Before fimbrioplasty, the surgeon should perform a diagnostic laparoscopy.

For diagnostic laparoscopy, the patient is placed in the dorsal lithotomy position with the hips flexed 45°, the knees flexed at 90°, and the buttocks extended at least 4 inches beyond the edge of the operating table. The patient is placed in approximately a 15° Trendelenburg position.

A thorough bimanual pelvic examination is performed.

The laparoscopic instruments are introduced as recommended, under Laparoscopy Technique, and the pelvis is thoroughly inspected. If there is gross hydrosalpinx or gross damage to the Fallopian tubes on both sides, it may be wise to abandon the procedure. The ideal patient for fimbrioplasty has a Fallopian tube that is normal except for the fimbriae, which are agglutinated or clubbed. The clubbed end of the tube is slightly distended by the injection of indigo carmine solution through the uterus during laparoscopy. The laparoscopic instruments are withdrawn; the small umbilical incision is closed with a 3-0 subcuticular suture.

Two positions can be used for fimbrioplasty. One, as shown here, is the dorsal supine lithotomy position in which the legs are lowered in obstetrical stirrups so that the hips are extended 10° rather than flexed and the knees are flexed approximately 90°. The legs are abducted approximately 15°, exposing the vulva and perineum. This position is preferable when a surgeon wishes to apply instruments to the cervix and a cannula in the endometrial cavity during the procedure. It allows injection of indigo carmine solution through the cervix by means of a cervical cannula. In addition, the uterus can be elevated into the appropriate operative position without using traction sutures on the fundus or packing the cul-de-sac with gauze.

A Pfannenstiel incision is generally preferred in these cases. Dye marks have been placed to aid closure of the abdomen for a better cosmetic appearance.

The abdomen has been opened through the Pfannenstiel incision. Adhesions are found between the Fallopian tube, ovary, and round ligament. The bladder is on the right; the fundus is in the middle. An occlusive Buxton-type clamp is applied to the lower uterine segment, and a 21-gauge needle on a 10-mL syringe filled with indigo carmine solution is inserted through the fundus. The endometrial cavity is filled with the dye. This dye should spill into the Fallopian tubes slightly distend the clubbed ends of the Fallopian tube that requires a fimbrioplasty.

Moist packs have been placed in the cul-de-sac to elevate the uterus, tubes, and ovaries into the incision. The microtip cautery is used to remove adhesions. Visual magnification and a source of excellent light are essential if this step is to be performed. The principle of traction/countertraction on the structure is essential to safely demonstrate the adhesions.

When the adhesions have been completely removed, the clubbed end of the Fallopian tube can be identified; it should be opened with the cautery on a low setting. Bright light and visual magnification will aid the surgeon in performing this delicate task.

A microforceps is used to elevate the serosal layer over the end of the clubbed Fallopian tube. Small vessels are coagulated prior to opening the clubbed end of the fimbriae with the microtip electrical cautery. When the scar tissue over the clubbed end of the tube has been transected, indigo carmine dye will be observed spilling from the Fallopian tube.

Microforceps and microscissors are used to pick up the scar tissue and transect the scarred serosal layer covering the fimbriae beneath. It is important to identify the fine blood vessels in the scarred covering of the fimbriae; the incisions into scarred serosa should be tailored to transect as few of the blood vessels as possible. Hemostasis is controlled with the microelectrode.

The scarred serosal covering of the clubbed Fallopian tube has been opened, and when it is folded back, the fimbriae should prolapse out of the Fallopian tube.

Irrigation with warm saline solution can be used to separate the fimbriae and identify the lumen of the ampullar portion of the Fallopian tube.

With 7-0 Prolene suture on a microneedle, the scarred serosa is sutured back to the serosa of the Fallopian tube in such a manner as to free the fimbriae and keep the Fallopian tubes patent.

To check the patency of the Fallopian tubes, the lower uterine segment is pinched between the thumb and first finger or held with an atraumatic clamp, and a 10-mL syringe on a 21-gauge needle is inserted through the fundus to inject 10 mL of indigo carmine into the endometrial cavity. The dye should fill the Fallopian tubes and spill from the fimbriae.

Hydrotubation should be performed every other day for 2 weeks. A solution containing a broad spectrum antibiotic, cortisone, and saline is injected through the cervix with a Rubin cannula.