The postal tubal ligation syndrome.

PIP: The frequency of symptoms following tubal ligation calls for an examination of the basic problem with the methods now used. This discussion recommends a modification of tubal ligation which as performed during the past 2-1/2 years has been symptom free, post operatively. What is meant by symptom free is those symptoms which can be directly related to tubal ligation. Symptomatology is complex and insidious. Characteristically, there is a latent period of no symptoms. This asymptomatic period may be totally subjective and may last several years during which time the correlation between surgery and symptoms is obscured. This is particularly the case if purely symptomatic therapeusis has had some degree of success. The latest period is followed by the gradual development of the following: menstrual disorders; abdominal pain which is usually located in the lower abdomen and is of 2 varieties, i.e., dysmenorrhea and nonmenstrual pain; and infection. Physical examination demonstrates little. This set of symptoms, which has been documented also by Poma et al., and when taken as a whole, constitutes a syndrome which should be termed the posttubal ligation syndrome. These patients give a history of repeat X-rays, biopsies, endoscopies, and surgical exploration. Some of these patients have had 4 or 5 celiotomies. A modification of the traditional method of tubal ligation definitely requires consideration. The characteristics of the oviducts which need mention and emphasis are reviewed. On the basis of the reviewed considerations, it becomes obvious that smooth transport of the ovum is a necessity and that obstruction in the tubes will cause a reaction similar to obstruction anywhere in the body. Tubal ligation should be performed in such a manner so as not to obstruct the ova from passing down the tube. The tubes should be cut fairly close to the uterus and be tied. The rest of the tube from fimbria to the isthmus should be left open. In this manner, the ovum passes into the fimbriated end of the tube and is gently passed out back into the peritoneal cavity. A sort of blind loop is created. Although this technique has been performed in only 6 cases, results have been good.^ieng

The "unrecognized" spigelian hernia.

The appearance at a community hospital of four cases of spigelian hernia within a 16-month period lends support to the supposition that this lesion is more common than reports would indicate. Main points to consider in establishing the likelihood of this condition primarily include an awareness of its existence and its multiple symptomatology, the anatomic schema of the lateral rectus border, careful abdominal examination and use of radiographic aids.