TuboplastyMicroresection and Anastomosis of the Fallopian Tube

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Tuboplasty - Microresection and
Anastomosis of the Fallopian Tube

Microresection and anastomosis of the Fallopian tube are indicated in those cases of infertility where tubal obstruction has been diagnosed by hysterosalpingography and confirmed by laparoscopy. In recent years, this procedure has been performed by a microtechnique, utilizing fine suture and magnification with ocular loupes or an operating microscope. If careful hemostasis and microtechnique can be used, excessive postoperative scarring and peritubular adhesions can be reduced. Scarring and stricture formation at the site of the anastomosis can be minimized. This allows greater motility of the Fallopian tube, giving it a greater chance of receiving the oocyte, which is transported down the Fallopian tube to meet spermatozoa emerging from the proximal end of the tube.

Physiologic Change. The Fallopian tube is restored to its normal function.

Points of Caution. Meticulous hemostatic technique is essential. To ensure that a proximal portion of tube is patent, indigo carmine dye is injected via fine-gauge spinal needle placed through the fundus into the endometrial cavity, with the lower uterine segment obstructed with a clamp.

The stent used to aid in performing the anastomosis is removed immediately after the operation.

Technique

A double-headed operating microscope with both surgeons focusing on the intra-abdominal pelvic contents is shown. Microsurgery of the Fallopian tube requires magnification to this level. Special eyeglasses and loupes are also helpful in this technique.

After the abdomen is entered, peritubular adhesions are totally excised, not lysed, with a microneedle cautery or fine microscissors. The uterus is elevated into an ideal operative position by packing off the cul-de-sac with wet gauze.

The proximal end of the scarred, distal segment of Fallopian tube is transected. A fine probe is inserted through the fimbriae and passed through the open Fallopian tube. A notch in the probe has been designed to accept a 2-0 Prolene or nylon suture.

The 2-0 Prolene suture is pulled through the distal segment of the Fallopian tube.

The proximal segment of tube is picked up and transected with microscissors.

The lower uterine segment is occluded with a Buxton clamp, and indigo carmine dye is injected via a 21-gauge spinal needle through the fundus into the endometrial cavity. Observation of spill from the stump indicates patency of the cornual portion of the tube.

A 2-0 suture is threaded through the proximal stump of the Fallopian tube into the endometrial cavity where it is allowed to coil.

A similar procedure is performed on the opposite tube.

The mesosalpinx of the Fallopian tubes is anastomosed with interrupted 8-0 Dexon suture via the microtechnique.

After the mesosalpinx has been closed, the first layer of 8-0 Vicryl suture is placed in a north, south, east, west position. Care is taken to place the microsuture in the submucosal layer of the tube and avoid the tubal mucosa when possible.

Approximatley 4 or 5 of these sutures are placed until the tube is completely closed.

A second layer of 8-0 Dexon suture is placed through the serosa and outer portion of the muscle of the Fallopian tube. When tied, the tube is anastomosed in such a manner that an indigo carmine solution injected into the fundus will flow through the Fallopian tube. The same procedure is carried out on the opposite side.

In this sagittal section of the pelvis after completion of surgery, the pelvis is filled with Hiscon (low-molecular-weight dextran) to reduce adhesion formation following microsurgery by creating intra-abdominal ascites, which keeps the various surfaces separated until mesothelialization is complete. R indicates rectum.