tubal ligation surgery

Tubal ligation is a permanent method of contraception. At present, the commonly used methods in China include incision of the mesenteric part of the fallopian tube and partial ligation (including proximal and bilateral embedding methods), tubal bi-fold ligation, and fallopian tube ligation and ligation. And the fallopian tube umbrella removal method, the tubal ligation operation has the abdomen, vaginal anterior and posterior iliac crest and groin. At present, Tichang is mainly based on abdominal surgery. With the skill of surgical operation and the updating of surgical instruments, the abdominal incision is significantly reduced, the operation time is significantly shortened, and the irritation of the instrument is also reduced. Tubal ligation is performed to sterilize a woman, and as a result, the movement of the egg to the uterine cavity is prevented. This procedure is only for women who decide to have no fertility needs and does not apply to temporary contraception. Treatment of diseases: rupture of tubal pregnancy Indication 1. A married woman is required to be a sterilization. 2, due to systemic diseases or certain genetic diseases are not suitable for childbearing. Contraindications 1, systemic disease can not load the operator. 2, the abdominal wall has infected lesions or severe skin diseases. 3, within 24h, the body temperature is above 37.5 °C. 4, severe neurasthenia and neurosis patients, emotional instability, the majority of concerns about surgery. Preoperative preparation 1. Those who accept female ceremonies should feel comfortable and eliminate their ideological concerns. 2, wash the abdomen with warm water, keep clean, in order to facilitate surgery, reduce the chance of postoperative infection. 3, fasting within 4 hours before surgery, so as not to cause vomiting when pulling and stimulating the internal organs during surgery. 4. The urination should be emptied before the upper operating table to facilitate the operation. Surgical procedure 1, preparation Abdominal routine disinfection, toweling. 2, cutting There are two kinds of straight incisions and transverse incisions in the lower abdomen. Both incisions have their own advantages and disadvantages, and they are not forced to be consistent, and are selected according to the habits of the surgeon. The straight incision after non-pregnancy or abortion is started from the pubic symphysis with 2 horizontal fingers (about 3cm), and the longitudinal incision is about 2~3cm along the abdominal white line. The straight incision after postpartum or mid-term induction of labor is used to massage the uterus. After contraction, the incision is about 2 to 3 cm long at the point of 2 to 3 cm below the bottom of the palace. The transverse incision is on the pubic symphysis, or 3 cm below the uterus, with the abdominal white line as the midpoint extending to the sides 2 to 3 cm, the skin and subcutaneous tissue are cut, the subcutaneous fat is separated by the vascular clamp, and the rectus abdominis anterior sheath is exposed. The longitudinal rectus sheath of the rectus abdominis is about 3 to 4 cm long. The rectus abdominis muscle is separated and the peritoneum is cut. If the pre-peritoneal fat is thick, it can be separated by a vascular clamp, and the peritoneum is gently lifted to the incision to confirm the peritoneum. After that, the longitudinal incision was made 2 to 3 cm, and the upper, lower, left, and right sides of the peritoneal incision were placed on the incision with 4 small blood vessel clamps, and then the incision was opened with a small hook to expose the surgical field. 3. Correct the position of the uterus The best position of the uterus is the anterior tilt or level. Generally, it can be detected during the gynecological examination before surgery. The uterus is severely tilted and flexed. It should be corrected during surgery to facilitate the removal of the fallopian tube. Commonly used reset methods are finger reset and instrument reset. (1) Finger reset: The surgeon enters the abdominal cavity with the left hand and explores the uterus. The uterus is turned to the front, and then continues to go straight to the back of the palace. The palace is placed in front of the palace, and the other is holding a fallopian tube hook or an oval pliers. Take the fallopian tube. (2) Device reset: severe posterior tilt, flexion of the uterus, difficulty in manual reduction, can be reset with oval clamp. Put the buckled oval clamp into the abdominal cavity and slide over the top of the uterus to the anterior wall of the uterus under the pubic symphysis, and then slide along the anterior wall of the uterus through the uterine anterior wall. At this time, there is a feeling of falling, and then the oval clamp is attached to the posterior wall of the uterus. Into the uterus rectal fossa, and then open the oval clamp, the distance between the two leaves is 2 ~ 3cm, the handle is slightly raised forward and upward, that is, the uterus is pushed to the anterior position in the direction of the pubic symphysis, and some people use the small hook of the abdominal wall to reset. 