Pomeroy technique

Named after Dr. Ralph Pomeroy, Pomeroy technique is a process of tubal ligation i.e. removal of a portion of the fallopian tube. It is a sterilization procedure for women devised by Dr. Ralph Pomeroy at the end of the 19th century and start of the 20th century. This procedure is still popular as it is an effective yet simple method to block the fallopian tubes.

The Pomeroy Technique

The technique adopts a simple yet effective procedure for tubal legation.

• In this technique, part of the tube (proximal portion of the tubal ampulla) is elevated so as to create a loop or a knuckle.
  
• An absorbable ligature (suture material) is tied around the base of the elevated part, and the tubal segment is cut out.
  
• Within a few days, the peritoneum, i.e. tissue that lines the organs of the abdominal cavity, grows and covers the severed ends of the tubal section.
  
• As the ligature dissolves, the severed ends of the fallopian tube separate from one another.
  
• The fallopian tubes remain separate without reattaching because of the above mentioned separation and the peritoneal covering.
  
• Eggs cannot travel down the separated fallopian tube, and so the woman does not get pregnant.

Variations of the technique include the following. These variations determine the length of the tubal segment that can be repaired from the remaining tube.

• Length of the tube that is tied up and cut.
  
• Location of the tube where it is going to be tied and cut.
  
• Number of ligatures placed around the tube.
  
• Type of ligatures placed around the tube.
  
• If the cut ends are crushed or coagulated.

There are many advantages of the modified Pomeroy technique. In rare cases, the severed ends drift back together and heal, or the suture does not dissolve and the fallopian tube becomes connected again.

The Pomeroy procedure is:

• Simple to perform
  
• Highly effective depending on the length of the tube removed
  
• Pomeroy ligation technique leaves two healthy segments of the fallopian tube which can be rejoined, if required through a tubal legation reversal surgery.
  
• Successful reversal rates are quite high; about two thirds of the women become pregnant following reversal of this procedure.
  
• Prior to tube reversal, the length of the tube that has been removed can be determined from the tube legation report.
  
• Procedure can be performed vaginally, abdominally or through laparoscope.
  
• Minimal complications.

Tubal Reconstructive Surgery

Tubal reconstructive surgery is performed to reconstruct the fallopian tubes which are obstructed or tied intentionally. This procedure helps in restoring the normal functioning of the fallopian tubes. Fallopian tubes play an important role in the reproduction process. The matured egg released by the ovary travels through the tube and converges with the sperm to facilitate fertilization. The fertilized egg gets implanted in the uterus to form the embryo. Sometimes the tubes may get blocked due to scar tissue caused by a pelvic infection, endometriosis, or pelvic surgery. When there is an obstruction, the egg cannot reach uterus nor can the sperm meet the egg causing infertility. Tubal reconstruction is a surgical method performed to repair the Fallopian tubes and thereby improving the chances of conception.

Tubal reconstructive surgery is also considered by those women who have undergone sterilization via tubal ligation earlier, but would want to reverse it now for personal reasons. Surgical techniques to reconstruct the fallopian tubes are aimed at achieving patency without harming the tubal anatomy. Hence microsurgical technique is the most preferred choice in conducting the tubal reconstructive surgery.

HSG (hysterosalpingogram) test is performed prior to surgery to evaluate the abnormalities inside the fallopian tubes. HSG Test will reveal the presence of blockage in the fallopian tubes.

Laparoscopic procedure is performed with micro instruments; it is minimally invasive, causes fewer traumas and relatively requires less hospital stay. Not all problems can be corrected using laparoscopy; few cases require an elaborate surgical procedure called laparotomy. Laparotomy is a procedure that involves making a large cut on the abdomen. Through Laparotomy, the surgeon can view the organs clearly, remove the blockage and join the healthy parts of the tubes. This procedure is usually adopted in case of reversal tubal ligation. The choice of the procedure depends upon various factors such as severity of the blockage, location of the obstruction and length of the Fallopian tubes.

There are three types of tubal reconstructive surgical techniques followed by the doctors to repair the Fallopian tubes. The technique chosen depends upon the nature of the problem.

Tubal anastomosis: Tubal anastomosis is a surgical procedure that is normally performed to restore the function of fallopian tubes, which have been blocked by a previous sterilization operation. It is also called tubal ligation reversal or reanastomosis. Typically, sterilization procedure would have closed the mid portion of the tube that lies between the uterus and fimbrial end. Tubal anastomosis technique removes the blocked segment of the tube and joins the two remaining open segments to make it patent.

Tubal implantation: Tubal implantation is a surgical technique that is opted when the blockage is detected at the proximal end (where the Fallopian tube and uterus join). In such cases a new opening will be created in the uterus and a healthy portion of the tube will be inserted into the uterine cavity.

Salpingostomy: Salpingostomy is used in case of distal tubal occlusion, an obstruction near fimbrial end or near ovaries. Salpingostomy involves creating an opening into the Fallopian tube surgically. Salpingostomy is also effective for treatment of hydrosalpinges, a condition where fluid builds up in the tubes leading to an occlusion. Through salpingostomy, excess fluid can be drained and tubes can be cleared to allow normal functioning. Sometimes the problem may occur in the fimbrial region, an end portion of the Fallopian tube that is responsible for sweeping the egg into tube. In such cases fimbria is reconstructed through a surgery called fimbrioplasty.

Tubal reconstructive surgery success rates

The degree of success from surgery will depend upon the extent of tubal damage. Surgery works very well, if the adhesions are small and thin. However with dense adhesions the chances of pregnancy become remote. Age is an important factor that is taken into consideration before proceeding with surgery. Women below 35 years of age have fair chances of becoming pregnant within an year of tubal surgery.

Those who fail to conceive through tubal reconstructive surgery, or, are not right candidates for a surgery are advised to chose an alternative method called IVF or other assisted reproductive techniques.

Risks associated with tubal surgery

The biggest risk associated with tubal surgery is the possibility of developing ectopic pregnancy (tubal pregnancy). Tubal pregnancy is a serious issue and may prove fatal to the mother and hence should be removed as early as possible. Other risks include infection, bleeding, trauma to adjoining organs and also the risk associated with anaesthesia.

Female Surgical Sterilization

Sterilization is a permanent method of birth control. To avert pregnancy, the female egg and the male sperm should be prevented from fusing. This can be done in women through two female sterilization methods; tubal ligation (surgical) and hysteroscopic sterilization, an essure procedure (non-surgical). Tubal ligation is considered to be a safe, reliable and highly effective form of female sterilization. The surgery is done to close a woman’s fallopian tubes. Two common methods of tubal ligation are:

Minilaparotomy: It involves making a small incision in the abdomen. The fallopian tubes are brought to the incision in order to be cut or blocked. The purpose of the procedure is to obstruct the fallopian tubes. Mini laparotomy is easier when done right after childbirth (post-partum period). It can also be done as a non-pregnancy related procedure. Minilaparotomy is considered to be a quick, highly effective, safe outpatient procedure that can be performed under local anesthesia.

Laparoscopy: It involves making a small incision just under the navel and inserting small, thin instruments to perform the procedure. Also termed as 'getting your tubes tied', herein a woman’s fallopian tubes are cut, clamped, blocked or tied with rings, bands or clips to prevent her eggs from traveling down to the uterus from the ovary. The procedure also restricts the male sperm from reaching the fallopian tube to fertilize an egg. An outpatient surgery which is done by administering local anesthesia, the patient may return home the same day and resume normal activities after a week. Slight stomach or shoulder pain, feeling dizzy, nauseated, bloated or gassy are possible symptoms that are likely to last for a few days after the surgical procedure.