Tubal Reversal

Tubal reversal - short for tubal sterilization reversal or tubal ligation reversal - is a surgical procedure that restores fertility to women after a tubal ligation. By rejoining the separated segments of fallopian tube, tubal reversal gives women the chance to become pregnant again. This delicate surgery is best performed by a reproductive surgeon with specialized training and experience in the techniques of tubal ligation reversal.

Other names: Tubal Sterilization Reversal, Tubal Ligation Reversal, Reverse Tubal Ligation, Tubal Reanastomosis, Tubal Anastomosis.

Tubal reversal procedures

Microsurgery

Tubal ligation reversal utilizes the techniques of microsurgery to open and reconnect the fallopian tube segments that remain after a tubal sterilization procedure. Microsurgery minimizes tissue damage and bleeding during surgery. Essential elements of microsurgical technique include gentle tissue handling, magnifying the operating field, keeping body tissues in their normal state with warmed irrigation fluids, and using the smallest sutures with the thinnest needles capable of holding the tubal ends together to promote proper healing of the rejoined tubal segments.

Tubotubal anastomosis

Following a tubal ligation, there are usually two remaining fallopian tube segments - the proximal tubal segment that emerges from the uterus and the distal tubal segment that ends with the fimbria next to the ovary. After opening the blocked ends of the remaining tubal segments, a narrow flexible stent is gently threaded through their inner cavities or lumens and into the uterine cavity. This ensures that the fallopian tube is open from the uterine cavity to its fimbrial end. The newly created tubal openings are then drawn next to each other by placing a retention suture in the connective tissue that lies beneath the fallopian tubes (mesosalpinx). The retention suture avoids the likelihood of the tubal segments subsequently pulling apart. Microsurgical sutures are used to precisely align the muscular portion (muscularis externa) and outer layer (serosa), while avoiding the inner layer (mucosa) of the fallopian tube. The tubal stent is then gently withdrawn from the fimbrial end of the tube.

Tubouterine implantation

In a small percentage of cases, a tubal ligation procedure leaves only the distal portion of the fallopian tube and no proximal tubal segment. This may occur when monopolar tubal coagulation has been applied to the isthmic segment of the fallopian tube as it emerges from the uterus. In this situation, a new opening can be created through the uterine muscle and the remaining tubal segment inserted into the uterine cavity. This microsurgical procedure is called tubouterine implantation, uterotubal implantation, or, simply, tubal implantation. Tubal implantation is performed when tubal anastomosis is not possible due to the absence of a proximal tubal segment and interstitial tubal lumen.

Ampullary salpingostomy

Fimbriectomy is an uncommon type of tubal ligation that is performed by removing the fimbrial portion of the fallopian tube next to the ovary, leaving the tubal segment attached to the uterus. After fimbriectomy, the remaining tubal segment can be opened by the technique ampullary salpingostomy. A microsurgical electrode is used to open the tubal end and expose the internal lining. When the opening has been enlarged sufficiently and the internal lining or endothelium has extruded from the tubal end, sutures are placed to keep the endothelium folded outward over the edge and to prevent the tube from closing again.

Mini-laparotomy tubal reversal

Mini-laparotomy for tubal reversal surgery involves making a small incision in the abdominal wall just above the pubic bone after shaving the hair with a sterile hair clipper. The size and location of the incision as well as the plastic surgery techniques used to close it make the hair-line scar invisible when it has healed. Atraumatic surgical techniques involve the use of local anesthesia at the incision site and other tissues operated upon. This makes the surgery comfortable and minimizes post-operative pain. As opposed to standard operative methods, avoiding the use of surgical retractors and packs, constantly irrigating tissues to keep them moist and at body temperature, and operating under magnification throughout the procedure results in very rapid patient recovery. Operating with microsurgical instruments allows precision in suturing of the tubal segments than is possible with longer needle holders and other instruments such as are used in laparoscopic surgery. In the experience of a tubal reversal doctor who has performed more than 8000 outpatient reversal procedures, this is the preferred method of minimally invasive surgery for tubal ligation reversal. After the mini-laparotomy approach, patients may attempt to become pregnant as soon as they are fully recovered from their surgery.

