The Filshie clip for female sterilization: a review of world experience.

Laparoscopic tubal electrocoagulation continues to be widely practiced; however, mechanical devices such as the Yoon band, the Hulka clip, and, most recently, the Filshie clip are becoming more popular because of the avoidance of accidental electrical burns, the diminished likelihood of subsequent ectopic pregnancy, and, in the case of the clips, the minimal degree of tubal destruction, thus allowing for maximum reversibility. This survey of worldwide reports from 1981 to the present reveals a high level of acceptance of the Filshie clip because of its effective design and ease of application.

Twenty-two years of office and outpatient laparoscopy: current techniques and why I chose them.

Since 1972 I have introduced the following technical modifications in outpatient laparoscopy under local anesthesia to improve safety, economy, and patient acceptability: avoiding the insufflating needle and sharp trocar in favor of open abdominal entry, using the Hasson cannula; introducing room air for insufflation instead of nitrous oxide or carbon dioxide; using the Hulka clip in place of tubal coagulation; making a single-incision, open surgical entry through the central umbilical fossa in obese patients; and completing fascial penetration with a blunt hemostat or Kelly clamp to minimize the risk of bowel or vessel injury.

Local anesthesia for female sterilization.

PIP: Experience has confirmed that both laparoscopy and minilaparotomy, the two most common surgical approaches to sexual sterilization in the US, can be performed on an outpatient basis under local anesthesia. However, general anesthesia is chosen in the majority of such cases. Gynecologists and operating room staff indicate a preference for a patient who is asleep or want to abolish all intraoperative discomfort for the patient. Few gynecology residency programs offer experience in performing female sterilization under local anesthesia. This ignores the fact that local anesthesia not only can be entirely adequate for pain relief, but also has the added advantages of increased safety, rapid recovery, and lower cost to the patient. Local anesthesia further provides psychological benefits to patients who are afraid of being put to sleep or want to be an active participant in their own operation.^ieng

How to prevent complications of open laparoscopy.

Infraumbilical minilaparotomy as a substitute for needle and trocar puncture continues to attract gynecologists for safety reasons. Although the open entry technique should eliminate aortic and iliac vessel injuries, other complications are occurring. In September 1984 a survey of 18 board-certified gynecologists who had performed a total of 10,840 open laparoscopies revealed 18 instances of wound infection and 6 cases of bowel laceration. Some features of surgical technique can minimize the risks of open laparoscopy.

Opinion: [on anesthesia for outpatient female sterilization].

In actual practice, the choice of anesthesia is more likely to be decided by the personal preference of the surgeon or anesthesiologist rather than by considerations of safety. Most gynecologists in the US and Canada, working in hospitals or surgicenters, choose general anesthesia becaused skilled anesthetists are available, and it is easier for them to operate if their patients are asleep. Most anesthesiologists prefer it that way also, since their services are being fully utilized. During residency training, gynecologists need the benefit of general anesthesia to learn surgical techniques. Because they learned that way, it is the course of least resistance for them to continue to favor general anesthesia. Thus hundreds of thousands of general anesthetics are given each year to suit the convenience and skills of the gynecologist. But minilaparotomy or laparoscopy may be performed with fewer potential complications under local anesthesia, provided the patient receives proper counseling and supportive care, and provided the gynecologist's surgical technique is gentle and precise. Unfortunately, most residency programs do not provide training in such techniques, so they are learned, if at all, during practice years.

Contraception and female sterilization.

PIP: Preferences in methods of contraception and sterilization among the U.S. population are assessed. Oral contraceptives, low-dose, are the leading reversible contraceptive method in the U.S., despite the risk of side effects. The diaphragm, among highly motivated women, is in second place. Sterilization methods are more diverse, but basically double incision laparoscopic tubal coagulation is preferred in the U.S. as an interval technique. Some clinics use the Yoon band and Hulka clip instead of coagulation. The favorite method of sterilization in the East has been the suprapubic mini laparotomy and it is gaining currency in the U.S. now. Contraindications to laparotomy are obesity, fixed uterine retroversion, and suspected adnexal pathology; in most patients who are nonobese, however, suprapubic minilaparotomy with Pomeroy tubal ligation, Yoon banding, or clip application is simpler, safer, and less expensive. And both the laparoscopy and minilaparotomy can be performed under local anesthesia. The IUD is recommended for women who are the least motivated, and is thought inappropriate for using in nulliparous women because of the likelihood of tubal scarring resulting from infection.^ieng

Minilaparotomy for female sterilization.

Minilaparotomy, as described in this report, is surgical entry into the lower abdominal cavity through a small transverse suprapubic incision, for the purpose of tubal ligation. The 200 operations reported were performed under local anesthesia in a free-standing office surgical unit. For most women requesting sterilization, minilaparotomy is a highly satisfactory approach. For patients with fixed uterine retroversion, enlarged uteri, or suspected adnexal disease, open laparoscopy under local anesthesia is preferable. The standard Pomeroy technique was used in all cases. Analysis of a follow-up minilaparotomy questionnaire indicates a high degree of patient satisfaction. No subsequent pregnancies have been reported by these patients, but since no patient in this series has been followed for more than 2 years, no conclusion as to long-term failure rate may be made.

Minilaparotomy for sterilization.

PIP: Both the minilaparotomy and the laparoscopy procedures for female sterilization are described. The minilaparotomy, which is performed under local anesthesia, is described in detail and pictured in a series of photographs. A preoperative counseling session is required, at which time any contraindicating situations, e.g., a history of abnormal uterine bleeding, are discovered and treated. A 6-week postoperative examination is performed. Excessive abdominal obesity is a condition which precludes the performance of both the minilaparotomy and the laparoscopy.^ieng

Laparoscopic sterilization under local anesthesia. 1200 cases.

Laparoscopic tubal fulguration operations were performed on 1200 patients under local anesthesia in two free-standing surgical units in Syracuse, New York, between June 1972 and March 1976. No operative accidents occurred. However, because of increasing understanding of the risks to major blood vessels from needle and trocar insertion, all patients undergoing laparoscopy since March 15, 1976, have received the additional safeguards of an operating room with full anesthesia and laparotomy capabilities. The major technical innovation in this series of operations was the use of the 23-guage needle cannula, inserted through the Wolf operating laparoscope for preliminary Xylocaine infiltration of the fallopian tubes. The advantages of local over general anesthesia are summarized.