4, extract the fallopian tube (1) Oval tube clamping method Simply use the oval round forceps to take the tube, which is suitable for the anterior or postpartum uterus. This method is safe and not easy to cause secondary damage. The closed non-toothed oval forceps are inserted into the abdominal cavity, and the pubic symphysis is moved to the side of the uterine cervix through the uterus, and then the oval pliers are opened obliquely to the lower back to grasp the fallopian tube; at this time, the pliers are not fastened to avoid the clip. Injury tissue, gently traction, if there is no resistance, the fallopian tube can be lifted to the incision. If it is safer and more accurate to find under the guidance of a finger, the incision is slightly larger than the incision of the pliers tube alone. (2) finger board taking method The fingerboard is safe and reliable, and it is difficult for beginners to master. The left hand of the operator extends into the abdominal cavity along the bottom of the uterus to the side of the fallopian tube to provoke it. The right hand holding fingerboard enters the abdominal cavity along the palm of the left finger and enters the front of the fallopian tube. The fallopian tube is sandwiched between the finger hole and the palm of the finger. When the fingertip has a hose-like feeling, move the finger pressure and the finger to the fallopian tube umbrella at the same time, clamp the middle part of the fallopian tube, and then gently lift it. The assistant gently presses the abdominal wall next to the incision to facilitate the exposure. Hold the fallopian tube and remove the fingerboard. (3) Fallopian tube hook tube method The tube hook is small in volume and does not affect the surgical field. It is suitable for uterus that is not pregnant, after abortion or slightly breast-feeding, and uterus that is backward. Hold the hook on the right, bend forward, back to the back, and follow the anterior wall of the uterus to the back of the uterus to the back of the uterine horn to bend the posterior lobe of the ligament, lift the hook forward and upward, when there is a slight anti-trapping force Is the symbol of hooking into the fallopian tube. (4) Internal diagnosis and direct management This method is applicable to the thinner abdominal wall, the smaller the uterus, and the difficulty in taking the tube. Taking the position of the bladder lithotomy, the assistant lifts the uterus into the incision with the other hand in the vagina, so that the uterine horn approaches the incision, and the surgeon removes the fallopian tube with a flat tooth or an oval clamp. 5, ligation of fallopian tubes The method of tubal ligation is safe, simple, and reliable. It is conducive to the future of tubal recanalization and small side effects. The following methods are commonly used: (1) Core entrapment method (Irving) It is characterized by avascular region in the isthmus of the fallopian tube; ligation, cutting of the fallopian tube core, proximal embedding, distal free, mesangial basically no damage, does not affect blood supply, proximal end embedded in the mesangium, distal tube The core is left outside the mesentery, and there is a serosa membrane at the two ends, and there is very little chance of re-passing. It is an ideal method of ligation. Two tissue clamps were used to clamp the serosa at both ends of the isthmus of the fallopian tube, and 0.5 to 15 ml of procaine was injected into the serosa, so that the serosa and the fallopian tube were separated, and the bulge was injected on the dorsal side of the fallopian tube. Cut the serosa about 2cm, clamp the edge of the serosa with 2 mosquito tongs, gently separate the serosa layer, clamp the ends of the dies, the clamp is 1.0cm, and cut the fallopian tube between the two tongs. About 0.5 to 1 cm, the two ends were ligated with the No. 4 silk thread, and the proximal end was embedded in the mesangium. The serosa incision was sutured