Abdominal tubal ligation

Abdominal tubal ligation is a family planning operation. Family planning surgery includes birth control, sterilization and re-pregnancy surgery. Commonly used in birth control surgery are intrauterine device placement and removal, early pregnancy abortion and mid-term pregnancy termination. Sterilization is the use of surgical methods to block fertility to achieve permanent contraception, women commonly used tubal ligation. Re-pregnancy is a kind of surgery that belongs to the family planning category because of the infertility caused by obstruction of the fallopian tube or the need for re-fertility due to some reasons after tubal ligation. Surgery requires less pain, safety, reliability, side effects, and is easily accepted. Therefore, the indications must be strictly controlled. The operation requirements are based on the principle of quasi-light, thin and fine, to minimize tissue damage and reduce complications. Tubal ligation is a female sterilization procedure in which the ligation of the fallopian tubes is performed by surgery, so that the sperm eggs cannot meet each other and achieve permanent sterilization. The tubal ligation has been developed for more than 100 years. As early as 1934, Blundell first proposed ligation of the fallopian tube during cesarean section. In 1981, Lungren performed tubal ligation during repeated cesarean section. Since Adair and Brown reported in 1934 that tubal ligation was performed early in calving to achieve sterilization, postpartum tubal ligation has become common practice. In the past, tubal ligation was only done to protect the mother, such as women with heart, liver, kidney, high blood pressure and other diseases or after the second cesarean section to avoid re-pregnancy endangering the mother's health and life. In recent years, with the accumulation of surgical experience, the operation technology, anesthesia, instruments and other aspects have been continuously improved, the safety of the operation has been improved, and the effect is reliable, which has become one of the important operations of family planning. Surgery can be performed by both abdominal and vaginal routes. Abdominal surgery can be operated under direct vision, safer, less complications, wide range of application, can be applied after various conditions and different times such as non-pregnancy, post-abortion, post-term pregnancy, postpartum, lactation . Due to the improved method of taking the fallopian tube, the method of oval-clamping tube method, finger-tube taking tube method and tubal hook-and-tube tube method is adopted, so that the surgical incision is greatly reduced compared with the prior, and only a 2 to 3 cm long incision can be made in the lower abdomen. There are many methods for tubal ligation, which have been recognized as the isthmus core-embedding method and the "sleeve" ligation method. These two characteristics are the ligature of the oviduct core in the isthmus, the damage is small, the effect is reliable, and it creates conditions for the future recanalization. Others can be used according to the need of folding ligation, cutting method, fallopian tube end embedding method, fallopian tube end cutting method. Transvaginal tubal ligation, surgical field of view is small, occasional adjacent organs such as the bladder, rectal injury, abnormal conditions need open laparotomy, generally not commonly used. With the development of laparoscopic techniques, laparoscopic sterilization has been the main method of female sterilization in some countries. Treatment of diseases: complications of hereditary disease after tubal ligation Indication 1. A married woman is required to be a sterilization. 2. Those who are not suitable for childbirth due to systemic diseases or certain genetic diseases. Contraindications 1. Systemic diseases cannot be loaded on the operator. 2. There are infected lesions or severe skin diseases on the abdominal wall. 3. Within 2 hours, the body temperature is above 37.5 °C. 4. Patients with severe neurasthenia and neurosis, emotional instability, and serious concerns about surgery. Preoperative preparation 1. The choice of operation time for non-pregnancy women can be done at any time, usually 3 to 7 days after menstruation, if the menstrual period or the second half of menstruation should exclude pregnancy, and at the same time for curettage. Surgery can be performed simultaneously after abortion or removal of the IUD. After spontaneous abortion and expired abortion, you need to wait for the next menstrual period. After normal delivery or mid-term induction of labor, if there is no abnormality in the puerperium, the operation can be performed after 24 hours. After dystocia, it is necessary to observe the operation for 3 to 4 days. Cesarean section, small cesarean section and other gynecological operations can be performed at the same time. 2. Inquire about the history of the whole body and gynecological examination in detail, test blood, urine routine, clotting time, chest penetration if necessary. 3. Procaine allergy test. 4. Abdominal skin preparation. 5. Soap water enema once a day before surgery. 6. Fasting a meal before surgery. 7. Empty the bladder. Surgical procedure 1. Preparation Abdominal routine disinfection, toweling. 