Task Analysis of Laparoscopic Fallopian Tubal Recanalisation

DR.LAKSHMI SREE ATMURI  [ MS OBGY, F.MAS, D.MAS]

TUBAL RECANALISATION:
Surgical approximation of tubal segment after tubal sterilization or excision of an occluded or diseased portion of the fallopian tube

INDICATIONS: Desire for fertility

REQUIREMENTS:

Normal semen analysis
Age more than 40yrs
Tubal sterilization previously by modified Pomeroy, fallopian rings, Filshie Clips
HSG to assess the length of the fallopian tube

CONTRAINDICATIONS:

Age more than 40 yrs
Decreased ovarian reserve 
Ovarian failure
Extensive tubal damage 
Tubal length less than 3cm
Severe male factor infertility

IMPORTANCE:

Respect to the delicate nature of the tissue
Minimum use of energy sources
Irrigate abdominal cavity with normal saline to minimum drying or adhesion 

PROCEDURE:
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1. Patient in lithotomy position under general anesthesia
2. Foleys catheterization
3. Check veress needle for its spring action and patency
4. Take 2allis forceps to evert and hold each side of umbilicus
5. Use number 11 blade to place small horizontal stab wound on the inferior crease of umbilicus
6. Mosquito artery to dissect subcutaneous adipose tissue and expose rectus sheath
7. Measure abdominal wall thickness and add 4cm for distance to hold veress needle
8. Veress needle should be held like a dart
9. Lift suprapubic part of abdominal wall with the left hand
10. Insert veress needle in stab incision with 45-degree elevation angle and distal end pointed towards anus and perpendicular to the abdominal wall
11. The surgeon can hear 2 click sound and maintain the 45-degree angle
12. Confirm correct veress needle placement by irrigation test, aspiration test, and hanging drop test
13. Connect carbon dioxide gas tube to veress needle 
14. Check quadromanometry for intraperitoneal placement of veress needle
15. Ideal preset pressure of 12mmhg, maximum of 15mmhg
16. The flow rate of 1lit/min
17. Check uniform distension of abdomen and obliteration of liver dullness
18. Once pneumoperitoneum is achieved remove veress needle
19. Take cannula of 10mm and mark its impression on the skin
20. Extend incision to the size of cannula impression
21. Introduce 10mm port by holding it like a piston,  perpendicular to the abdomen
22. Confirm intraabdominal placement of port by escaping air sound and audible click
23. Take out trocar
24. Set flow rate increased to 6lit/min
25. Connect gas tubing to the primary port
26. Insert telescope
27. Inspect entry point to exclude any bowel or vessel injury
28. Request for Trendelenburg of 30-degree position
29. Perform diagnostic laparoscopy with special attention to tubes
30. Insert uterine manipulator to aid ease of suturing fallopian tubes
31. Secondary and tertiary port placement with help of baseball diamond principle
32. Ipsilateral port placement may be desired
33. Vasopressin 5IU diluted in 20ml normal saline is injected into mesosalpinx with help of aspiration needle
34. Dissecting scissors in the dominant hand
35. Maryland forceps on another hand
36. Excise occluded area of the tube
37. Freshen up the ends of the fallopian tube
38. Minimize injury to mesosalpinx
39. Preferred suture 4-0 vicryl cutting edge needle
40. First Mesosalpinx is to be approximated, to prevent tension over the tube and also anastomosis becomes easy
41. Surgeon knots to be applied
42. Avoid torsion of tube
43. Avoid catching tube directly with a grasper or any other instrument
44. Seromuscular sutures are placed at 6, 10, 2* clock position on right fallopian tube 
45. Seromuscular sutures are placed at 6, 10, 2* clock position on left fallopian tube
46. Patency of the tube can be checked
47. stop insufflation
48. remove all ports under the vision
49. close port sites 10mm port with help of veress needle, or port closure devices

Elaborated Steps:

Position the patient in the supine position.

Administer general anesthesia.

Insert a urinary catheter to empty the bladder.

Preoperative antibiotics are administered.

Make a 10-12mm incision at the level of the umbilicus.

Use a Veress needle to insufflate CO2 into the abdomen.

Insert a 10mm trocar through the incision.

Insert a laparoscope through the trocar and visualize the abdominal cavity.

Identify the fallopian tubes and the site of previous sterilization.

Use a monopolar or bipolar electrosurgical device to make an incision at the site of previous sterilization.

Use a laparoscopic grasper to grasp the proximal end of the fallopian tube.

Use microscissors to make a small incision in the proximal end of the fallopian tube.

Repeat the same procedure for the distal end of the fallopian tube.

Use a microforceps to remove any scar tissue or sutures that may be present at the site of previous sterilization.

Use a guide wire to cannulate the proximal end of the fallopian tube.

Use a catheter or balloon catheter to dilate the proximal end of the fallopian tube.

Use a guide wire to cannulate the distal end of the fallopian tube.

Use a catheter or balloon catheter to dilate the distal end of the fallopian tube.

Use a 10-0 or 9-0 nylon suture to perform the anastomosis between the proximal and distal ends of the fallopian tube.

Use interrupted sutures to ensure a watertight closure.

Use a dye test to confirm patency of the anastomosis.

Inspect the pelvic organs and surrounding structures for any signs of bleeding.

Remove the laparoscope.

Remove the trocars.

Deflate the abdomen.

Close the incisions with sutures or staples.

Apply sterile dressing to the incisions.

The patient is awakened from anesthesia.

Extubate the endotracheal tube.

Move the patient to the post-anesthesia care unit.

Administer analgesics for pain management.

Monitor vital signs and urine output.

Check the dressing for bleeding or drainage.

Observe the patient for any signs of infection or complications.

Advise the patient to avoid strenuous activity for 2-4 weeks.

Advise the patient to avoid intercourse for 2-4 weeks.

Schedule a follow-up appointment.

Evaluate the patient's postoperative course.

Monitor for any complications, such as bleeding or infection.

Evaluate the patient's recovery of bowel and bladder function.

Adjust medication as needed.

Evaluate the healing of the incisions.

Provide the patient with a detailed report of the procedure and postoperative care.

Advise the patient on any potential complications or side effects of the procedure.

Provide the patient with instructions on follow-up appointments and monitoring.

Advise the patient on when to resume normal activities, such as driving, work, and exercise.

The patient follows up with the surgeon at regular intervals.