The uterus or womb is a pear shaped organ that is found in the female pelvis at the top of the vagina. It varies in size and shape depending on the hormonal and childbearing status of the woman.  It has a cavity, which is essentially closed when the woman is not pregnant. The inside lining of the uterus, called the endometrium, separates from the uterine wall each month. The vaginal bleeding that occurs is called the menses or period. The menses do not occur during pregnancy and normally continues until the menopause.(Figures 1 and 2)

Figure 1 - Uterus, Fallopian tubes, ovaries and ligaments to the uterus as seen from in front	Figure 2 - View of the uterus, ovaries, Fallopian tubes, and round ligament through a laproscope. (Courtesy O. Kadry, M.D.)

• The lowest portion of the uterus at the point that it connects to the vagina contains the neck of the uterus or cervix. The opening in the center of the cervix is the entrance to the to the uterine cavity. The inside of the uterus is lined with a layer of special cells, the endometrium.
• The Fallopian tubes are found at the upper end of the uterus. There is one Fallopian tube on each side of the uterus. These are hollow tubes through which the fertilized egg travels to reach the uterus.
• The ovaries lie just beneath the other end of the Fallopian tubes and contain the female’s eggs. The Fallopian tubes hang over the ovaries like a hood
• When an egg leaves the ovaries, it is directed by the hood into the Fallopian tubes and then through the tubes into the uterus where the egg may implant into the uterine wall
• There are a series of ligaments that attach the uterus and Fallopian tubes to the pelvic wall. The blood vessels to the uterus and ovaries are contained within these ligaments
• In some patients there may occur congenital abnormalities of the uterus including a completely double uterus or a doubling of only parts of the uterus. Sometimes there is only one Fallopian tube

Indications for Tubal Ligation

Tubal ligation is a voluntary act on the part of the women requesting the procedure and, therefore, there are no specific indications. Occasionally a women may have an illness which may be severely affected by pregnancy. This is a relative indication for tubal ligation.

Contraindications

The only absolute contraindications to tubal ligation are

• Cancer of the female pelvic organs
   
• Disease in the pelvis requiring the need for a future major surgical procedure
   
• There are, however, situations in which the woman may regret the choice
  1. Single or recently married
      
  2. Husband is opposed to sterilization
      
  3. Having been pressured into having the procedure
      
  4. No children or no male children
      
  5. Being under the age of thirty
      
  6. Decision made immediately after childbirth
      
  7. When there are few alternative methods available

The Surgical Procedure

Tubal ligation should only be performed when permanent sterilization is desired. There is surgery to reverse the procedure, but there is no guarantee that is will be successful Tubal ligation may be carried out following Cesarean section, shortly after a normal vaginal delivery, or completely separate from a pregnancy. The surgical approach for tubal sterilization varies.

• Laparoscopy is the most common surgical approach
  1. The procedure is usually performed through one to three, 1-2 centimeter (0.4-0.8 inch) abdominal incisions. The first incision is typically made just in the lower fold of the navel
  2. A laparoscope is inserted through the incision into the abdominal cavity. A laparoscope is a long narrow tube that contains a fiber optic channel. A lens focuses an image onto the fiber optics which transmits the image to a video camera attached to the other end of the scope. The pelvis including the tube, ovaries and uterus are visualized with the laparoscope
  3. Other instruments are inserted through the other abdomimal incisions to perform the tubal ligation. Though the picture of the pelvis can be seen directly through the laparoscope, it is usually displayed on a video monitor placed in front of the surgeon
• Laparotomy, opening of the abdomen, may also be used to carry out a tubal ligation This method is usually reserved for cases in which there is another procedure also being performed such as a Cesarean section
• Minilaparotomy is an approach in which the abdomen is entered through a much smaller incision then used with a the usual laparotomy
  1. The incision is usually two to three centimeters long
  2. This approach is usually used when a tubal ligation is desired within 6 weeks following delivery
• Method of ligation. There are several different methods used to actually ligating the Fallopian tubes. The basic principle is to interrupt the Fallopian tubes in order to prevent sperm from fertilizing an egg and to prevent the egg from travelling into the uterus. The Fallopian tube may be interrupted by removing a piece of the tube, cutting the tube after each end has been tied off with suture, coagulating (heat sealing) a piece of the tube, obstructing the tube with clips or Silicone rubber bands or a combination of these methods
  1. Irving procedure interrupts the Fallopian tube by tying two separate sutures around the tube approximately 2-3 centimeters (1 inch) apart. The segment of tube between these two sutures is then cut and removed. The cut end of the tube closest to the uterus is then buried under a thin layer of tissue on the outer wall of the uterus called the serosa
  2. Uchida procedure is similar to the Irving procedure. The Fallopian tube is sutured in two places and the segment between removed. In this technique the end of the tube that is closest to the uterus is buried in the tissue underneath the tube
  3. Parkland method is performed by suturing the tube in two areas approximately 2-3centimeters apart and simply removing the tube between the two sutures (Figure 3)
  4. The fallopian tube may be burnt using a method called coagulation.  The tube is interrupted because the lumen (center channel) is destroyed by the heat. The tube is then transected in the area of coagulation using scissors
  5. Silicone rubber bands and small clips can also be placed around the Fallopian tube to seal the tube. The use of these two methods have greater success when placed on a normal tube that is free of scar tissue. This procedure also has the best prognosis for restoring the tube when the woman wishes to reverse the process for the purpose of pregnancy (Figure 4)

Figure 3 - The Fallopian tube is tied off in two places about one inch apart. The segment of tube between the sutures is removed	Figure 4 - Laparoscopic view of the Fallopian tube tied off with a silastic rubber band. (Courtesy D. Schuchman, M.D.)

Complications

There is no surgical procedure that is free of the possibility of complications.

• As with any surgical procedure there may be a complication of the anesthetic
• Injury to the bowel
• Injury to the ureters
• Hemorrhage that may require a blood transfusion
• Wound Infection
• Bowel perforation (hole in the bowel)
• Accidental pregnancy occurs in approximately 0.4% of women with tubal sterilization. The failure rate is slightly higher for women who have had a coagulation procedure, spring clip placement or only partial removal of the tube

Care after the procedure

Care after a tubal ligation depends on the surgical procedure used

• Laparoscopic approach
  1. The patient is discharged on the same day as the surgery
  2. A prescription is given for pain medication
  3. Sutures are removed in the surgeon’s office. Many surgeons close the skin of the incision with sutures that are absorbed by the body and do not need to be removed
  4. Office follow up is usually between 7 and 14 days
• Laparotomy (opening of the abdomen)
  1. The postoperative care depends on the procedure performed in along with the tubal ligation (such as Cesarean section)
  2. These patients are usually in the hospital for a minimum of 2-3 days
  3. Sutures, staples or absorbable suture may be used to close the incision
  4. The sutures or staples may be removed during the hospital admission or in the surgeon’s office
  5. A follow up appointment is usually scheduled at 1to 2 weeks after surgery
• Minilaparotomy
  1. The postoperative course can vary. Some women may be discharged the same day of surgery, while others require a day or two in hospital for pain control or other complaints such as nausea
  2. Care of the incision is similar to that of a laparotomy including the removal of sutures or staples
  3. Follow up in the surgeon’s office is again between one and two week