors until you see her peritoneum. Pick it up, open it, and secure it with haemostats. Optionally, inject 10[nd]20 ml of lignocaine over her pelvic organs for a topical effect.

Feel for her fundus with your index finger. Feel behind it laterally to the point where each ovary is attached. Her tubes lie just anterior to them. As you hook a tube towards the incision with your finger, rotate her uterus to bring its cornua close underneath it. Next, insert two long Langenbeck retractors at right angles to one another. Use the upper one to pull gut and omentum away, and the other to pull laterally, so that you can see the tube. Grasp it with ovum forceps. If it is difficult to find, go to the cornua of her uterus, and follow the tube from there to its fimbriated end.

Deliver a tube into the wound. If it is difficult to deliver, try lowering the head of the table. Look for its fimbrial end, to make sure that it is her Fallopian tube, and not her round or ovarian ligament. Either, (1) apply two clamps, 2 cm apart, cut out a piece of tube between them, and tie each end. Or, (2), alternatively, tie catgut (not monofilament, you want to cause a mild inflammatory reaction) round a loop of tube, and excise it as in Fig. 15-3 (Pomeroy tubal ligation). Does the tube you cut have a lumen? If not, it is her round ligament! There is no need to bury the stumps. Do the same thing on the other side.

CAUTION ! Be sure to use catgut, which is more reliable for this particular purpose than other materials.

Check carefully that there is no bleeding, cut the sutures on the tube, and then operate on the other tube in the same way.

CLOSING HER ABDOMEN. Close her peritoneum and fascia with a suture of 2/0 monofilament. Close all dead space to minimize oozing when the vasoconstrictor effect of the adrenalin wears off.

Sit her up, dress her, and let her walk back to the ward. If you have had to give her extra sedation, she will need help. If she lives close she can go home the same day. If she comes from a remote village, don't discharge her until her sutures have been removed, and her wound has been carefully inspected and palpated[md]she must not develop a wound infection at home.

Fig. 15-4 CHOGORIA SUPPORTS hold a patient's legs only partly flexed, so that you can have simultaneous access to her abdomen and her perineum. They are from a mission hospital of this name in Kenya, and are a cheaper locally-made alternative to Lloyd Davies stirrups, or to an attachment for an operating table that enables you to angle its lithotomy poles.

DIFFICULTIES [s7]WITH A MINILAP CAUTION ! If you are not operating in a hospital, and there are any complications, treat her as best you can and immediately refer her for admission.

If she complains of PAIN when you are injecting the local anaesthetic, give her intravenous pethidine. A wide area of local anaesthesia should prevent this. She is starved, and if you have great difficulty pulling her tubes into the wound, give her ketamine 2 mg/kg and atropine 0.6 mg intravenously.

If she is OBESE, it will be difficult to pull her tubes into view through a layer of fat. Enlarge the incision and apply more head-down tilt. An umbilical incision may be easier than you expect, because there is less fat around it.

If you CANNOT FIND HER TUBES, (1) the incision may be too far above her fundus; it should be slightly below it. Turning her uterus with your finger behind it helps. If she is is postpartum, and her uterus is large, try manipulating it through her abdominal wall. You may find it helpful not to release the first tube, until you have moved across her fundus and found the other one. Try passing Cusco's speculum through the incision to help you look around. (2) Her uterus may be stuck down with adhesions. A careful initial pelvic examination should have excluded this.

If you find ADHESIONS, you may be able to divide fine ones. Dense ones need general anaesthesia. If her tubes are adherent to her uterus or her pelvis, you may have to make a standard incision, or abandon the operation. This is particularly likely to happen if she has adhesions following Caesarean section.

If you find any CYSTS on her ovaries, leave them if they are small ([lt]5cm). All normal ovaries have some physiological cysts. If a cyst is larger, collapse it by draining it with a syringe and needle, pull it into the wound, and if you don't think it is malignant (20.7), excise it.

If you OPEN HER BLADDER (rare), close it with 2/0 absorbable sutures in two layers, and leave a catheter in for 10 days. Prevent a full bladder by having her empty it just before she enters the theatre. If you find it full at surgery, empty it with a needle and syringe.

If you OPEN HER GUT (rare), close it in two layers transversely, ''suck and drip' her for a few days, and observe her closely.

Fig. 15-5 MINILAPAROTOMY. If you wish, you can use a special manipulator to push a patient's fundus up against her abdominal wall, so that a very small incision can be made in her abdomen. If she is immediately postpartum, a manipulator is unnecessary..