Robotic Single-Site Tubal Reanastomosis: The Robotic Factor.

STUDY OBJECTIVE: To investigate the advantages of using robotic assistance in tubal reanastomosis surgery. DESIGN: A narrated instructional video. SETTING: University Hospital, Baylor College of Medicine, Houston, Texas (Canadian Task Force Classification III). PATIENT: A 33-year-old woman, G2P2003, who regretted her prior tubal ligation; she continued to request for a tubal reversal with a desire to conceive in the near future. A single-site approach was decided on when she expressed concern for the cosmetic aftermath of multiport surgery. INTERVENTIONS: Robotic single-site tubal reanastomosis. MEASUREMENTS AND MAIN RESULTS: We performed robotic single-site tubal reanastomosis on the patient. We used the energy instruments of the monopolar hook and the bipolar slotted grasper. Entry was performed in the umbilicus, after which an abdominal survey was conducted to determine and locate the blocked fallopian tubes. A cold scissor, to avoid additional damage to the tubes, was used to resect the portion of the right blocked tube, and a neonatal feeding tube was inserted though both sections of the tube to ensure proper alignment during the repair. Additionally, a figure of eight suture was placed in the mesosalpinx to reduce the amount of tension during the tubal reanastomosis. We used 4 interrupted 5-0 PDS sutures, with 2 wristed needle drivers, to establish and precisely align the 2 sections of tube, first in the mucosal layer and then in the serosal layer, to achieve proper retention. Upon successful chromopertubation with methylene blue dye, the process was repeated on the left side. A successful tubal reanastomosis was completed and chromopertubation clearly demonstrated that the tubes were patent. Total operation time was approximately 100 minutes, resulting in a successful surgery. Estimated blood loss was only 20 mL. At 2 months after surgery a fluoroscopic hysterosalpingogram was conducted to verify the patency of the tubes. We concluded that both tubes were patent. CONCLUSIONS: The single-site robotic approach provides a potent and valuable method for tubal reanastomosis, rendering difficult surgical techniques more accessible.

Laparoscopic Tubal Reanastomosis Using Barbed Sutures.

STUDY OBJECTIVE: To show a new technique of laparoscopic tubal reanastomosis using barbed sutures. DESIGN: Step-by-step explanation of the technique using videos. SETTING: Laparoscopic tubal reanastomosis is an effective procedure with a high success rate for reversal of tubal sterilization. Conventionally, 4 equidistant interrupted sutures are placed under a magnified view for laparoscopic tubal reanastomosis. This step demands high precision and requires a lot of skill and experience. We have tried to simplify this suturing technique by using barbed sutures because they do not require knotting. Two separate 5-0 Quill barbed sutures (Angiotech Puerto Rico Inc, Aguadilla, Puerto Rico) are used in this technique. The first suture is used for taking 6 and 3 o' clock stitches. The second suture is used for taking 9 and 12 o' clock stitches. With this technique, the purse-string effect on the tubal lumen is reduced. INTERVENTIONS: Laparoscopic tubal reanastomosis using 5-0 Quill barbed sutures (equivalent to United States Pharmacopeia suture size 6-0). CONCLUSION: This technique of laparoscopic tubal reanastomosis using barbed sutures is a feasible and simpler alternative to conventional suturing.

Hysterosalpingography in the investigation of women requesting reversal of sterilization. Should it play a role?

OBJECTIVE: To evaluate the role of hysterosalpingography (HSG) in the investigation of women requesting reversal of sterilization (ROS). STUDY DESIGN: A prospective, cohort study at a university-affiliated, tertiary fertility clinic. All women proceeding to surgery were investigated with HSG in addition to other routine screening. Findings from HSG were tabulated to document the prevalence of abnormalities and correlated with histologic findings in resected tubal segments. RESULTS: One hundred sixteen women of 166 referred for ROS underwent HSG during the initial evaluation. HSG depicted abnormal tubal images in only 2 cases (1.7%) and abnormal uterine images in 15 (12.9%) cases. In the cases of abnormal tubal findings, there was no association with histologic findings. The specificity of HSG as a diagnostic screening tool was 90%; however, the small number of cases with abnormal histology prevented calculation of an accurate estimate of sensitivity of HSG as an investigative tool before ROS. A less invasive method of imaging the uterus, such as a vaginal ultrasound, may provide more valuable information in evaluating the future fertility outcome in these women. CONCLUSION: The prevalence of abnormalities of the proximal oviductal segment identified by HSG is too low to warrant the routine use of HSG as a diagnostic tool.

