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|Year : 1985 | Volume
| Issue : 3 | Page : 167-9
Early puerperal laparoscopic sterilization--a new technique.
Parulekar SV, Bhattacharya MS, Madhav HT
This paper describes the results of 23 cases of puerperal laparoscopic sterilization performed within 72 hours of delivery. A new method was employed to avoid injury to the uterine fundus and to make the tubes more accessible. Before insertion of the Veress needle, the anterior and posterior lips of the cervix were held with forceps and Hulka's uterine manipulator was introduced into the uterine cavity. The uterus was pulled down toward the introitus by applying traction to the sponge-holding forceps. Pneumoperitoneum of 3-4 liters was induced through use of a Veress needle, followed by introduction of a Storz single puncture operative laparoscope through an incision in the lower umbilical fold. Tubal occlusion was achieved with silastic bands. The average time required for sterilization from induction of general anesthesia was 6 minutes. There was no instance of injury to the uterine fundus, nor were there any cases of uterine perforation, injury to other pelvic structures, laceration of the cervix, or puerperal sepsis. At the time of follow-up 15 days after the procedure, all patients were in satisfactory condition. It is concluded that this method can enhance postpartum family planning programs. Since it can be carried out within the 1st 48 hours after delivery, the routine hospital stay of 3 days does not have to be prolonged as a result of sterilization.
|How to cite this article:|
Parulekar S V, Bhattacharya M S, Madhav H T. Early puerperal laparoscopic sterilization--a new technique. J Postgrad Med 1985;31:167
The uterus remains large and easily palpable for upto 10 days following delivery. A small subumbilical incision is adequate for sterilization, but takes more time and involves greater handling of tissues including intraperitoneal structures. Operative laparoscope offers a cosmetic scar, rapidity of procedure and minimal handling of tissues. It also eliminates the risk of incisional hernia. However, the incidence of direct injury to the uterine fundus by Veress needle or trocar and cannula is high. Also, the fallopian tubes run backwards and are difficult to catch. The lower segment is collapsed, atonic and folded, so that it is difficult to achieve any leverage by means of intrauterine instrumentation.
With a simple modification of the older technique, all these problems can be eliminated. This modification forms the basis of the present report.
Twenty-three women were subjected to laparoscopic tubal ligation under controlled general anaesthesia, within 72 hours after delivery. Prior to insertion of the Veress needle, the anterior and the posterior lips of the cervix were held with sponge holding forceps. Hulka's uterine manipulator was introduced into the uterine cavity. The uterus was pulled down towards the introitus by giving traction on the sponge holding forceps applied to the cervix, which lowered the level of the uterine fundus by 4-5 cm. Pneumoperitoneum of 3-4 litres was induced using a Veress needle, followed by introduction of a Storz single puncture operative laparoscope, through a semilunar incision in the lower umbilical fold. During manipulation of the uterine position with Hulka's manipulator, traction was maintained on the cervix. Tubal occlusion was achieved with silastic bands.
Post-operatively, the patients were given injection tetanus toxoid 0.5 ml, benzathine penicillin 2.4 magaunits i.m. after a test dose and 6 hours later, oral ampicillin 250 mg which was continued every 6 hourly for 5 days. All the patients were discharged 3 days after delivery, which is the usual time of discharge of non-operated women after delivery in our hospital.
The patients were seen again after 15 days.
Eighteen sterilization procedures out of twenty-three were done between 48 and 72 hours from delivery, 4 between 24 and 48 hours, and 1 in the first 24 hours. The average time required for sterilization from the time of induction of anaesthesia was 6 minutes, the range being 4 to 10 minutes.
There was no instance of injury to the uterine funds by the Veress needle or the trocar and cannula, nor were there any cases of uterine perforation by the manipulator, injury to other pelvic structures, laceration of cervix by sponge holding forceps or puerperal sepsis.
At the time of the first follow-up after 15 days, all patients were in a satisfactory condition.
There have been various reports on puerperal laparoscopic tubal ligations.,,,, Different methods have been employed to achieve a contracted uterus by administering oxytocin or ergot and to lower the height of the uterus by keeping self retaining catheter in the bladder. Neely et al introduced trocar and cannula tangential to the uterine fundus and taking advantage of the lax abdominal wall, moved the laparoscope sideways to visualise the fallopian tubes. Mueller et al used a second puncture at a higher level and a third puncture, whenever required, to displace the uterus medially with a blunt probe. However, such manoeuvers are not without risk.
Lowering the height of uterus by cervical traction combined with the use of Hulka's uterine manipulator offers a simple, rapid and effective method of performing laparoscopic sterilization in a recently delivered woman. It eliminates complex laparoscopic manoeuvers and handling of intraperitoneal structures and leaves a cosmetic scar. Traction on the cervix for 6 minutes is too brief to cause any permanent weakening of uterine supports and predispose to prolapse of the uterus in future.
The height of uterine fundus is 12-15 cm above the pubic symphysis immediately after delivery and for the next 48 hours. With the present method, the procedure of sterilization can be easily carried out within the first 48 hours of delivery without prolonging the routine hospital stay of 3 days. In the recent years, there has been a growing acceptance of laparoscopic sterilization over puerperal abdominal sterilization. This method will help to enhance the family planning programme especially, the post-partum family planning programme.
We thank Dr. G. B. Parulkar, Dean of K.E.M. Hospital and Seth G.S. Medical College for allowing us to use hospital data and publish this paper. We also thank Dr. M. Y. Rawal, Head, Department of Obstetrics & Gynaecology, K.E.M. Hospital, Parel, Bombay 400 012.
|1.||Houser, K. T. and Norborg, C. S.: Puerperal laparoscopic sterilisation, In, 'Endoscopy in Gynaecology', Editor: J. M. Phillips, The proceedings of The 3rd International Congress on Gynaecological Endoscopy, San Francisco, California, Publishers: American Association of Gynaecological Laparoscopists, Departmental Publications, 1978, pp. 175-177. |
|2.||Keith, L., Webster, A. and Houser, K. T.: Laparoscopy for puerperal sterilisation. Obstet. Gynecol., 39: 616-621, 1972. |
|3.||Mueller, R. L., Scott, C. S. and Bukeavich, A. P.: Puerperal laparoscopic sterilization. J. Reprod. Med., 16: 307-309, 1976. |
|4.||Neely, M. R. and Elkady, A. A.: Modified technique of puerperal laparoscopic sterilization. J. Obstet. Gynaecol., Brit. Cowlth., 79: 1025-1027, 1972. |
|5.||Tamaskar, K. P.: Early postpartum laparoscopic sterilization. J. Obstet. Gynaecol. India, 28: 217-219, 1978. |