2. Incision There are two kinds of straight incisions and transverse incisions in the lower abdomen. Both incisions have their own advantages and disadvantages, and they are not forced to be consistent, and are selected according to the habits of the surgeon. The straight incision after non-pregnancy or abortion is started from the pubic symphysis with 2 horizontal fingers (about 3cm), and the longitudinal incision is about 2~3cm along the abdominal white line. The straight incision after postpartum or mid-term induction of labor is used to massage the uterus. After contraction, the incision is about 2 to 3 cm long at the point of 2 to 3 cm below the bottom of the palace. The transverse incision is on the pubic symphysis, or 3 cm below the uterus, with the abdominal white line as the midpoint extending to the sides 2 to 3 cm, the skin and subcutaneous tissue are cut, the subcutaneous fat is separated by the vascular clamp, and the rectus abdominis anterior sheath is exposed. The longitudinal rectus sheath of the rectus abdominis is about 3 to 4 cm long. The rectus abdominis muscle is separated and the peritoneum is cut. If the pre-peritoneal fat is thick, it can be separated by a vascular clamp, and the peritoneum is gently lifted to the incision to confirm the peritoneum. After that, the longitudinal incision was made 2 to 3 cm, and the upper, lower, left, and right sides of the peritoneal incision were placed on the incision with 4 small blood vessel clamps, and then the incision was opened with a small hook to expose the surgical field. 3. Correct uterine position The best position of the uterus is the anterior tilt or level. Generally, it can be detected during the gynecological examination before surgery. The uterus is severely tilted and flexed. It should be corrected during surgery to facilitate the removal of the fallopian tube. Commonly used reset methods are finger reset and instrument reset. 1 finger reset: the surgeon uses the left hand to enter the abdominal cavity to explore the uterus, the uterus is turned to the front, and then continue to go straight to the back of the palace, the palace body top to the front, another hand with a fallopian tube hook or oval pliers to find the fallopian tube . 2 device reset: severe posterior tilt, flexion of the uterus, difficulty in manual reduction, can be reset with oval clamp. Put the buckled oval clamp into the abdominal cavity and slide over the top of the uterus to the anterior wall of the uterus under the pubic symphysis, and then slide along the anterior wall of the uterus through the uterine anterior wall. At this time, there is a feeling of falling, and then the oval clamp is attached to the posterior wall of the uterus. Into the uterus rectal fossa, and then open the oval clamp, the distance between the two leaves is 2 ~ 3cm, the handle is slightly raised forward and upward, that is, the uterus is pushed to the anterior position in the direction of the pubic symphysis, and some people use the small hook of the abdominal wall to reset. 4. Extraction of fallopian tubes (1) Oval tube clamping method Simply use the oval round forceps to take the tube, which is suitable for the anterior or postpartum uterus. This method is safe and not easy to cause secondary damage. The closed non-toothed oval forceps are inserted into the abdominal cavity, and the pubic symphysis is moved to the side of the uterine cervix through the uterus, and then the oval pliers are opened obliquely to the lower back to grasp the fallopian tube; at this time, the pliers are not fastened to avoid the clip. Injury tissue, gently traction, if there is no resistance, the fallopian tube can be lifted to the incision. If it is safer and more accurate to find under the guidance of a finger, the incision is slightly larger than the incision of the pliers tube alone. (2) finger board taking method The fingerboard is safe and reliable, and it is difficult for beginners to master. The left hand of the operator extends into the abdominal cavity along the bottom of the uterus to the side of the fallopian tube to provoke it. The right hand holding fingerboard enters the abdominal cavity along the palm of the left finger and enters the front of the fallopian tube. The fallopian tube is sandwiched between the finger hole and the palm of the finger. When the fingertip has a hose-like feeling, move the finger pressure and the finger to the fallopian tube umbrella at the same time, clamp the middle part of the fallopian tube, and then gently lift it. The assistant gently presses the abdominal wall next to the incision to facilitate the exposure. Hold the fallopian tube and remove the fingerboard. (3) Fallopian tube hook tube method The tube hook is small in volume and does not affect the surgical field. It is suitable for uterus that is not pregnant, after abortion or slightly breast-feeding, and uterus that is backward. Hold the hook on the right, bend forward, back to the back, and follow the anterior wall of the uterus to the posterior wall of the uterine horn to bend to the posterior lobe of the ligament, and lift the hook forward and upward (Figure 11.3.4.14) When there is a slight reaction, it is a symbol of hooking to the fallopian tube. (4) Internal diagnosis and direct management This method is applicable to the thinner abdominal wall, the smaller the uterus, and the difficulty in taking the tube. Taking the position of the bladder lithotomy, the assistant lifts the uterus into the incision with the other hand in the vagina, so that the uterine horn approaches the incision, and the surgeon removes the fallopian tube with a flat tooth or an oval clamp. 