Tubal anastomosis by robotic compared with outpatient minilaparotomy.

OBJECTIVE: To compare tubal anastomosis by robotic system compared with outpatient minilaparotomy. METHODS: In this retrospective case-control study, women were identified by current procedural terminology code for tubal anastomosis. We included all cases of tubal anastomosis for reversal of a prior tubal ligation by either outpatient minilaparotomy or robotic system technique. Cases performed by laparoscopy without aid of the robot were excluded. Comparisons were based on Fisher's exact, chi(2), and Wilcoxon rank sum tests. RESULTS: There were 26 cases of tubal anastomosis performed with the robot and 41 cases performed by outpatient minilaparotomy. The two groups were comparable in age, body mass index, and parity. Anesthesia time for the robotic technique (median with interquartile range) was 283 (267-290) minutes compared with 205 (170-230) minutes with outpatient minilaparotomy (P<.001). Surgical times for the robot and minilaparotomy were 229 (205-252) minutes and 181 (154-202) minutes respectively (P=.001). Hospitalization times, pregnancy, and ectopic pregnancy rates were not significantly different. The robotic technique was more costly. The median difference in costs of the procedures was $1,446 (95% confidence interval $1,112-1,812) (P<.001). The time to return to work was significantly shorter in the robotic system group by approximately 1 week (P=.013). CONCLUSION: Robotic surgery for tubal anastomosis was successfully accomplished without conversion to laparotomy. The robotic technique for tubal anastomosis required significantly prolonged surgical and anesthesia times over outpatient minilaparotomy (P

Robotically assisted laparoscopic tubal anastomosis in a porcine model: a pilot study.

As with standard microsurgical procedures performed at laparotomy, laparoscopic tubal anastomosis requires great dexterity. Handling fine suture materials under magnification to anastomose tubal segments with lumens less than 3 mm in diameter while working with your hands at a distance from the tissue makes these fine movements even more difficult. This is exacerbated by the tremor induced by the fatigue caused by a prolonged laparoscopic procedure and the need for precise control. We conducted a pilot study to evaluate the feasibility of performing laparoscopic tubal anastomosis with robotic assistance in a live porcine model. Two anastomoses were performed on one uterine horn via each of the following techniques: laparoscopy, laparoscopy with robotic assistance, and open microsurgery. Immediate necropsy demonstrated all the anastomoses to be patent. There were no intraoperative complications. Laparoscopic tubal anastomosis was associated with surgeon fatigue and neck, shoulder, and back pain. The surgeons were more comfortable performing the procedure with robotic assistance. The device functioned well and without incident. This acute animal study suggests that robotic assistance in laparoscopic tubal anastomoses is safe and feasible. It enhances surgeons' dexterity and precision while reducing fatigue. It is promising for future use in chronic experimental studies.

Carbon dioxide laser tissue welding: an alternative technique for tubal anastomosis?

Microsurgical tubal anastomosis is the gold standard for treatment of tubal occlusion. The present study was performed to establish the feasibility of tubal anastomosis by welding tissue with a defocused CO2-laser beam during laparotomy and with an endoscope. In an animal experiment, 70 white New Zealand rabbits were randomized in 2 study groups (E1, E2) and 3 control groups (C1, C2, C3) as follows: C1, 10 animals, no operation, as controls for the efficiency of the insemination technique; C2, 5 animals, spontaneous healing after tubal segment resection, to quantify spontaneous recanalization of the tube; C3, 15 animals, microsurgical end-to-end adaption after tubal segment resection; E1, 20 animals, laser welded anastomosis after segment resection via laparotomy; E2, 20 animals, laparoscopic laser welded anastomosis after segment resection. The pregnancy rate in C1 was 80%. None of the animals in C2 but 60% of the rabbits in C3 conceived. After sutureless anastomosis by laser welding 50% of the laparotomized, and 40% of the laparoscopically operated group became pregnant. Morphological examination of the oviducts after relaparotomy showed comparable patency rates of 70% in C3, 70% in E1, and 65% in E2. Whereas no dehiscence of anastomoses was observed in C3, 20% of the welded tubes in E1 and 22.5% in E2 were dehiscent. Tubal anastomosis took approximately three times as long laparoscopically as during laparotomy. Thus, laser welding as a sutureless alternative technique of tubal anastomosis should be viewed critically. A reduction of sutures through laser-assisted anastomosis might, however, be considered.