intermittently with a No. 1 silk thread, and the distal end was sutured with a No. 1 silk thread and fixed outside the serosa. (2) Sleeve ligation method (Uchida method) The method is basically the same as the core embedding method. The method is characterized in that the serosa is made into a circular incision, the incision is small, and the operation is simple and easy. In the fallopian tube, use the small mosquito forceps to lift the serosa, and inject 0.5% procaine 1~2ml into the subserosal membrane to separate the serosa layer from the tube. The serosa layer and the tube are placed at the proximal end of the isthmus. The core is cut together, the cut can not be too deep, only the core can be cut to prevent tearing of the film. The two ends of the die were respectively clamped with a mosquito clamp, and the serosa was peeled off by another mosquito pliers to form a sleeve shape, separated from the die, and the core was peeled off by about 1 cm, and the ends were respectively ligated with a No. 4 wire. The end tube is retracted into the sleeve of the serosa, shaped like a "sleeve, the distal core is exposed outside the serosa, and the distal serosal layer is sutured with a 1st wire to fix the ruptured end. Outside the serosa. (3) Fallopian tube ligation and cutting method (Pomeroy method) This method is simple, safe, and easy to implement, but it has a higher failure rate than the previous two methods. Use the tissue forceps to cling to the isthmus of the fallopian tube and clamp the fallopian tube to fold it. Use the vascular clamp to clamp the fallopian tube and the intima of the fallopian tube about 1 to 1.5 cm from the top of the clamp. Remove the vascular clamp and use the No. 4 silk thread. After the frustration of the mesentery, the indentation is ligated separately, and the fallopian tube is cut off above the ligature. (4) Fallopian tube end embedding method The operation is relatively simple, does not destroy the physiological function of the fallopian tube, and is suitable for those who need to restore fertility in the future. At that time, the embedded umbrella end can be separated and restored to the original position. The incision of the abdominal wall is about 3 to 4 cm longer than that of the general ligation. After entering the abdominal cavity, the peritoneum of the anterior lobe of the broad ligament is close to the end of the umbrella to make a vertical incision with the fallopian tube. The length is about 2cm. Use the curved vascular clamp to extend into the incision to separate the anterior and posterior peritoneum. The depth is about 2cm. Use a small round needle to wear the No. 1 silk thread to sew a needle before and after the wall of the oviduct wall. Do not penetrate the endometrium and the fallopian tube umbrella. The knot is introduced into the incision of the broad ligament, and the umbrella part of the fallopian tube enters the separated bag. The cutting edge of the broad ligament peritoneum and the muscular layer of the fallopian tube are sutured and fixed by the No. 1 silk thread to close the incision, and the suture can not be too thin. In case of failure. (5) Fallopian tube umbrella removal method (Fimbriectomy method) The umbrella part is easy to find and identify, can avoid mistakes, and the method is simpler, and it is suitable for permanent sterilization. The tissue of the fallopian tube is clamped with tissue, and the vascular clamp and the proximal part of the fallopian tube are vertically clamped, including a part of the mesentery. After the resection, the suture is sutured with a 4th wire, and then a needle is sutured with a 7th wire. Buried in the anterior lobe of the broad ligament. (6) Fallopian tube resection method (Fallectomy method) Applicable to the first ligation failure and again require sterilization or due to fallopian tube disease need to be removed. Use 2 tissue clamps to clamp the fallopian tube, flatten the mesangium, use the curved vascular clamp to cling to the fallopian tube and parallel the fallopian tube to the uterine horn, and then use the vascular clamp to clamp the root of the fallopian tube, remove the fallopian tube, and suture with 4th thread. The ligament of the fallopian tube was ligated, and the root of the fallopian tube was sutured by the No. 7 silk thread, and the broken end was covered with a round ligament. 6, check the broken end without bleeding, sent back to the original place. 7, according to abdominal surgery routine inventory of equipment, gauze. 8. Suture the layers of the abdominal wall.