Laparoscopic tubal reversal

Laparoscopic Tubal Reversal is a minimally-invasive surgical procedure (laparoscopy), using small, specially-designed instruments to repair and reconnect the fallopian tubes.

After general anesthesia has been administered, a 10mm (less than ½-inch) tube (trocar) is inserted just at the lower edge of the navel, and a special gas is pumped into the abdomen to create enough space to perform the operation safely and precisely. The laparoscope (a telescope), attached to a camera, is brought into the abdomen through the same tube, and the pelvis and abdomen are thoroughly inspected. The tubes are evaluated and the obstruction (ligation, burn, ring, or clip) is examined. Three small instruments (5mm each, less than ¼-inch) are used to remove the occlusion and prepare the two segments of the tube to be reconnected.

One technique involves the use of a tubal cannulator, which is inserted into the uterus through the cervix, allowing the tube to be threaded with a fine stent. This allows for improved alignment of the tubes, so a much better connection can be accomplished. Tiny sutures (less than a hair in thickness) are carefully and meticulously placed to connect the two segments.

Once the connection (anastomosis) is completed, a blue dye is injected through the cervix, traveling through the uterus and tubes, all the way to the abdomen. This is to make sure the tubes have been aligned properly and that the connection is working well.

All instruments are removed, the gas is extracted from the abdomen, and the patient is awakened and taken to the recovery room to be watched and cared for by the nurses, as well as by the anesthesiologist who makes sure the patient is comfortable and without pain. On the average, two to four hours later most patients are ready to be discharged.

Patients are seen between 5-7 days after the operation to look at the small incisions and remove any stitches if necessary. Most of the time, the few stitches that were placed will be under the skin and will be absorbed by the body, without need for removal.

Patients should wait two to three months prior to attempting pregnancy in order to give the tubes a chance to heal completely. Trying to conceive before could result in an increased risk of ectopic pregnancy (pregnancy inside the fallopian tube instead of in the uterus).

When performed by a trained laparoscopic or outpatient tubal reversal surgeon, laparoscopic tubal reversal combines the success rates of micro-surgical techniques with the advantages of minimally-invasive surgery – namely faster recovery, better healing, less pain, fewer complications, and no large disfiguring scars.

Robotic assisted tubal reversal

Robotic assisted tubal reversal surgery is a surgical procedure in which the fallopian tubes are repaired by a surgeon using a remotely controlled, robotic surgical system.

The robotic system involves two components: a patient side-cart (also referred to as the robot) and a surgeon’s console. The robot is placed adjacent to the patient and has several attached arms. Each arm has a unique surgical instrument and performs a specialized surgical function. The surgeon sits near the patient at the surgeon’s console and visualizes the surgery through a monitor. The surgeon performs the entire reversal surgery using controllers located inside the surgeon's console.

Robotic surgery experts have suggested robotic tubal ligation reversal offers the advantage of smaller incisions when compared to traditional laparotomy tubal reversal surgery. These smaller incisions have been reported to result in less pain and quicker return to work after robotic tubal reversal when compared to traditional tubal ligation reversal using larger abdominal incisions. Robotic experts have also suggested the robotic system offers a greater range of motion and more surgical dexterity than a surgeon can obtain during laparoscopic tubal ligation reversal. The potential disadvantages to robotic surgery are longer operating times and higher costs.

Essure sterilization reversal

Essure sterilization is a hysteroscopic tubal occlusion procedure and was approved by the FDA in 2002. Essure sterilization can be done as a simple, outpatient procedure. The Essure procedure requires a small camera (hysteroscope) be inserted through the cervix and into the uterine cavity. Two small, metallic coils are then inserted into each tubal ostia and into the isthmic portion of the fallopian tube. The coils cause the isthmic portion of the fallopian tube to scar (or heal) closed. To confirm tubal closure, a HSG x-ray should be performed three months after the Essure procedure. If either fallopian tube is open after the Essure procedure, then the Essure procedure should be repeated or another type of tubal occlusion method should be performed.

