Standard “Open” Tubal Reversal Technique
Performing a standard tubal reanastomosis requires microsurgical techniques (see Microsurgery), however, obtaining access to the fallopian tubes first requires a standard surgical procedure called a minilaparotomy. In a minilaparotomy, a side-to-side incision is performed in the middle of the lower abdomen (just below the pubic hair line and above the pubic bone), approximately 5-7 cm (2-2.5 inches) in length. The incision is carefully extended into the deep subcutaneous tissues until the pelvic cavity is entered and the pelvic organs (uterus, fallopian tubes, and ovaries) can be visualized. The uterus and fallopian tubes are next partially raised above the abdominal incision (exteriorized), providing the surgeons easy access to the fallopian tubes. The use of self-retaining retractors is avoided to minimize tissue damage. The surgeon next puts on specialized surgical “loupes” (magnifying glasses) in order to clearly visualize the fallopian tubes. From this point on, microsurgical techniques are employed (see below).
Robotically-Assisted Laparoscopic Tubal Reversal Technique
In robotically-assisted laparoscopic tubal reversal, a standard laparoscopy is performed whereby visualization of the abdominal and pelvic organs is achieved by insertion of a fiber optic camera, the laparoscope, through a small umbilical or peri-umbilical (around the belly button) skin incision (typically 8 mm long). Furthermore, as in a standard laparoscopy, additional ports (normally 3) are introduced after performing small skin incisions (all less than 8 mm long each) in various locations in the abdomen (typically in the lower and mid-abdomen, and occasionally the upper abdomen, depending on the procedure performed) in order to gain surgical access to the fallopian tubes. The difference between a standard laparoscopy and robotically-assisted laparoscopy comes next: instead of inserting laparoscopic instruments through previously-established abdominal ports that are maneuvered using the surgeon’s hands directly, robotic instruments (fine graspers, scissors…) are inserted through the abdominal ports and the robot’s arms are locked onto the laparoscopic instruments. The surgeon next relocates away from the operating room table (a surgical assistant remains at the patient’s side at all times) and to the robotics surgical console, located a few feet away from the patient in the operating room. In the surgical console, the surgeon is served with a three-dimensional view of the operative field (achieved through the robotics laparoscope located within the patient’s abdominal cavity), and is able to command the robot to perform the tubal reversal through the previously-engaged robotic arms using virtual reality movements, which imitate those used during a standard “open” tubal reversal surgery. Since the robotics instruments can achieve fluid and multiple degrees of motion and articulation which match those of a surgeon’s hands, far superior to the limited maneuverability of standard laparoscopic instruments, the robotics surgeon can complete the tubal reversal in the same manner as the standard “open” technique. Due to enhanced visualization (the operative field may be magnified by 10-fold), stability of the surgical instruments in the robot’s “hands” (shaking is avoided completely), and the ability to achieve exceptionally fine microscopic surgical movements (which is extremely important when handling the delicate tissue of the fallopian tubes), robotically-assisted laparoscopy is ideal for microsurgical tubal reversal (tubal reanastomosis) surgery. This means superior tubal reversal results with recovery times up to 1/3 to 1/5 those with the standard minilaparotomy tubal reversal, which traditionally requires longer recovery times as a result of a lower abdominal incision which can often reach up to 5-7 cm in length. Moreover, since the laparoscopic approach involves several small incisions without a larger lower abdominal incision, blood loss and risk of pelvic or wound infection in robotically-assisted laparoscopic tubal reversal is significantly lower than that experienced during a standard “open” tubal reversal. Additionally, in patients with multiple prior cesarean sections and/or those with a high body mass index (BMI=measure of weight status in relation to height; BMI>30=obese range), exteriorization of the uterus and fallopian tubes (raising the uterus and fallopian tubes up through the abdominal incision for adequate visualization) may be quite difficult using the standard “open” tubal reversal procedure, often requiring the surgeon to work on the fallopian tubes while they are “in situ” (deep in the pelvis), making visualization of the tubes somewhat limited. In contrast, with robotically-assisted laparoscopic tubal reversal the uterus and fallopian tubes remain in their natural location in the pelvis, while the robotic camera and arms are advanced deep into the pelvis for excellent visualization accessibility of the tubes for the reversal procedure; making the patient’s weight and history of prior cesarean sections less important factors in the reanastomosis procedure.
Microsurgical Techniques (for both standard and robotically-assisted tubal reversals)
Since all tubal ligation procedures result in some degree of damage and scarring to the tube, the first step of microsurgical tubal reversal is to carefully remove the damaged portion of the tube, along with any materials which were used to block the tube during the ligation (sutures, clips, bands…). Great care is taken to avoid removing healthy portions of the tube and to preserve the final tubal length. After the damaged portion of the tube is removed, a proximal segment (originating from the uterus) and a distal segment (originating at the fimbriae adjacent to the ovary) remain, which require re-connection. The blocked end of each tubal segment is next carefully opened. A single or two retention suture(s) are next placed just below the tubal segments in an area called the mesosalpinx, which aligns the two segments and ensures that the reanastomosis procedure will be tension-free. Finally, the two open ended tubal segments are sutured to one another using small gauge microscopic sutures (see Microsurgery) placed in the middle muscular layer (muscularis) of each tube, avoiding both the outer layer (serosa) and inner layer (endosalpinx/mucosa) in order to minimize scar tissue formation on the outside and inside of the tube. A sterile dye injected into the uterus and out of the fallopian tubes confirms that the reanastomosis was successful by illustrating the spillage of dye from the tubal fimbriae.
Standard “Open” Tubal Reversal Technique