Microsurgery in Pelvic Desease
Microsurgical techniques have been adopted to treat pelvic adhesions, tubal obstruction, endometriosis and myomas of the uterus. The principals involved are gentle tissue handling, use of physiologic solutions such as saline or lactated Ringer's solution for irrigation of the tissue during surgery to prevent hydration. It also entails the use of nonreactive suture material. The site of surgery is usually covered with a type of membrane to act as a barrier to prevent adhesions. These principals of microsurgery are used whether the surgery is performed by laparotomy or laparoscopy.
Laparoscopic surgery is an advance in our field to aid in the diagnosis and treatment of certain pelvic conditions leading to infertility. Laparoscopy is commonly used for correction of tubal obstruction, lysis of peritubal adhesions, or creating a new tubal osteum known as neosalpingostomy. However, severe tubal obstruction leading to hydrosalpinx (tube distended with fluid) may need removal of the fallopian tube and consideration of in vitro fertilization (IVF) if both tubes are obstructed. Removal of the hydrosalpinx is recommended before IVF because the inflammatory fluid in the tube is embryotoxic and can reduce implantation rates by as much as 50%.
It is estimated that 5-10% of patients who had tubal sterilization return for consultation because they would like to have their tubes repaired or anastomosed. This may be due to any number of reasons such as desire for more children, change in marital status, etc. In our division the reproductive endocrinologists are experienced in microsurgical tubal anastomosis. Tubal patency rates can be as high as 80% with pregnancy rates equivalent to the patient's natural fecundity (per cycle probability of pregnancy based on the patient's age) and affected by the type of prior tubal ligation procedure, length of tube after anastomosis and other fertility factors. The best success is a tubal reversal after a non-cautery (non-electrical) method of ligation such as clips, rings, and the Pomeroy procedure. Most of these pregnancies occur between six months to one year after the procedure is completed.
This is a very highly specialized procedure and requires proper training. The tube is usually anastomosed in two layers using 8-0 or 9-0 nylon interrupted sutures. Magnification is essential and a special microscope is necessary for this procedure.