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FEMALE STERILISATION
Labeeb Pc
Topics discussed
• Timing of sterilisation
• Guidelines
• Surgical -
• Minilaparotomy
• Laparoscopic Sterilisation
• Vagin...
TIMING OF STERILISATION
1. Postpartum sterilisation
• After 24 hrs to 7 days of delivery
2. Interval sterilisation
• Non p...
CASE SELECTION
• Females – 22 to 45 yrs (male – below 60y)
• Married
• Atleast one child , above one yr
• Sound state of m...
Delay procedure….
• Suspected pregnancy
• 7-42 days postpartum
• Active pelvic infection/ peritonitis
• PID within 3M
• ST...
• Pregnancy conditions-
• Puerperial sepsis
• PROM >24 hrs
• Postpartum Psychosis
• Severe trauma to genital tract
• Recen...
Special precautions..
• Past Cardiovascular disease
• c/c resp disease
• Hyperthyroidism
• Diabetes with vascular disease
...
COUNSELLING
1. Permanency
2. Surgical procedure
3. Possible failure
4. Complications
5. Not protect against STD or HIV
6. ...
CONSENT
• Not under coercion, sedation
• Signed berfore surgery
• Consent of spouse not required
Minilaparotomy
Laparoscopic sterilisation
Vaginal tubal ligation
Hysteroscopic sterilisation
SURGICAL APPROACH
MINI LAPAROTOMY
• Post partum, post abortal, or interval period.
• Interval sterilisation –
• Empty stomach , void urine
•...
Post partum sterilisation
• local anaesthesia
• 2-3 cm subumbilical incision, 2cm below the fundus
• Tube identified by th...
1. Pomeroy method
2. Parkland procedure
3. Madlener procedure
4. Fimbriectomy
5. Irwing technique
6. Uchida technique
7. A...
POMEROY METHOD
• Babcock’s forceps
• Catgut suture
• Difficult in tubal adhesion
• Babcock’s forceps
PARKLAND PROCEDURE
MADLENER PROCEDURE
• Crushed at base
• Ligated with silk
• Failure rate high
FIMBRIECTOMY ( Kroener )
Failure rate high
IRWING TECHNIQUE
• Catgut
• Proximal tube buried within
substance of myometrium.
• Distal end buried in
mesosalpinx
• Very...
UCHIDA TECHNIQUE
• Saline with epinephrine
injected into subserosal
area of tube
• Medial stump buried in
mesosalpinx
• La...
ALDRIDGE METHOD
• Hole in ant leaf of broad ligament
• Fimbrial end buried into this.
• High failure rate
SHIRODKAR’S METHOD
• Cut ends are turned in opposite directions,
so that spontaneous recanalisation does not occur
COMPLICATIONS
• Anaesthetic hazards
• Bowel & bladder injury
• Broad ligament hematomas
• Infection
• Wound sepsis
• Perit...
LAPAROSCOPIC STERILISATION
Advantages
• Direct visualisation & manipulation
• Associated pelvic & abdominal abnormality de...
Veress needle
Trocar & canula
• Lithotomy position
• Local anaesthesia
• Bladder catheterised, uterine manipulator applied
• Trendendeleburg position ( ...
VERESS NEEDLE
OPEN LAPAROSCOPY
METHODS
1. Rings
2. Clips
3. Electrocoagulation
RINGS
• Falope ring – silicone
rubber with barium
sulphate
CLIPS
• Filshie clip
• Silicone
• Better
• Hulka Clemens clip
• Spring loaded
ELECTRO COAGULATION
• Unipolar& Bipolar cautery
• Reversal difficult
COMPLICATIONS
• Anaesthetic complications
• Injury of large vessels
• Bleeding from epigastric vessels – trocar
• Tearing ...
CONTRA INDICATIONS
• Severe cardio pulmonary disease
• Prior abdominal surgery
• Postpartum sterilisation
• Extreme obesit...
VAGINAL TUBAL LIGATION
• Colpotomy performed
• Complications – bowel injury, pelvic abscess
HYSTEROSCOPIC STERILISATION
• Essure
• Buscopan & NSAID to
prevent tubal spasm
• Fibrotic tissue reaction
• Backup contrac...
SEQUELAE OF STERILISATION
1. Ectopic pregnancy
• Partial recanalisation, tuboperitoneal fistula
• More likely after 3 yrs
...
FAILURE
• Typical failure rate – 0.3%
Procedure Failure rate %
Irwing 0.1
Parkland 0.25
Laparoscopic rings & clips 0.2 - 0...
• Due to –
• Recanalisation
• Incomplete division
• Incomplete occlusion
• Ligation of round ligaments in place of tubes
•...
REVERSAL
• Micro surgical anastomosis
• Depends upon –
• Type of procedure
• Length of tube remaining
• Associated conditi...
Female sterilisation
Female sterilisation
Female sterilisation
Female sterilisation
Female sterilisation
Female sterilisation
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Female sterilisation

