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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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POSTOPERATIVE CARE
If only one tube is removed, the patient can attempt to conceive again immediately. If both tubes are removed, the patient
should proceed with an in vitro fertilization cycle.
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COMPLICATIONS
Excessive damage to mesosalpinx–ovarian blood flow, possibly diminishing ovarian function.
Injury to the ovarian blood supply during removal of the distal portion of the tube, where the mesosalpinx can merge with the
IP ligament.
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KEY REFERENCES
1. Zeyneloglu HB, Arici A, Olive DL. Adverse effects of hydrosalpinx on pregnancy rates after in vitro fertilization–embryo
transfer. Fertil Steril. 1998;70:492–499.
2. Gelbaya TA, Nardo LG, Fitzgerald CT, et al. Ovarian response to gonadotropins after laparoscopic salpingectomy or the
division of fallopian tubes for hydrosalpinges. Fertil Steril. 2006;85(5):1464–1468.
3. Xi W, Gong F, Tang Y, et al. Ovarian response to gonadotropins after laparoscopic salpingectomy for ectopic pregnancy.
Int J Gynaecol Obstet. 2012;116(2):93–96.
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Chapter 4.4
Tubal Reanastomosis
Travis W. M cCoy
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GENERAL PRINCIPLES
Definition
Tubal reanastomosis, also known as a tubal reversal, is a fertility-restoring procedure that involves surgically reattaching the
distal and proximal portions of a fallopian tube.
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Nonoperative Management
In vitro fertilization (IVF) is an alternative to a tubal reanastomosis to achieve pregnancy in patients who have had a tubal
sterilization or other interruption of the fallopian tubes.
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IMAGING AND OTHER DIAGNOSTICS
Imaging studies are generally not helpful in determining candidates for a tubal reanastomosis. An HSG can show the level
of occlusion and length of the proximal segment, but this information has only a limited role in decision-making. It is
reasonable to perform a standard transvaginal ultrasound to evaluate for other pathology such as fibroids prior to proceeding
with surgery.
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PREOPERATIVE PLANNING
The most important factor in determining the suitability of a patient for this procedure is the type of sterilization performed.
It is important to review the operative and pathology report from the procedure to confirm the type of procedure and lengths
of tubal segments excised, if applicable.
In general, the smaller amount of tube removed/destroyed, the better the odds of having a successful reversal and
subsequent functional success. As the lumen of the tube is tapered proximally, the more tube that is removed, the larger the
discrepancy in size of the tubal ends. This size discrepancy makes the reanastomosis more challenging, and the shorter
length of tube likely limits the tube’s interaction with the ovary and the overall functionality of the tube. The postreversal
tubal length correlates with pregnancy rates, though even with shorter lengths, pregnancies can occur.
1
Due to the inconsistent amount of tube that is destroyed with cautery, reversals in these patients can be very difficult and
they have a lower success rate. These patients may be better suited to undergo IVF.
In cases where operative reports are not available, performing a diagnostic laparoscopy prior to the procedure may be more
cost effective than just attempting the reversal without knowledge of the tubal status.
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SURGICAL MANAGEMENT
Tubal reanastomosis can be performed through a mini-laparotomy or laparoscopically. The surgical steps are the same
whether the procedure is done through an open or laparoscopic route.
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Positioning
For mini-laparotomy, the patient may be placed supine or in stirrups in the dorsal lithotomy position. In both situations, a
uterine manipulator should be placed to allow for chromotubation during the procedure. Appropriate intrauterine
manipulators include the ClearView
®
(Clinical Innovations, Murray, UT), HUMI
®
(Cooper Surgical, Trumbull, CT),
ZUMI™ (Cooper Surgical, Trumbull, CT), or Kronner Manipujector
®
(Cooper Surgical, Trumbull, CT).
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