LEEPS and TUBALS

1. LEEPS and TUBALS M. Chantel Long, M.D. July 22, 2011

3. Tubal Ligation • Surgical sterilization is the most popular form of contraception in the U.S. (includes tubal ligation and vasectomies) • Female sterilization is chosen by about 28% of couples • Can be performed at any time, but half of them are performed in conjunction with a cesarean or vaginal delivery

4. Puerperal Tubal Sterilization • Since oviducts are easily accessible at the umbilicus for days after delivery, is considered technically simple and doesn’t prolong hospitalization • Some physicians prefer to wait 12-24 hours after delivery

5. Tie the Tubes • The first tubal was performed over 120 years ago • Consisted of a silk suture placed around the tubes one inch distal from the uterine attachment at the time of a C-Section • This led to many different techniques to disrupt tubal patency

6. Irving Procedure • Most difficult • Least likely to fail • The cut oviduct is separated from the mesosalpinx to free a medial segment. • Then, the medial cut end is buried in the myometrium posteriorly and the distal cut end is buried in the mesosalpinx

8. Pomeroy Procedure • Simplest method • Plain catgut is used to ligate the knuckle of the tube • This ensures prompt absorption and separation of the severed tubal ends • Ectopic pregnancy can occur in the distal segment • Suture slippage is a concern

13. Parkland Procedure • Similar to the Pomeroy but avoids the intimate approximation of the cut ends of the oviduct • The avascular mesosalpinx is opened with blunt dissection • A 2cm segment is ligated with O-Chromic and excised between the sutures

16. Risks and Benefits • Failure rate is less than 1/400 for the last 4 decades and is now close to 3-12/1000 • Electrocautery destroys more tissue and makes reversal less possible • Puerperal sterilization fails for two major reasons: Surgical Error: ligation of the round ligament or only partial transection of the oviduct Formation of a fistulous tract between the severed stumps or spontaneous reanastomosis

18. Risks • Anesthesia Complications • Injury to adjacent structures • Failure (with subsequent intrauterine or ectopic pregnancy) • Case Fatality rate is 1.5/100,000 • Complication rate is 1/100

19. Failure Rates • Surgical error accounts for 30-50% of cases • Failures after one year are not likely due to technical errors • Fistula formation (peurperal), faulty clips (interval) • Luteal Phase Pregnancy – With interval tubals, woman is already pregnant at the time of surgery

20. Ectopic • Half of pregnancies that follow a failed tubal with electrocautery are ectopic versus 10% with ring, clip, or resection • ANY symptom of pregnancy in a woman after a tubal sterilization must be investigated and an ectopic must be ruled out

21. Posttubal Ligation Syndrome • Increased incidence of menorrhagia and intermenstrual bleeding • Current studies lean toward decreased duration and volume of menstrual flow, less dysmenorrhea, yet increased irregularity • Talk to patients about their prior contraception

22. Factoids? • Protects against ovarian cancer • Increase in functional ovarian cysts • 80% no change in sexual interest • Of the 20% with a change, positive effects were 10-15 times more likely • At 5 years, 6-7% of women express regret (same as women whose husbands had vasectomies)

23. Reversal • No woman should undergo sterilization believing it can be reversed • Difficult, expensive, and unsuccessful • Rates vary based on method, tube length, age, fimbriectomy, etc • Almost 10% of women who undergo reversal have an ectopic pregnancy

24. Nonpuerperal (Interval) Tubal • Ligation and resection at laparotomy • Application of permanent rings, clips, or electrocautery to the fallopian tubes via laparoscopy with or without transection • Electrocoagulation of a segment of the tubes, usually through a laparascope or via vagina (hysteroscopy)

25. Disadvantages • Laparascopic tubal ligation is under general anesthesia with endotracheal intubation • Disrupts breastfeeding • Technically more difficult

26. Intratubal • Chemicals – silicone, erythromycin, quinacrine • Devices – Essure microinsert (stainless steel inner coil with expandable outer coil of nitinol; outer coil expands after placement, tissue grows, occlusion occurs) is costly; requires HSG at 3 months to ensure tubal blockage

27. Consent and Restrictions • Female (male) • Insurance Guidelines (Medical Card)

28. Surgery • Small infraumbilical incision is made through the skin (between two alices pulled taut) • Bluntly dissect with a kelly to the fascia • Lift and open the fascia with mayo scissors between two kellys • (I keep the kelly on the fascia) • Open the peritoneum, again between two kellys; check for bowel • Place army/navy • Rotate/tilt the patient and identify the oviduct

30. Surgery Cont’d • Can put a kelly on a mini-lap and push into abdominal cavity and upward with pick-ups for better visualization • Grasp with a babcock and “walk” to the distal end to visualize the fimbriae and ovary (to be sure you don’t have the round ligament, which is smoother, less vascular, and more taut) • If you drop the oviduct, start over • Suture is placed times two (with one tagged), the oviduct resected, and segments are sent for pathology