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Female sterilisation

A Family Planning & Gynecology topic for MBBS

Female sterilisation

  1. 1. FEMALE STERILISATION Labeeb Pc
  2. 2. Topics discussed • Timing of sterilisation • Guidelines • Surgical - • Minilaparotomy • Laparoscopic Sterilisation • Vaginal tubal ligation • Hysteroscopic sterilisation • Complications • Failure • Reversal
  3. 3. TIMING OF STERILISATION 1. Postpartum sterilisation • After 24 hrs to 7 days of delivery 2. Interval sterilisation • Non preg , >6 weeks, within 7 days of menses 3. Postabortal sterilisation 4. Caesarean sterilisation • Laparoscopic tubal ligation –not recommended? when? *tubes are vascular & oedematous , may get torn easily
  4. 4. CASE SELECTION • Females – 22 to 45 yrs (male – below 60y) • Married • Atleast one child , above one yr • Sound state of mind • Mentally ill patients - psychiatrist & legal guardian
  5. 5. Delay procedure…. • Suspected pregnancy • 7-42 days postpartum • Active pelvic infection/ peritonitis • PID within 3M • STD • Active liver/gall b disease • Cerebrovascular/ CAD • Complicated heart diseases • Severe anemia • Psychiatric disorder • Multiple scars of prev laporotomies
  6. 6. • Pregnancy conditions- • Puerperial sepsis • PROM >24 hrs • Postpartum Psychosis • Severe trauma to genital tract • Recent septic abortion • Severe post abortal hemorrhage • Pre ecclampsia/ ecclampsia
  7. 7. Special precautions.. • Past Cardiovascular disease • c/c resp disease • Hyperthyroidism • Diabetes with vascular disease • c/c liver disease • Pelvic TB, endometriosis • Obesity • Coagulation disorders
  8. 8. COUNSELLING 1. Permanency 2. Surgical procedure 3. Possible failure 4. Complications 5. Not protect against STD or HIV 6. Reversal is available ??
  9. 9. CONSENT • Not under coercion, sedation • Signed berfore surgery • Consent of spouse not required
  10. 10. Minilaparotomy Laparoscopic sterilisation Vaginal tubal ligation Hysteroscopic sterilisation SURGICAL APPROACH
  11. 11. MINI LAPAROTOMY • Post partum, post abortal, or interval period. • Interval sterilisation – • Empty stomach , void urine • Local anaesthesia • Premedication – meperidine, promethazine • Uterine manipulator • 2-3cm transverse suprapubic incision, 2.5cm above.
  12. 12. Post partum sterilisation • local anaesthesia • 2-3 cm subumbilical incision, 2cm below the fundus • Tube identified by the fimbrial end • Tubal ligation done using modified Pomeroy’s method / clips or rings • Kept for observation for 4 hrs,discharged • Antibiotics & analgesics are given
  13. 13. 1. Pomeroy method 2. Parkland procedure 3. Madlener procedure 4. Fimbriectomy 5. Irwing technique 6. Uchida technique 7. Aldridge method 8. Shirodkar’s method
  14. 14. POMEROY METHOD • Babcock’s forceps • Catgut suture • Difficult in tubal adhesion
  15. 15. • Babcock’s forceps
  16. 16. PARKLAND PROCEDURE
  17. 17. MADLENER PROCEDURE • Crushed at base • Ligated with silk • Failure rate high
  18. 18. FIMBRIECTOMY ( Kroener ) Failure rate high
  19. 19. IRWING TECHNIQUE • Catgut • Proximal tube buried within substance of myometrium. • Distal end buried in mesosalpinx • Very low failure rate
