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Tubal ligation
Tubal ligation is a sterilization method for women that consists of a surgical operation in which the connection between the fallopian tubes and the uterus is interrupted.Before the Decade of the sixties of the last century, sterilization techniques were used only when medical indication was to prevent additional pregnancies in women. However, the change of the role of women in society developed this technique in a viable option to prevent additional pregnancies if the woman did not want it. During the last decades tubal ligation has improved his technique avoiding complications and improving their results.
Reminder anatomical
The female genital tract is composed of the vagina, allowing the entry of the penis and the insemination; the ovaries, which produce eggs for fertilizing; and the uterus, which mainly has three functions:
• Allow the passage of sperm from the vagina to the encounter with the egg.
• Host the fertilized egg and the developing fetus.
• Contract during labor to expel the fetus and the placenta.
The uterus, in turn, can be divide into three parts: the neck, body and the fallopian tubes. The fallopian tubes are two tubes that come out of the bottom of the uterus and ovaries is not enough to pick up the egg in each ovarian cycle. The tubes have a narrow initial section close to the uterus called isthmus and another close to the ovary called blister, more widened, which usually occurs between the ovary and sperm.
When is tubal ligation recommended?
Tubal ligation surgery is indicated to all those women who want a permanent contraception method and do not have any disease - gynecology or not - that prevented the realization of this surgery or requiring a different operation. Tubal ligation is also indicated to women for which a pregnancy represents a health risk too high.Contraindications of tubal ligation
There are certain situations that a tubal ligation may not be advisable to:
The right woman to receive tubal ligation should have taken the decision by itself, without external coercion, and knowing other contraception options
Tubal ligation is considered a technique of irreversible contraception, although it may be reversible by another union of tubal surgery or can be the conception by fertilization in vitro, but the result is far from the fertility with intact fallopian tubes. Therefore, it is not indicated for women who are not sure of wanting to permanent sterilization. The right woman to receive tubal ligation should have taken the decision by itself, without external coercion, and knowing other contraception options.
Tubal ligation is not indicated for women who have recently given birth. For two reasons: first, the woman's body is not yet ready to receive such surgery unless it is an emergency; and second, the puerperium is not the best time to make a decision that then women can repent.
Laparoscopic surgery is contraindicated in women who have Morgagni hernia (a hole that is on the back of the diaphragm and abdomen with chest).
It is also contraindicated in women with severe cardiopulmonary illness, since large veins that prevent the return can be compressed to insufflate the abdomen with carbon dioxide (which is done in all laparoscopy in order to have a good field of view) of the blood to the heart. In addition a part of carbon dioxide is absorbed by the peritoneum and can produce cardiac arrhythmias.
Obese women and which have been subjected to any abdominal surgery laparoscopic surgery are contraindicated. In terms of open abdominal surgery, they must take into account these factors and increase vigilance during the operation. It is also an option to value for this type of people by Hysteroscopy tubal ligation. The hiteroscopia is contraindicated for women with allergies to nickel or means of contrast, pregnant women with pelvic infection or parturients with just six weeks from birth.
Medical tests prior to a tubal ligation
Once taken the decision and prior to the tubal ligation surgery, proceeded to make a series of studies that allows to know the State of women's health:• Detection of human chorionic gonadotropin (hCG) in urine: hCG is a hormone that appears in the body of the woman produced after the implantation of the embryo in the uterus wall. Its detection allows us to know if a woman is pregnant, it can condition the surgery. It is preferable to carry out two measurements with a week of distance between them, the last one would be the same day of the surgery, which should be done preferably the first days of the ovarian cycle to avoid false negatives by hormonal distortions.
• Test Papanicolaou: this test is to take a sample of cells from the epithelium of the cervix and identify if they have alterations of infection by the human papillomavirus (HPV) virus. It should be done within six months prior to the operation.
• Analysis of blood and urine: in all surgery must be.
• Detection of infection for gonorrhea and chlamydia: the presence of any of these two bodies makes us know that there is a pelvic infection in evolution. They must eradicate with antibiotics before surgery, because if not, the risk of complications after the surgery is very high.
• Ultrasound: an ultrasound should be performed before the operation in search of anatomical variations, abscesses and tumors. Transvaginal ultrasonography should be done especially in obese patients routine ultrasound where not allowed to explore the interior of the pelvis. If during the operation is suspected or found some inner mass in the fallopian tubes can be used intraoperative ultrasound that will help us to discern its origin.
Types of surgery employed in tubal ligation
Tubal ligation surgery is simpler than other surgical processes. In essence consists of interrupting the duct of the fallopian tubes so that the eggs from the ovary fail to reach the inside of the uterus, and that, on the other hand, sperm may not come from inside the uterus until the ovary. To achieve this there are different techniques - listed below - but all perform the same basic steps:• Cutting the fallopian tubes by its narrowest segment.
• Remove or not the outer-most segment of the fallopian tubes without damage to the ovaries.
• Plug the ends of the fallopian tube, to prevent a subsequent repair by scarring of the fallopian tubes and the sperm out from the uterus.