32. Surgery Cont’d • Electrocautery • Inspect each end for hemostasis • Close fascia and skin

33. Conclusions • A thorough discussion of the risks, benefits, and alternatives to permanent sterilization should take place for informed consent • Is safe (complication rate <1% and failure rate approx. 5/1000) • Pregnancy after tubal ligation is more likely to be ectopic • Procedure should be considered permanent

34. Conclusions, Cont’d • Laparoscopic and minilaparotomy have comparable safety and efficacy • Sexual desire and menses overall not affected • Less likely to develop ovarian cancer and PID • Women with preexisting gyn conditions (menorrhagia, irregularity) may be better served by hormonal contraception

36. LEEP

37. Definition • Loop Electrosurgical Excision Procedure • The electric arc does the cutting not the loop itself • The high density current vaporized the tissue, exploding cell releases steam which forms a steam envelope that prevents contact between the electrode and the tissue, ionization of the steam in the electric field forms an arc which cuts the tissue • Since the arc does the cutting, placing the electrode in direct contact with the tissue reduces the power density and causes dessication

38. Dessication • Dessication interrupts the continuous current, which collapses the steam envelope • You can also cause this to happen by forcing the loop to move faster than the arc can cut (the loop drags through the tissue, bends, changes shape of the specimen and can get “stuck”) • Dessication damages the specimen causing cautery artifact that makes pathological interpretation more difficult

39. Treatment Options • Ablation = Cryotherapy or Laser with Destruction of the transformation zone • Excision = LEEP or Cold Knife Conization with Removal of the transformation zone • Observation: • CIN1 • CIN2,3 in adolescents and young • Cytology/Histology Discrepancy

40. LEEP • Adult Women • CIN 2,3 • HSIL • Adolescent/Young Women • CIN 3 • CIN 2,3 that persists for > 2 years • CIN 2 with unsatisfactory colposcopy • CIN 3 Any Age

41. CIN 2 in women >30 usually persists or worsens • CIN 2 in women <25 usually regresses • Cryotherapy can lead to cervical stenosis and secondary unsatisfactory colposcopies

42. LEEP • Two classes of Loop Electrosurgical Excision Procedure • Routine • 7-8 mm in depth • Single Pass • For lesions confined to ectocervix • LOOP Conization • LEEP with Top Hat (Second pass into endocervical canal) • Used when lesions extend into the canal • 1x1 cm loop

43. Indications for Routine LEEP • CIN 2,3 (Biopsy Confirmed) • Satisfactory Colposcopy • Patient prefers over ablative therapies • Recurrent CIN after prior therapy (because they automatically have an unsatisfactory colposcopy) • Can not treat the entire lesion with the cryo gun (size, geographic) • When “see and treat” is advantageous

44. Indications for LEEP Cone • CIN 2,3 with unsatisfactory colposcopy • HSIL Pap with unsatisfactory colposcopy • CIN 2,3 with positive ECC (neoplasia of any grade present) • Some observe if felt the positive ECC is contamination from ectocervical lesion • Some observe if CIN1 on ECC and pap is only ASCUS or LSIL • Once they have had cryotherapy or an unsatisfactory coloposcopy with an abnormal pap they need to proceed to LEEP

45. Advantages of LEEP • Office Procedure • Minimal Pain (from local anesthetic and reflexive cramping) • Easy to learn and perform • Equipment is simple to maintain • Entire TZ is assessed histologically to rule out cancer!

46. LEEP Counseling • Cervical Stenosis • Occurs in 1-6% • Bleeding • Immediate post-procedure bleeding • Ball Cautery (Avoid cauterizing near the os) • Monsel’s • Suture • Premature Delivery

47. LEEP Counseling • Vaginal Wall Burns and Lacerations • Risk lessened with insulated vaginal sidewall retractors • Recurrence or Persistence of Disease • 5-15% • 6 year risk of CIN 2 or 3 after LEEP with clear margins • CIN 2: 3.6-4.3% • CIN 3: 8.6-13.6%

48. Obstetric Outcomes after LEEP • Increase in: • Late preterm births (>32 weeks) • pPROM • Low birth weight infants • No increase in: • Preterm births <32 weeks • C/S • NICU admissions • Perinatal Mortality

49. Contraindications • Suspected Invasive Cancer • AIS or Squamous Cell Cancer (can have skip lesions; need excisional procedure that shows clear margins without thermal artifact to exclude invasion and to determine if she needs simple or radical hysterectomy) • Cervicitis (Treat it first, because they bleed with procedures; check wet mount, KOH, GC testing for causes of trich, yeast, GC) • Pregnancy • Permanent Pacemaker • Allergy to local anesthetic • Oral Anticoagulants or Hemorrhagic Disorder

50. Follow-Up • Wait 6 months after a LEEP to get pregnant • Pap at 6 and 12 months then yearly (can add HPV testing if desired; because a negative HPV is highly predictive for treatment success, but note that testing is not type-specific so a positive could be new infection and not persistant/recurrence) • Annual paps for 20 years • If any paps are abnormal or positive HPV, then colposcopy (to rule out persistence or progression) • Most recurrences are found within 24 months