[Laparoscopic tubal sterilization reversal: a technic using a single stitch]. / Déstérilisation tubaire percoelioscopique: la technique par un point.

We report our laparoscopic technique of tubal sterilization reversal. We perform a simple and atraumatic technique with a single point. After preparation and approximation of the two tubal segments, the anastomosis consists of one single suture placed at the "12 o'clock" site of the antimesenteric border. The feasibility, the advantages and the preliminary results are presented.

[Possibilities and limits of endoscopic fallopian tube surgery]. / Möglichkeiten und Grenzen der endoskopischen Tubenchirurgie.

Treatment of distal tubal occlusion by microsurgical means allows a pregnancy rate of about 30-40% per patient. The success rate directly depends on patient's age and the grade of tubal destruction and increases to 50% in younger patients. Therefore microsurgical repair still represents a sufficient alternative to IVF. The introduction of endoscopical techniques further facilitates distal tubal surgery and offers the opportunity to evaluate the grade of tubal destruction. When performed correctly based on longstanding experience pregnancy rates after endoscopical salpingostomy are similar to microsurgery via laparotomy. In contrast microsurgery by laparotomy is still the method of choice in cases of proximal tubal occlusion or reversal of tubal ligation. Furthermore laparotomy is still indicated in patients presenting with distal tubal pathology, if the endoscopical approach does not lead to a sufficient postsurgical result.

Laparoscopic tubal anastomosis. A pilot study.

Five previously sterilized patients underwent laparoscopically guided tubal anastomosis. Patency was documented in at least 5 of 10 tubes operated on. The crude pregnancy rate was 50%.

Recanalización tubaria microquirúrgica en Curicó: caso clínico / Microsurgical tube rechanalization in Curicó: clinical case

Se presenta el caso clínico de una paciente ligada quirúrgicamente a quien se le practica reversión de esta condición mediante técnica microquirúrgica, que en este caso, corresponde a una anastomosis ámpulo ampular en 2 planos bajo visón microscópica, logrando embarazarse al cumplir 5 meses de ser intervenida

[Fibrin gluing in surgical, laser-assisted laparoscopy]. / Fibrinklebung in der operativen, laser-assistierten Laparoskopie.

Fibrin sealing has proved a successful procedure for a variety of indications in operative gynecologic laparoscopy. Ovaries can be reshaped after cystectomy, serosa and peritoneal defects as well as perforations of the uterus can be sealed with fibrin adhesive. At present, application for salpingotomy, fimbrial eversion and tubal anastomosis is being investigated in clinical studies. Yet larger collectives and a longer follow-up are necessary for a final evaluation of the method. No complications were observed in 75 laparoscopic fibrin sealing performed at our department for established indications. Fibrin adhesive can replace time-consuming, complicated endoscopic sutures. It is an atraumatic tissue-sealing and hemostatic technique, easy in handling, thus leading to a considerable reduction in operation times. The excellent hemostyptic and wound healing characteristics of fibrin adhesive are also an advantage.

PIP: Fibrin sealing has proven successful in a variety of situations in operative gynecologic laparoscopy. Ovaries can be reshaped after cystectomy, serosa and peritoneal defects as well as uterine perforations can be sealed with fibrin adhesive. At the present time, application for salpingostomy, fimbrial eversion, and tubal anastomosis are being investigated in clinical studies. Larger samples and longer follow-up periods are necessary for a final evaluation of the method. No complications were observed in 75 laparoscopic fibrin sealings performed at the authors' department. Fibrin adhesive can replace time-consuming, complicated endoscopic sutures. It is an atraumatic tissue sealing and hemostatic technique, easy in handling, and thus leading to a considerable reduction in operation times. The excellent hemostyptic and wound healing characteristics of fibrin adhesive are also an advantage. (author's modified)

Comparison of the operating microscope and loupe for microsurgical tubal anastomosis: a randomized clinical trial.

Reversal of sterilization was performed by microsurgical tubal anastomosis in 72 women using either loupe (n = 36) or microscope (n = 36). The study design called for the randomization of patients within pairs, which were matched for method of sterilization and site of anastomosis. A significant difference between methods could not be demonstrated at 12 months (P = 0.39) or 24 months (P = 0.37) after the procedure.

