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

A tubal plug and clip method for female sterilization.

Animal studies using rabbits, stumptailed macaques monkeys, and baboons demonstrate that the tubal plug and clip device is an effective and safe method for female sterilization in these animal models. The devices were placed in 18 baboons that were bred regularly for six to 18 months without conception. Ten of these 18 animals conceived within 12 months after removal of the devices and carried normal pregnancies without any other surgical procedure. Six of the ten animals conceived and carried a second pregnancy for a total of 16 successful pregnancies. The expected pregnancy rate for baboons is 64.9% per year so that the 55.6% success rate of reversal and 16 total pregnancies clearly represents a high degree of reversibility for the method in this animal species.

End-to-end tubal anastomosis using an absorbable stent.

Using absorbable suture as a stent, end-to-end anastomosis of previously ligated or cauterized fallopian tubes was performed in 15 cases. Luminal patency of at least one fallopian tube has been achieved in all cases, and thus far seven pregnancies have occurred in six cases. The technique for inserting the absorbable suture into the distal and proximal portions of the tube is fully described, and the importance of repeated hydrotubations to maintain tubal patency is emphasized.

PIP: This paper reviews the use of absorbable, rather than nonabsorbable, stent in tubal reanastomosis. The new operative technique was used for anastomosis of previously ligated fallopian tubes in 14 cases and for unilateral midsegmental inflammatory tubal obstruction (previously left salpingectomy due to an ectopic pregnancy) in 1 case. The subjects were from 22 to 39 years of age, with a mean age of 29 years. Description of the technique for inserting the absorbable suture into the distal and proximal portion of the tube is presented in detail. Patency of at least 1 fallopian tube was reported in all cases. 7 pregnancies out of 6 cases occurred. The patient with twin pregnancies had one pregnancy resulting in spontaneous abortion and the other pregnancy resulting in a full-term delivery. Hysterosalpingography performed between the 2 pregnancies revealed bilaterally patent tubes. Although the results of this study are inconclusive because of the limited number of cases, shortness of postoperative period in 4 cases, and postponement of pregnancy by another patient with patent and grossly normal-appearing fallopian tubes as revealed by hysterosalpingography, the favorable results suggest the usefulness of the new approach in tubal reanastomosis. The use of absorbable suture for a stent eliminates the need for a second operation. Adequate hemostasis should be observed when using this technique. Battery-operated ophthalmologic cautery is beneficial for controlling bleeding from fallopian tubes. Tubal sterilization should be performed in a young patient with low parity with a view towards future reanastomosis; thus, preservation of as much tube as possible is important. A Pomeroy or laparoscopic silicone band tubal ligation is a good procedure to use.

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.

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.

Vasovasostomy and vas occlusion: preliminary observations using artificial devices in guinea pigs.

Intravas devices designed to reverse a vasectomy or to occlude the vasa instead of transecting them were evaluated in guinea pigs. Absorbable intravas devices (AID) were inserted into the vasa at the time of vasovasostomy and produced a return of normal semen quality in 73% of the experimental animals as compared with only 40% in the control group. Seventy per cent of the AID group sired litters. In a second group of guinea pigs, vasectomy was replaced by the bilateral insertion of reversible intravas plugs (RIP) which occluded the lumina. After a period of azoospermia, the central, occlusive pins were removed from the devices. Sperm-positive animals were bred and three of five sired normal offspring. Histologic examination of the vasa revealed morphologic changes in some AID animals, these being attributed to the vasectomy procedure. A similar evaluation of the functional RIP insertion site revealed the desired occlusive tissue-device interfaces.

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

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%.

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.

Development and initial evaluation of a vas deferens valve.

In 17 cases of vasectomy, the external diameter of vas deferens was found to be 2.07 +/- .27 mm (Mean +/- S.D.) with a range from 1.7 to 2.8 mm. The internal diameters were 0.93 +/- 0.13 at 5 g and 1.24 +/- 0.16 mm at 100 g insertion force applied to the measuring cone, with lumen ranges from 0.7 to 1.2 and 1.0 to 1.7 mm, respectively. The left-right variations in the same inidividual were of a similar order as between different individuals. Measurements in 6-10 kg rhesus monkeys revealed an internal vas diameter around 0.6 mm with the measuring cone only eased in. At considerably high pressure the vas could be distended to show an internal diameter around 1 mm. The external diameters ranged from 1.5 to 2 mm. Local application to the vas in vivo or in vitro of alpha or beta adrenergic blocking agents, and sodium nitrate had no appreciable effects on the diameters. Three types of valves were developed and tested. The tap-like and the rotary valves were not satisfactorily leak-proof. But the valve with stop-cock mechanism was found to be satisfactory. It was further tested by examining the ejaculate obtained by the method of electro-ejaculation after implanting the valve in the monkey vas. The stop-cock valve is being proposed as a working model for producing reversible vas-occlusion.