Techniques commonly employed to perform a tubal ligation are as follows:
Postpartum tubal sterilization
Bilateral tubal ligation may be performed after suturing the uterus after birth by caesarean section or even 72 hours after a vaginal birth. It is a fairly simple surgery, since the bottom of the uterus is at the level of the navel and that makes the fallopian tubes very accessible through a periumbilical incision (around the belly button). It should remember, however, that the decision to carry out a sterilization right after childbirth should be taken consciously by women and preferably before parturition, puerperium is an emotional period that can be tricky.Minilaparotomy
It's a laparotomy with an incision of less than 5 cm. The operation can be done through an incision above the pubis, or below the navel done 48 hours after childbirth. The surgery is simple and begins by performing the described incision previously through the skin until reaching the fascia covering the abdominal muscles is important at this point to cut small bleeding happen to damage the muscles. When it comes to the peritoneum, it crosses and is reached the uterus that can be mobilised and raised so that the hanging from each end of the uterine fundus fallopian tubes are better displayed. Almost the only serious error that can be committed in this type of surgery is to confound the fallopian tubes with round ligaments that hold the uterus ends to the skeleton of the pelvis.Laparoscopy
The difference between a laparotomy and laparoscopy is that in the last small incisions are made in the skin of the abdomen where enter trocars (a kind of punches) and clamps that allow internal surgery without exposing the inside of the abdomen towards the outside. It is possible to manipulate internal organs because it is introduced a camera that shows all of the surgical field.Its advantages are many, such as the small size of the incisions in the skin, the rapid improvement in the postoperative period and ease to find the fallopian tubes and explore the pelvis. The disadvantages include the increased risk of damage to vessels or internal viscera accidentally (although in expert hands, the risk is minimal). There is an added difficulty if the patients are obese or if the patient has received any previous surgery created accessions in the peritoneum. Yet success in this type of surgery more than 99% of the cases.
Microlaparoscopia
This technique consists of using a microendoscopio between 1.2 and 2 mm which enters through the skin incisions of about 6 mm. The advantages are, in theory, less postoperative pain, less expensive and more rapid recovery of women subjected to this type of intervention. However, there are no reliable studies that have demonstrated these benefits, and that's why, after 20 years of existence, the microlaparoscopia is not even used on a regular basis.Hysteroscopy
Consists of performing the sterilization of the fallopian tubes from the inside of the uterus by inserting instruments into the vagina and cervix. Its advantages are a lower cost, not need skin incisions or general anesthesia and a lower risk of accidents within the operation. The intervention is performed with local anesthesia, allowing women to return to their daily lives in almost 24 hours. Obese women or that they have been subject to previous abdominal surgeries are fully suitable to perform Hysteroscopy.It has shown that this technique is effective for preventing pregnancy in 99.8% of the cases. After surgery must be done a hysterosalpingogram which check if the fallopian tubes are blocked completely, this test consists of introducing a liquid, which can be seen with X rays, through the cervix, so he painted the entire interior of the uterine and, if it weren't for tubal ligation, would emerge through the fallopian tubes into the abdominal cavity.
Possible complications of tubal ligation
Any surgery has its risks and possible complications. Also there are tubal ligation, although they are rare, since it is a surgery scheduled and performed mainly in healthy women. However, these are some of the problems that may arise during the operation or as a result of it:Mortality
The risk of death is 1-2 cases per every 100,000 operations, almost all for complications from anesthesia. Despite what may seem, the figures are lower than that in other situations, for example, a hysterectomy (removal of the uterus) operation has a mortality of 5-25 cases for each 100,000 operated, and a birth of itself has a mortality rate of 8 cases per every 100,000 live tits children (the figure is up to 500 cases per 100,000 live births in countries developing).Damage of viscera and vessels internal
During the handling of surgical instruments within the abdominal cavity organs and blood vessels of the environment can be damaged accidentally. The vast majority of cases is detected immediately and is easy to solve.Failure of the method
Sometimes the tubal ligation fails as a contraceptive method, while the operation was successful. During the first year after the operation the woman has a risk of 0, 1-0, 8% become pregnant, and in case that happens to one-third of pregnancies are Ectopic pregnancies, i.e., the implantation of the fertilized egg occurs outside the uterine cavity, with the risks that this entails. The reasons for these pregnancies are:• False negative pregnancy test performed before the intervention. So there are cases where it operates of tubal ligation a woman who already had a pregnancy in course.
• Incorrect occlusion of the internal segment of fallopian tubes, allowing the passage of sperm to the ovary
• Partial or complete fusion of the two cut segments of Horn. To prevent this there are many surgeons who removed the outer segment of the fallopian tube or a middle segment of about 2 cm.
Postoperative pain
That is solved with painkillers the first days.Infection
After the surgery is an antibiotic prophylaxis to prevent contamination of the internal wounds by microbes. The risk is moderate, since the uterus and the fallopian tubes are cavity which is in contact with the exterior in an indirect way through the neck of the uterus and the vagina.Repentance of the patient
Tubal ligation is intended to be a permanent contraceptive technique, but the repentance of the woman who has been subjected to this technique is not uncommon. Around 20% of women under age 30 they repent has been tubal ligation, but only 6% of the over 30 years do so. It is clear that several factors of each person's life influence the decision and subsequent repentance (age, partner, being a mother...)Article contributed for educational purposes
