Khairia F. Omran

Classification of Adnexal Adhesions: A Proposal and Evaluation of Its Prognostic Value *

A system of classification of adnexal disease is proposed. Hysterosalpingography is important to determine tubal patency (stage I) and to distinguish between the presence of rugae in early fillage of the ampullae (stage II) and their absence (stage III or IV). Diagnostic laparoscopy under general anesthesia with the double-puncture technique is recommended to inspect the ovaries thoroughly and to put adhesions on a stretch for evaluation of thin, avascular adhesions (A) and thick, vascularized adhesions (B). The extent of adnexal disease can be classified as stage I minimal if most or all of the ovarian surface is visible; stage II, over 50% of the ovary is visible; stage III, less than 50% of the ovary is visible; Stage IV, no ovarian surface is visible. Each adnexum should be described separately. The worst aspect of each adnexum should be described. The best adnexal classification should be used in describing the patient for purposes of comparing surgical treatments. Using this approach, the authors describe a gradient from stage I (best prognosis) to stage IV (poorest) in a personal series of 99 tuboplasties over a 10-year period.

Comparative Tubal Occlusion: Rigid and Spring-Loaded Clips *

An exploratory series of tests has been carried out comparing rigid tantalum and spring-loaded clips designed for tubal occlusion. Sows of proven fertility were used in all experiments. Five control animals were used five animals underwent tantalum clip application and five animals underwent spring-loaded clip application. Three control animals became pregnant and three sows with tantalum clips became pregnant while none of the sows with spring clips became pregnant. Patency of the tubal lumen was maintained with the rigid clips but was eliminated with spring clips. A laparoscope designed to apply the spring clips under local anesthetic is described and implications regarding reported clinical trials and future human investigation are discussed.(AUTHORS MODIFIED)

Sterilization by Spring Clip: A Report of 1000 cases with a 6-Month Follow-Up *

In September 1972, clinical trials of a spring-loaded clip for laparoscopic sterilization were begun and extended to a number of centers in the United States and overseas. As of March 1974, more than 1000 patients had undergone the procedure, usually performed under local anesthesia in an outpatient setting, with no fixed contraindications. Complications and pregnancy rates based on a preliminary 6-month follow-up are presented. Complications due to application of the clip appeared to be limited to postoperative cramps lasting 24 to 48 hours (26% of the patients). No ectopic pregnancies were reported. Pregnancies, when corrected for unsuspected pregnancies and misapplication of the clip, occurred in 2 of these first 1000 patients. The difficulties and relative contraindications learned from this unselected series and the advantages over electrocagulation techniques are discussed.

Spring clip sterilization: one-year follow-up of 1,079 cases.

This is a report of 1,079 patients who underwent laparoscopic clip sterlization as of March, 1974. A one-year follow-up was obtained on 977 patients, or 90.5 per cent. Complications due to the clip technique appear limited to postoperative cramps for 24 to 48 hours in 26 per cent of patients. No ectopic pregnancies were detected. Pregnancies, when corrected for unsuspected existing pregnancies and surgical and manufacturing errors, occurred in 2 to 6 cases, for a method failure rate of 2 to 6/1,000. This report documents that experienced laparoscopists can perform this practice with local anesthesia, in combination with first-trimester abortion, and in hospital facilities other than an operating room.

Laparoscopic Tubal Clip Sterilization Under Local Anesthesia

Tubal anesthesia with lidocaine during laparoscopic tubal clip appli cation was evaluated in 149 women; 147 tubes received no lidocaine and 151 received 1 or 2 ml of 1% or 4% lidocaine. For unanesthetized tubes the mean pain rating depended on the dose of diazepam and fentanyl given to the patient (p less than .1); pain ratings were higher in women who received no drug. When any diazepam and/or fentanyl was given the anesthetized tubes were given a significantly lower pain rating (p less than .01). 23.8% of unanesthetized tubes received a pain rating of 2 12.9% a rating of 3 or 4 while no anesthetized tube received a 3 or 4 (on a scale of 0 to 4) and only 4% received a 2. 68.5% patients were their own control; 42% rated the pain equal in each tube (1 was anesthetized) while 58% rated the anesthetized tube less painful. 3.4% of the patients experienced vasovagal reflex stimulation. It is concluded that using a local anesthetic solution substantially reduces discomfort associated with fallopian tube manipulation during sterilization.

Sterilization by Cryosurgery: A Report of Animal Fertility Studies*,†,‡

The results of an investigation by which the uterotubal junction (UTJ) of the human uterus could be occluded with crosurgery as the physical agent are reported. A uterine cryoprobe patterned after the uterine sound was introduced through the vagina and cervix to reach the UTJ. The healing process after such treatment was studied by freezing UTJs of 12 rabbits at surgery under direct view for 2 minutes at -35 degrees to -50 degrees C with freon gas. The rabbits were sacrificed in groups of 3 at 4 7 14 and 21 days. Saline was injected to obtain gross evidence of occlusion and histological sections were also studied. Potential harm was evaluated by intentionally freezing bowel femoral artery nerve and veins of the inguinal area. To minimized recanalization of depo form of progesterone was given. To study the effect of cryosurgery on fertility 31 mature sows of proven fertility underwent cyrosurgery of the UTJ under direct vision. The sows were mated twice during each subsequent estrus. Temperatures achieved at the end of the probe were -30 to -35 degrees C with a rate of thaw of 2-4 minutes. Grossly 50% of the tubes appeared occluded. Histologically they were all patent. Subsequent fertility of the pigs although imparied was similar to controls. Dramatic bowel lesions were produced with the instrument indicating that even if occlusion could be produced monitoring the cryosurgery with fluoroscopic safeguards would be necessary. Thus elaborate equipment would make this method impractical for field use.

LAPAROSCOPIC TUBAL CLIP STERILIZATION UNDER LOCAL ANESTHESIA

Tubal anesthesia with lidocaine during laparoscopic tubal clip appli cation was evaluated in 149 women; 147 tubes received no lidocaine and 151 received 1 or 2 ml of 1% or 4% lidocaine. For unanesthetized tubes the mean pain rating depended on the dose of diazepam and fentanyl given to the patient (p less than .1); pain ratings were higher in women who received no drug. When any diazepam and/or fentanyl was given, the anesthetized tubes were given a significantly lower pain rating (p less than .01). 23.8% of unanesthetized tubes received a pain rating of 2, 12.9% a rating of 3 or 4, while no anesthetized tube received a 3 or 4 (on a scale of 0 to 4) and only 4% received a 2. 68.5% patients were their own control; 42% rated the pain equal in each tube (1 was anesthetized), while 58% rated the anesthetized tube less painful. 3.4% of the patients experienced vasovagal reflex stimulation. It is concluded that using a local anesthetic solution substantially reduces discomfort associated with fallopian tube manipulation during sterilization.