PIP: This paper describes a randomized, controlled clinical trial to compare the efficacy of the loupe and the microscope in performing a microsurgical anastomosis of tubal segments other than the cornual-isthmic region. 72 women evaluated at the Johns Hopkins Hospital in Baltimore between January 1, 1978 and December 31, 1980, for reversal of sterilization met the criteria for entry into the trial: under 36 years of age and at least 5 cm of oviduct remaining. The surgeon was informed of which device to use for magnification just prior to the procedure. The study design called for the randomization of patients within pairs, which were matched for method of sterilization and site of anastomosis. No significant differences were observed between the loupe and microscope groups in age, parity, or interval from sterilization to reversal. 75% of each group had had an ampullary-isthmic anastomosis, 22% of the loupe and 20% of the microscope group had had an amupllary-ampullary anastomosis, and 3% of the loupe and 6% of the microscope group had had an isthmic-isthmic anastomosis. At 12 and 24 months after the reversal procedures, no differences could be demonstrated between the groups with respect to total pregnancies, term pregnancies, spontaneous abortions, or ectopic pregnancies. 23 of 36 loup patients and 19 of 36 microscope patients had term pregnancies, but the differences were not significant.

Laser-assisted vas anastomosis: a preliminary report.

A new technique is described for performing vas anastomoses in experimental animal (rats). A low-power CO2 laser appears to be effective in welding together the cut ends of the divided vas deferens.

Reversible occlusive devices.

PIP: Research in the development of reversible vas and tubal occlusive de vices is reviewed. Flexible vas deferens occlusive device have been found to be safe and effective in dogs. Theses devices incorporate a stainless steel shuttle stem valve which can be repeatedly turned on and off. The rigid vas occlusive devices have a tendency to perforate the vas deferens. The flexible device can be implanted in either the transected vas or by a dual-incision technique. The device has been successfully attached to the vas, without leakage, by application of a Dacron velour ingrowth material. Those designs which utilize a shuttle stem which directly impedes the flow of spermatozoa appear to be more effective than those which depress a continuous rubber tube. Experiments on baboons with tubal occlusive devices have shown that the devices blocked the flow of dye contrast material. Nonetheless, the transcervical approach to the implantation of such devices is only in the early stages of development. The development of a steerable hysteroscope should enhance the potential for the transcervical approach and the types of devices that can be implanted.^ieng

Vasectomy and vasovasostomy. II. A comparison of two methods of vasovasostomy: silastic versus chromic stents.

Twelve adult, bilaterally vasectomized dogs were used to compare two different procedures for reuniting the severed vas deferens. Approximately 5 months postvasectomy six dogs had vasovasostomies utilizing Silastic stents and the vasa deferentia of six additional dogs were rejoined with intravasal chromic stents. Ejaculates were subsequently obtained at 2-week intervals and evaluated for sperm count, motility, viability, and seminal ion concentrations. All of the dogs in which Silastic had been utilized as the stent had sperm reappear in the ejaculate, whereas only 40% of the dogs in which chromic catgut had been utilized had reappearance of spermatozoa. The over-all quality of the ejaculate was also better in the animals in which Silastic had been utilized. Testicular and epididymal histology was normal in most dogs of both groups, but three of the dogs with chromic stents in which the anastomosis had not been a success had abnormal histology, with reduced numbers of spermatocytes, spermatids, and spermatozoa. The data suggest that Silastic stents are better than chromic stents for vas reanastomosis. They also suggest that some dog testes react negatively to vasectomy and do not recover by 1 year postvasectomy when vas patency is not reversed.

PIP: The use of Silastic and of chromic stenting materials for restoration of the patency of the severed canine vas deferens is compared. 12 adult male dogs were bilaterally vasectomized; 5 months later all has vasovasostomies. 6 animals had an intravas chromic stent and 6 had Silastic tubing rejoining the vas. Semen samples were evaluat ed for sperm count, motility, viability, andm orphology as well as for i on concentrations. Sperm reappeared in the ejaculate of all of the dogs in which Silastic had been utilized, but only 33% of the dogs with chromic stents had sperm appearing in the ejaculate. The overall quality of the semen was better in the dogs with Silastic stents; sperm motility, concentration, and viability was significantly higher than in the dogs with chromic stents. Most of the dogs had normal testicular and epididymal histology; 3 of the dogs with chromic stents with unsuccessful anastomosis had abnormal histology with reduced numbers of spermatocytes, spermatids, and spermatozoa.