Essure sterilization can be reversed and does not have to be permanent. Reversal of Essure sterilization requires the blocked isthmic portion of the tube be bypassed. The procedure to bypass the blocked portion of the tube is called a tubouterine implantation.

Tubouterine implantation requires the reversal surgeon to make an incision into the uterus and reinsert the healthy portion of the tube through the uterine muscle and into the uterine cavity. Experts who specialize in tubal reversal surgery and tubouterine implantation are able to perform this type of reversal as an outpatient procedure and provide success rates comparable, if not better, than IVF pregnancy success rates.

Adiana sterilization reversal

Adiana sterilization was approved by the FDA in 2009. Adiana sterilization is a hysteroscopic tubal occlusion procedure, which is very similar to Essure sterilization. The Adiana procedure is a outpatient procedure performed by inserting a small camera (hysteroscope) through the cervix and into the uterine cavity. A smaller catheter is inserted into the tubal ostia. The catheter emits radiowaves (microwaves). The radiowaves cause injury to the tubal lining and will result in the tube gradually healing closed. Prior to removal of the catheter a small silicone stent is left inside the isthmic portion of the tube and this promotes tubal closure by the acceleration of the tubal scarring. To confirm tubal closure, a HSG x-ray should be performed three months after the Adiana procedure. If either fallopian tube is open, then the Adiana procedure should be redone or another type of tubal occlusion method should be performed.

Adiana sterilization can be reversed and does not have to be permanent. Reversal of Adiana is similar to reversal of Essure sterilization and requires the blocked isthmic portion of the tube be bypassed. The procedure to bypass the blocked portion of the tube is called a tubouterine implantation.

Reasons for tubal reversal

Women give many reasons for having a tubal ligation reversal. The most common reasons are:

Remarriage with desire to have children with new spouse
Same marriage with desire to have more children
Death of a child
Relief of symptoms of "Post Tubal Ligation Syndrome"
Religious or spiritual concerns

Risks

Injuring a blood vessel, resulting in bleeding
Complications associated with anesthesia
The possibility of infection
Tubal pregnancy (ectopic pregnancy)

Nursing Interventions

During the procedure, nurses will monitor the patient's vital signs and oxygen saturation. They will also provide emotional support. After the procedure, nurses will continue to monitor the patient's vital signs and assess for any complications. They will also provide pain medication and educate the patient about post-operative care.

Specific Nursing Interventions

Preoperative care:
- Assess the patient's medical history, allergies, and medications.
- Provide education about the procedure and its risks and benefits.
- Obtain informed consent.
- Administer preoperative medications as ordered.
- Start an intravenous (IV) line.
Intraoperative care:
- Monitor the patient's vital signs and oxygen saturation.
- Provide emotional support.
- Administer medications as ordered by the surgeon.
Postoperative care:
- Monitor the patient's vital signs and assess for any complications.
- Provide pain medication.
- Educate the patient about post-operative care.
- Encourage ambulation.
- Monitor for bleeding and infection.

Additional Considerations

The patient may experience cramping, bleeding, and fatigue after the procedure.
The patient should avoid strenuous activity for 1-2 weeks after the procedure.
The patient should not douche or use tampons for 1-2 weeks after the procedure.
The patient should call her healthcare provider if she experiences any heavy bleeding, fever, or severe abdominal pain.

Documentation

Nurses should document all interventions, assessments, and patient education provided before, during, and after the procedure.

Here are some additional nursing interventions that may be specific to tubal reversal surgery:

Provide emotional support to the patient and her partner or family member.
Educate the patient about the signs and symptoms of potential complications, such as infection or bleeding.
Encourage the patient to rest and avoid strenuous activity for the first few weeks after surgery.
Help the patient to manage her pain with medication or other strategies.
Provide ongoing education and support to the patient as she recovers from surgery and tries to conceive.