  20. 20. UCHIDA TECHNIQUE • Saline with epinephrine injected into subserosal area of tube • Medial stump buried in mesosalpinx • Lateral stump ligated , kept outside mesosalpinx – purse string suture • Failure rate very low.
  21. 21. ALDRIDGE METHOD • Hole in ant leaf of broad ligament • Fimbrial end buried into this. • High failure rate
  22. 22. SHIRODKAR’S METHOD • Cut ends are turned in opposite directions, so that spontaneous recanalisation does not occur
  23. 23. COMPLICATIONS • Anaesthetic hazards • Bowel & bladder injury • Broad ligament hematomas • Infection • Wound sepsis • Peritonitis
  24. 24. LAPAROSCOPIC STERILISATION Advantages • Direct visualisation & manipulation • Associated pelvic & abdominal abnormality detected • Hospitalisation not needed • Cosmetic advantage • Min postop pain & discomfort • Reversibility more after clip application.
  25. 25. Veress needle Trocar & canula
  26. 26. • Lithotomy position • Local anaesthesia • Bladder catheterised, uterine manipulator applied • Trendendeleburg position ( head down 15o ) after placing first trocar • Entering abdominal cavity – 1. Veress needle 2. Direct trocar 3. Open laparoscopy
  27. 27. VERESS NEEDLE
  28. 28. OPEN LAPAROSCOPY
  29. 29. METHODS 1. Rings 2. Clips 3. Electrocoagulation
  30. 30. RINGS • Falope ring – silicone rubber with barium sulphate
  31. 31. CLIPS • Filshie clip • Silicone • Better • Hulka Clemens clip • Spring loaded
  32. 32. ELECTRO COAGULATION • Unipolar& Bipolar cautery • Reversal difficult
  33. 33. COMPLICATIONS • Anaesthetic complications • Injury of large vessels • Bleeding from epigastric vessels – trocar • Tearing of mesosalpinx & hemorrhage • Bowel injury • Thermal burns • Surgical & Mediastinal emphysema
  34. 34. CONTRA INDICATIONS • Severe cardio pulmonary disease • Prior abdominal surgery • Postpartum sterilisation • Extreme obesity, umbilical hernia Laparoscopy best used for interval sterilisation or following abortion of less than 12 weeks.
  35. 35. VAGINAL TUBAL LIGATION • Colpotomy performed • Complications – bowel injury, pelvic abscess
  36. 36. HYSTEROSCOPIC STERILISATION • Essure • Buscopan & NSAID to prevent tubal spasm • Fibrotic tissue reaction • Backup contraception – 3M • Then hysterosalpingogram to confirm occlusion
  37. 37. SEQUELAE OF STERILISATION 1. Ectopic pregnancy • Partial recanalisation, tuboperitoneal fistula • More likely after 3 yrs 2. Post tubal ligation syndrome • Abnormal bleeding, isolated ovarian syndrome • Pain, cystic ovaries 3. Regret & Depression
  38. 38. FAILURE • Typical failure rate – 0.3% Procedure Failure rate % Irwing 0.1 Parkland 0.25 Laparoscopic rings & clips 0.2 - 0.3 Pomeroy’s 0.3 Madlener’s 2 Fimbriectomy 2 - 3
  39. 39. • Due to – • Recanalisation • Incomplete division • Incomplete occlusion • Ligation of round ligaments in place of tubes • Presence of early pregnancy
  40. 40. REVERSAL • Micro surgical anastomosis • Depends upon – • Type of procedure • Length of tube remaining • Associated conditions like endometriosis, post op adhesions affecting infertility
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Female sterilisation A Family Planning & Gynecology topic for MBBS

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