5. Ligation of the fallopian tube The method of tubal ligation is safe, simple, and reliable. It is conducive to the future of tubal recanalization and small side effects. The following methods are commonly used: (1) Core entrapment method (Irving) It is characterized by avascular region in the isthmus of the fallopian tube; ligation, cutting of the fallopian tube core, proximal embedding, distal free, mesangial basically no damage, does not affect blood supply, proximal end embedded in the mesangium, distal tube The core is left outside the mesentery, and there is a serosa membrane at the two ends, and there is very little chance of re-passing. It is an ideal method of ligation. Two tissue clamps were used to clamp the serosa at both ends of the isthmus of the fallopian tube, and 0.5 to 15 ml of procaine was injected into the serosa, so that the serosa and the fallopian tube were separated, and the bulge was injected on the dorsal side of the fallopian tube. Cut the serosa about 2cm, clamp the edge of the serosa with 2 mosquito tongs, gently separate the serosa layer, clamp the ends of the dies, the clamp is 1.0cm, and cut the fallopian tube between the two tongs. About 0.5 to 1 cm, the two ends were ligated with the No. 4 silk thread, and the proximal end was embedded in the mesangium. The serosa incision was sutured intermittently with a No. 1 silk thread, and the distal end was sutured with a No. 1 silk thread and fixed outside the serosa. (2) Sleeve ligation method (Uchida method) The method is basically the same as the core embedding method. The method is characterized in that the serosa is made into a circular incision, the incision is small, and the operation is simple and easy. In the fallopian tube, use the small mosquito forceps to lift the serosa, and inject 0.5% procaine 1~2ml into the subserosal membrane to separate the serosa layer from the tube. The serosa layer and the tube are placed at the proximal end of the isthmus. The core is cut together, the cut can not be too deep, only the core can be cut to prevent tearing of the film. The two ends of the die were respectively clamped with a mosquito clamp, and the serosa was peeled off by another mosquito pliers to form a sleeve shape, separated from the die, and the core was peeled off by about 1 cm, and the ends were respectively ligated with a No. 4 wire. The end tube is retracted into the sleeve of the serosa, shaped like a "sleeve, the distal core is exposed outside the serosa, and the distal serosal layer is sutured with a 1st wire to fix the ruptured end. Outside the serosa. (3) Fallopian tube ligation and cutting method (Pomeroy method) This method is simple, safe, and easy to implement, but it has a higher failure rate than the previous two methods. Use the tissue forceps to cling to the isthmus of the fallopian tube and clamp the fallopian tube to fold it. Use the vascular clamp to clamp the fallopian tube and the intima of the fallopian tube about 1 to 1.5 cm from the top of the clamp. Remove the vascular clamp and use the No. 4 silk thread. After the frustration of the mesentery, the indentation is ligated separately, and the fallopian tube is cut off above the ligature. (4) Fallopian tube end embedding method The operation is relatively simple, does not destroy the physiological function of the fallopian tube, and is suitable for those who need to restore fertility in the future. At that time, the embedded umbrella end can be separated and restored to the original position. The incision of the abdominal wall is about 3 to 4 cm longer than that of the general ligation. After entering the abdominal cavity, the peritoneum of the anterior lobe of the broad ligament is close to the end of the umbrella to make a vertical incision with the fallopian tube. The length is about 2cm. Use the curved vascular clamp to extend into the incision to separate the anterior and posterior peritoneum. The depth is about 2cm. Use a small round needle to wear the No. 1 silk thread to sew a needle before and after the wall of the oviduct wall. Do not penetrate the endometrium and the fallopian tube umbrella. The knot is introduced into the incision of the broad ligament, and the umbrella part of the fallopian tube enters the separated bag. The cutting edge of the broad ligament peritoneum and the muscular layer of the fallopian tube are sutured and fixed by the No. 1 silk thread to close the incision, and the suture can not be too thin. In case of failure. (5) Fallopian tube umbrella removal method (Fimbriectomy method) The umbrella part is easy to find and identify, can avoid mistakes, and the method is simpler, and it is suitable for permanent sterilization. The tissue of the fallopian tube is clamped with tissue, and the vascular clamp and the proximal part of the fallopian tube are vertically clamped, including a part of the mesentery. After the resection, the suture is sutured with a 4th wire, and then a needle is sutured with a 7th wire. Buried in the anterior lobe of the broad ligament. (6) Fallopian tube resection method (Fallectomy method) Applicable to the first ligation failure and again require sterilization or due to fallopian tube disease need to be removed. Use 2 tissue clamps to clamp the fallopian tube, flatten the mesangium, use the curved vascular clamp to cling to the fallopian tube and parallel the fallopian tube to the uterine horn, and then use the vascular clamp to clamp the root of the fallopian tube, remove the fallopian tube, and suture with 4th thread. The ligament of the fallopian tube was ligated, and the root of the fallopian tube was sutured by the No. 7 silk thread, and the broken end was covered with a round ligament. 6. Check that there is no bleeding at the broken end and return it to the original place. 7. Check the instruments and gauze according to the abdominal surgery routine. 