Abstract - In 30 years, 1,669 patients underwent open microsurgery for tubal diseases. Several techniques like adhesiolysis, reanastomosis, fimbrioplasty, salpingoneostomy, proximal reconstruction, isthmo-ostial anastomosis and reimplantation are described. Results were excellent for patients with a favourable prognosis (1,517 patients) and with very high pregnancy rate: 80% pregnancies with delivery for tubal reversal, 68% for proximal diseases, 75.1% for fimbrioplasty and 55% for salpingoneostomy. Risks of ectopic pregnancy were very low: 1.5% for tubal reversal (because the tubes were healthy), 4% for proximal diseases, 4% for fimbrioplasty and 6.7% for salpingoneostomy. Results were very low for patients with a poor prognosis (152 patients): 10% pregnancies with delivery for distal diseases, less than 20% for proximal diseases and 22% ectopic pregnancies. Open microsurgery can still be helpful in treating tubal infertility: results are better than those obtained with laparoscopic reconstructive surgery and better than those obtained with in vitro fertilization for patients with a favourable prognosis. Patients are only operated one time and can have several pregnancies. Open tubal microsurgery is a minimal invasive surgery and saves costs (it requires a small number of instruments and minimises sutures; patients can return home 4 days after surgery, at the latest). Results on fertility are very favourable.
Between 1977 and 2007, 1,669 patients underwent a minilaparotomy for tubal diseases. Minilaparotomy means a laparotomy with minimal tissue injury, applying microsurgical principles and procedures.
One of the first principles we followed was the temporary but absolute contraindication for surgery in case of active infection and active inflammation (for example endometriotic red lesions).
We also applied the following principles:
- gentle handling of tissues
- atraumatic manipulation of the tubal serosa and mucosae, of the ovary and of the peritoneum
- selective bipolar coagulation: only the vessels (and not the surrounding area) must be dessicated by fine bipolar microelectrodes
- continuous irrigation to keep the surgical area clear at all times and to avoid the tissue from drying out (and especially the tubal serosa and the ovary)
- perfect protection of the abdominopelvic cavity against infection risk using the sterile “wound drape”
- complete resection of pathologic tissues
- complete restoration of the serosa: closure of all peritoneal defects to avoid formation of de novo adhesion and recurrence of previous adhesion (peritoneal defects in case of adnexal disease due to previous infection or inflammation do not scar easily and quickly because the subserosal tissue is not a normal tissue; it is usually rich in inflammatory cells). A peritoneal closure with fine material and inverted stitches scars better and faster than a large defect without peritoneal closure
- use of very fine resorbable sutures 7/0 and 8/0
- last, use of a well mastered surgical technique: the surgery must be successful the first time. Repeat surgery never gives favourable results
Most of these principles were described by Gomel [1] in 1977. Open microsurgery is a method that proves to be cost efficient: the same microscope has been used for 17 years. Sets of instruments were only changed every 4 to 5 years. We only need one suture of 7/0 and one of 8/0 for two tubes. The maximum length of hospital stay is 4 days (only 3 days for 40% of the patients).
Materials and methods
Patient characteristics
- bifocal tubal lesions (distal and proximal occlusion in the same tube)
- distal tubal lesions with poor prognosis: extended dense adhesion, sclerohypertrophic tube, intra-ampullary adhesions, lack of mucosal folds [2]
- significant and extended proximal lesions including the isthm, the intramural segment and the ostium uterinum
After 1987, when in vitro fertilization (IVF) results became acceptable, we abandoned reconstructive surgery for these lesions and decided to perform salpingectomy in order to increase IVF results. We only operated tubal lesions with a favourable prognosis.
As a consequence, 1,517 patients with a favourable prognosis underwent reconstructive microsurgery between 1977 and 2007:
485 tubal reversals
527 distal tubal lesions
505 proximal tubal lesions
Materials
From 1977 to 1994, we used a Zeiss OPMI 6 microscope. A Leica-Wild M-690 was introduced after 1994. Five instruments of 15 and 18 cm long were needed:
- two Moria forceps with very fine extremity (0.5 and 0.2 mm)
- one Martin–Landanger microscissor
- one Jacobson–Aesculap needle holder
- one Codman forceps for bipolar coagulation
- For two tubes, one 7/0 and one 8/0 polydioxanone sutures are usually sufficient.
Methods
Preoperative investigations
All patients had complete investigations: hormonal analysis, male analysis, hysterosalpingography, hysteroscopy and sometimes recanalisation, diagnostic laparoscopy with blue dye test. Results were written down before surgery and then compared with operative images (all surgery were taped first with 8-, then 16-mm film camera Beaulieu, and then with 3-CCD Sony DXC 930 P video camera) and with postoperative histological examination of all resected lesions. The analysis is therefore not entirely retrospective.
Preoperation and per operation procedures
Prior to the laparotomy, a Pezzer catheter is introduced into the uterine cavity. This catheter is brought into sterile fields and allows the preoperative injection of sterile dilute methylene blue solution for verification of the tubal patency. After a short Pfannenstiel incision (6/7 cm), we protect the pelvis with a “wound-drape”. The uterus and adnexa are elevated by packing the Douglas cul-de-sac with moistened compresses. Continuous irrigation of the surgical area using a physiological salt solution mixed with noxytioline and corticoid (permanently evacuated by a Redon drain positioned in the Douglas pouch) keeps the operating area always clear. It keeps the tissues always moistened to prevent tissue drying, avoids formation of adhesion and allows for bipolar coagulation. Extreme gentleness is exercised. Tissue traumatism is prevented by the gentle handling the tubes and the ovary with fingers rather than sharp instruments. At the end of the operating time, a meticulous cleaning of the pelvic cavity is useful.
For 30 years, several peritoneal instillates were used: Ringer's lactate which is not compatible with noxytioline, 30% dextran 70, Intergel, icodextrin 4% solution, etc., but we think it is not necessary to use instillates if the microsurgical technique is perfect: minimal tissue traumatism, perfect haemostasis, no tissue necrosis, no infection risk. We do not use these instillates in case of tubal reversal because the tubes are healthy; there is no peritoneal defect and no risk of adhesion.
Postoperation procedure
All patients (except tubal reversal) were treated with antibiotics and dexamethasone during the postoperative inflammatory time (18 to 25 days).
Patients could return home 4 days after surgery (40% of them left hospital after 3 days). Ovarian induction was prescribed after the second postoperative menstruation. Hysterosalpingography was prescribed 6 months and laparoscopy 1 year after surgery if the patient failed to conceive.
Follow-up procedure
Ninety-one percent of patients were followed up for at least 2 years. Loss of follow-up patients was classified as surgical failure because infertile women always inform their surgeon when they are pregnant or when they have an ectopic pregnancy.
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