Laparoscopic treatment of distal tubal disease

Practical Training and Research in Gynecologic Endoscopy

J. Bouquet de Joliniere
Service de Gynécologie Obstétrique
Hopital Beaujon, Paris
G. de Candolle
Geneva WHO Collaborating Centre for Research in Human Reproduction

INTRODUCTION

Operative laparoscopy in the early 1970s was confined to tubal sterilisation but, by the middle of the decade, the use of laparoscopy as a means of access to perform other operations began to gain acceptance. Among the first procedures to be performed were those to promote fertility and included the treatment of peri-adnexal adhesions and distal tubal obstruction.

Diagnostic laparoscopy should always commence with a detailed examination of the abdominal organs. This should be followed by inspection of the pelvic organs commencing with the uterus and then proceeding systematically to examine the tubes, ovaries and pelvic peritoneum. The presence of adhesions and the patency of the tubes will be noted. If there is distal tubal obstruction, assessment of the status of the tube may be carried out (see Chapter 13) before a decision is made to perform neosalpingostomy.

INSTRUMENTS

Cutting Instruments.
Adhesiolysis is best carried out with scissors. The scissors may have a post for attaching them to a monopolar electrosurgical unit to allow coagulation and cutting at the same time. Scissors tend to become blunt with use. Disposable scissors are expensive but a recent development is reusable scissors with replaceable blades which combine the advantages of machine tooled instruments with the ability to replace or re-sharpen blades which have become blunt with use.
Electrosurgical Instruments.
Effective tissue cutting can be performed with a non-modulated monopolar current in the cutting mode. This is best applied with a retractable micro-needle. A blended current may be used to coagulate vessels using either monopolar or bipolar forceps.
Laser.
Four laser systems are in current use in gynaecological surgery - carbon dioxide, KTP, Argon and Nd:YAG. CO2 laser with a penetration of less than 5mm is the most suitable for laparoscopic infertility surgery. It must be delivered through a rigid lens system whereas the other lasers are suitable for delivery through flexible lenses. Cutting of tissues may be performed very accurately but electrocoagulation may be required to achieve haemostasis.
Other Instruments.
Fertility promoting surgery requires the standard instruments used for all laparoscopic surgery - intra-uterine cannula for manipulation and chromopertubation, 5mm trocars and cannulae, atraumatic grasping forceps, irrigation cannula and pump system and, possibly, needle holders for suturing the tube.

TECHNIQUE

Laparoscopic fertility promoting surgery should encompass the principles of microsurgery - magnification, gentle tissue handling and keeping the tissues moist at all times. Magnification is obtained by the inherent design of the laparoscopic lens which allows magnification x2. This is augmented by the use of a video screen. Tissues should be handled gently with atraumatic forceps or retractors. Copious irrigation during and after the procedure to remove blood and debris and prevent tissue desiccation are vital to success. Tissue trauma and desiccation may encourage adhesion formation.

There are limitations to laparoscopic surgery. The number of portals of entry are limited to two or three so the variety of angles of approach to the target organ are also limited. This disadvantage may be partially overcome by manipulating the uterus with the intra-uterine cannula, resting the adnexa on the retroverted uterus so that it acts as an internal operating table and by traction on other organs such as omentum during adhesiolysis.

Adhesiolysis.
Distal tubal occlusion is usually a sequel to pelvic inflammatory disease (PID) which often causes adhesion formation. The adhesions must be divided to gain access to the tube or to free the tube and ovary to facilitate ovum release and uptake. Postoperative adhesions are usually more dense and cohesive than those resulting from PID. While peri-adnexal adhesions are usually associated with obstructive tubal disease, they may present without tubal occlusion. In this case simple adhesiolysis may restore the normal tubal anatomy. If there is distal tubal occlusion, adhesiolysis must precede neosalpingostomy.
The principles of adhesiolysis must be respected. The adhesion should be completely removed if possible. Section of the adhesion should be close to the organ of attachment unless electrosurgery is being used in which case section should be at a distance from vital structures to prevent thermal injury. Filmy adhesions should be divided first. Fine adhesions involving the tube and ovary and in the pouch of Douglas may be displayed by floating the organs in N-saline at 400C. They can then be divided with micro-scissors or laser. Vascular adhesions should be coagulated prior to section using bipolar electrocoagulation. If dense adhesions involve the uterus, bowel or pelvic side-wall they may be divided safely by hydro-dissection using an irrigation cannula. This creates a space and defines the adhesion which may be then sectioned with scissors or laser. Peritoneal defects should be avoided as they may create potential sites for recurrent or fresh adhesive disease. Suturing or covering defects with Goretex membrane may help to reduce new adhesion formation.
Neosalpingostomy.
The technique of laparoscopic neosalpingostomy closely mimics that of microsurgery. The tube should be distended with trans-cervical insufflation with saline or dilute methylene blue. This confirms proximal tubal patency. Methylene blue has the advantage of outlining the tube clearly but the disadvantage of obscuring the mucosa during subsequent evaluation. The cruciate scar at the site of obstruction should be identified and the central dimple opened with scissors, micro-needle or laser. The initial incision should run from the dimple towards the ovary to form a new fimbriae ovarica. The surgeon may then grasp the edge of the tubal incision and gently evert the tube to allow inspection of the mucosa of the infundibulum. This eversion is usually self-holding. Further radial incisions may be made avoiding the vascular mucosal folds.
Eversion of the tubal osteum.
The new ostium must be kept open by eversion. Eversion may be effected by causing a superficial thermal injury to the serosa by using defocussed CO2 laser at 15 watts, contact with Nd:YAG laser or by touching the serosa with fine bipolar forceps. Alternatively the fimbriae may be sutured back on to the serosa with 5/0 prolene sutures. Another technique where the tube is folded back on itself lik a shirt cuff may be used and is usually self holding.
Tubal mucosal evaluation.
Following neosalpingostomy the tubal mucosa should be evaluated salpingoscopically as described in Chapter 13.

RESULTS

A number of series of laparoscopic neosalpingostomy have been published in the literature. These are summarised in Table I.

Table I

Year	Author	Number	IUP %
1984	Daniell	21	19
1984	Nezhat	33	36
1987	Bouquet	20	25
1987	Reich	7	29
1989	Manhes	19	48
1990	Dubuisson	31	26
1990	Larue	15	20
1991	Hery-Suchet	28	32
1991	McComb	22	23
1991	Matvienko	50	48
1991	Canis	87	33
1992	Audebert	142	20
1994	Donnez	85	27

The results of laparoscopic salpingotomy appear to slightly inferior to those of microsurgery. The main factor in determining the results is not the technique but the status of the fallopian tube. Unfavourable factors are a distended tube, a thick tubal wall, mucosal damage and peritubal adhesions. Full assessment of these factors at preliminary diagnostic laparoscopy can help to define those patients who are suitable for tubal reconstructive surgery or require assisted conception.