8. Suture the layers of the abdominal wall. complication Although the tubal ligation is a simple and easy operation, it is a relatively delicate operation, requiring the surgeon to master the local anatomy, and the operation is gentle and meticulous. Intraoperative, short-term and long-term complications are also prone to occur if not handled properly. Intraoperative complications (1) Bladder injury: It is common to have a small incision in the abdomen, and it is easy to occur when the uterus is small, the incision is low, or the bladder is not empty. Prevention: empty the bladder before surgery, the incision should not be too low, the lower edge of the incision should be 3 to 4 cm in the pubic symphysis. After separating the rectus abdominis, the peritoneum should be taken upward. Treatment: Intraoperative bladder injury should be repaired immediately, and the catheter should be indwelled for 7 days after surgery. Antibiotics can prevent infection. (2) Intestinal tube injury: It can occur when the peritoneum is opened open or the intestine wall and the peritoneum are adhered. The separation level is unclear and directly damages the intestine. It is also caused by accidental injury to the intestine or excessive clamping of the intestine. Prevention: The subject takes the supine head and lower hip height, so that the intestine is moved to the upper abdomen, and the peritoneal tissue should be clamped less. After the identification is clear, the peritoneum can be cut. The vascular clamp and the oval clamp should be toothless. Treatment: Intestinal tube injury is found during surgery, and suture repair should be performed immediately to prevent contamination of the surgical field and antibiotics should be given after fasting. (3) Fallopian tube hemorrhage and hematoma, more common in the fallopian tube when the fallopian tube is removed, the fallopian tube mesenteric tear or suture to break through the blood vessels caused by bleeding or hematoma. Prevention: The extraction of the fallopian tube should be gentle and extract the distal part of the fallopian tube. The needle is selected to be avascular free area of the fallopian tube mesangium. Hemorrhage or hematoma should be treated in time to ligature the bleeding blood vessels. 2. Recent postoperative complications (1) Infection: The most common recent infections after tubal ligation are wound infection, salpingitis and parametrial inflammation. Acute infection is not well controlled and can become chronic pelvic inflammatory disease, long-term non-union of the incision, repeated fluid flow and even formation of sinus. If strict aseptic technique is used during surgery, it can be avoided. Treatment: Apply appropriate amount of effective antibiotics, local debridement and drainage, pelvic infection should be taken in semi-recumbent position, use antibiotics, increase nutrition and enhance the body's resistance. (2) Hematoma at the incision site: The hematoma at the incision site should be found to expand the wound in time to remove the blood, and suture after strict hemostasis. If there is a hematoma liquefaction, the effusion can be taken out under aseptic operation, and the secondary infection should be expanded and drained. 3. Postoperative long-term complications There are many factors in the formation of long-term postoperative complications, such as chronic pelvic inflammatory disease, intestinal adhesion and omental adhesion after acute infection. Whether it has adverse effects on ovarian function is a controversial issue for many years. Clinically, a series of chronic symptoms such as abdominal and lumbosacral pain in menstrual disorders have been found in some cases. Common ones are: (1) menstrual changes: Some studies have shown that menstrual disorders in sterilization, may be due to intraoperative damage to the oviductal mesangial blood vessels, interfere with the oviductal mesangial circulation, affecting ovarian blood supply caused by ovarian dysfunction. The menstrual cycle is prolonged or shortened, and the amount of menstruation is increased or decreased. The appearance of these symptoms is generally thought to be related to the surgical ligation method. During the operation, the mesangial blood vessels are not damaged, and the ovary is not disturbed. The less the tissue damage, the lower the incidence of menstrual changes after surgery. In order to avoid or reduce the ovarian dysfunction caused by surgery, the surgery should be selected with less tissue damage, especially for patients with preoperative menstrual disorders should be actively treated before and after surgery. (2) pelvic venous hemorrhage: injury to the fallopian tube or ovarian vein, tubal distortion, adhesion caused by obstruction of blood circulation in the broad ligament, pelvic varicose veins, lumbosacral pain caused by blood stasis, lower abdominal pain, exacerbation after sexual intercourse and blood stasis Dysmenorrhea, rectal anal pain and so on. Elderly patients with long-term disease may have a series of autonomic dysfunctions such as nausea, vomiting, weight loss and fatigue. Treatment: Mainly based on conservative treatment, using traditional Chinese medicine to promote blood circulation, calming nerves and other drugs. With the passage of time, the blood flow of the fallopian tube collateral circulation is improved, and the symptoms can be gradually reduced or disappeared. It is generally inappropriate to take premature surgery. If the long-term conservative treatment is ineffective or the symptoms continue to worsen, the veins of one or both sides of the varicose veins may be surgically removed or ligated.

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