Minilaparoscopy with local anaesthesia: an even less invasive surgery for female sterilization

J.F. Garrido, P. Deulofeu, M. Colodrón

Department of Gynaecology, Municipal Hospital of Badalona, Spain

Introduction: Fallopian tubes sterilization is the most popular choice for definitive female contraception. Local anaesthesia (LA), with or without intravenous sedation, has been used in the last 25 years in this procedure. However, this intervention is usually made under general anaesthesia (GA) in our country. After 133 laparoscopic procedures in the Ambulatory Surgery (AS) Unit, we considered the possibility of making tubal ligation under LA and intravenous sedation, based on two important facts: we had the availability of a minilaparoscope (3,3 mm scope, 3 mm tools) and we deal with the necessity of reducing the postoperative stay in the recovery of the AS Unit. We present a retrospective five years study of the results of our cases of sterilization with minilaparoscopy under LA.

Aims and Methods: 1846 gynaecologic surgical procedures were made between 1999 and 2003 in our Department; 697 of them in the AS Unit (38%). We made 228 laparoscopic tubal interruptions in these years, 100 of them (44%) as Ambulatory Surgery cases. Patients included in the minilaparoscopy group must not be obese, be interested in avoiding GA and sign the informed consent. 29 patients underwent tubal sterilization under LA and were included in this study. After local injection of mepivacaine or bupivacaine in the umbilicus and suprapubic zone, and in uterine cervix, a carbon dioxide pneumoperitoneum was induced up to 6–8 mmHg. Slight Trendelenburg position was made. Fallopian tubes were electrocoagulated with a bipolar forceps and afterwards sectioned.

Results: 3 of the 29 procedures began with GA, as the presence of adhesions because of previous operations was suspected. 15 of the 26 procedures beginning with LA and sedation were completed. 11 cases had to be finished under GA, 6 of them because of the pain of the patient and 5 as a consequence of technical failures. These failures were a bad evaluated obesity; a preperitoneal false way of the port; no vision of fallopian tube in one case, and two cases of breakdown of the bipolar forceps

Conclusions: Tubal ligation under LA with minilaparoscopy is useful to selected patients, and has to be included as an Ambulatory Surgery indication. This method provides a good quality view, but reduced visual field. Surgeons have to be trained to develop a careful proceeding and to manage with limitations like an undersized visual field and a slight Trendelenburg position.