Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана

range from mildly damaged tubes leading to the successful repair of the affected tube(s) to the more severe finding of badly

pregnancy following repair attempts is very low, and subsequent reclosure could lead to the formation of a recurrent

hydrosalpinx which can lead to diminished success through IVF and/or pelvic pain. In this situation, the patient will benefit

from a definitive salpingectomy.

laparotomy approach, but a laparoscopic approach is recommended due to a lower risk of subsequent pelvic adhesions. Due

to the delicate nature of the repair required, often a significantly better repair can be accomplished with the use of a robotic-

assisted laparoscopic approach. The procedure involves lysis of adhesions to restore a normal ovarian/tubal relationship,

rates have been seen with suturing open the tubes as described here.

procedures. An intrauterine manipulator capable of allowing chromotubation is helpful. Devices such as the ClearView

Kronner Manipujector

(Cooper Surgical, Trumbull, CT) allow both manipulation as well as chromotubation. We prefer to

use a very dark chromotubation solution consisting of 10 mL of indigo carmine 0.8% solution (two ampules) mixed in 100

Lysis of peritubal /periovarian adhesions

The first step is restoring the normal anatomic relationships between the fallopian tube and the ovary. This includes lysing

cases of partial closure there may be some exposed fimbria present. It is possible that the tubes may not fill due to a false

cornual blockage induced by uterine manipulation. Due to the significant chance of finding a false blockage, in this situation

tubes without significant wall thickening, three radial cuts are often the easiest and give good results. Thicker-walled tubes

are generally easier to repair using a cruciate four-incision cut. Attempts should be made to place incisions in less vascular

possible. Initial incisions should be made with scissors without the use of electrocautery. The first attempt to cut the tube

often opens only the serosa and a subsequent cut must be made to enter the thicker muscular and mucosal layers. After the

4.2.3 and 4.2.4).

Use pinpoint electrocautery to achieve hemostasis along the incisions. Use a low wattage bipolar or monopolar energy

source. Use of fine tipped instruments such as a micro-bipolar or Maryland bipolar instrument allows targeting of active

bleeding while minimizing excess tissue damage. A monopolar scissor may also be used by opening the scissor and using

only the tip to cauterize bleeding. Use low wattage settings of 15 to 20 W to minimize thermal damage. Small amounts of

pinpoint bleeding can be observed so that energy use may be limited (Tech Fig. 4.2.5).

directly related to the functional ability of that tube. A normal tube will have a thick red lumen with multiple linear folds

covering all portions of the tube. In contrast, a smooth whitish-pink lumen indicates an absence of normal mucosa and a

Tubes with even limited amounts of pink/red mucosa can still be functional and can be left in place and repaired. If there is

a complete absence of functional mucosa, a repair of that tube should not be undertaken and the entire tube should be

removed (Tech Fig. 4.2.6).

repair.

Small absorbable braided or monofilament suture may be used. A smaller diameter suture facilitates knot tying and may

minimize the inflammatory response and adhesion formation. A preferable size suture would be a 5–0 monofilament

23 (Covidien, Medtronic Minimally Invasive Therapies, Minneapolis, MN) size, respectively (Te ch Fig. 4.2.7).

shallow at this point, just through the outer serosal layer of the tube. Now pass the suture through the apex of the tubal

(Te ch Fig. 4.2.8).