Laparoscopic sterilization in camps and institutional set-up.
Voluntary sterilization is possibly the most popular method of fertility control all over the world. Laparoscopic sterilization of women would appear to be the method of choice of achieving voluntary sterilization. We wish to record, in this paper, out experience of laparoscopic sterilization in the K.E.M. Hospital and in camps conducted by the staff of the Department of Gynaecology and Obstetrics of the K.E.M. Hospital in the State of Maharashtra.
Between January 1977 and December 1980, 22 laparoscopic sterilization camps were held in rural areas, where 5584 female sterilizations were performed. Between January 1972 and October 1980, 830 laparoscopic sterilizations were performed in the K.E.M. Hospital. The camps had facilities for short admission of patients and operative procedures in case of emergency.
At the time of the first visit, all the patients were registered. Their obstetric and medical history was noted, and motives of sterilization were discussed. A thorough examination was performed to rule out disorders that would contraindicate laparoscopy and to check if the patient was pregnant. A haemogram and urinalysis were done to confirm fitness for surgery.
All the patients were starved overnight. Injection atropine sulfate 0.5 mg was given intramuscularly half an hour before the operation. Controlled general anaesthesia was used in K.E.M. Hospital patients, when the operating surgeon was inexperienced or was in training. In other cases at the K.E.M. Hospital, local anaesthesia with sedation as described below was used. The former was used in about 60% of the patients and the latter in 40%. In the camps, 3 types of anaesthesia procedures were used.
a) Local anaesthesia (in 40% of cases) comprising local infiltration of 5 ml of 1% xylocaine at the site, and preceded by 50 mg of pethidine intravenously and 5 mg of trifluopromazine intramuscularly.
b) About 40% of patients received 10 mg of diazepam and 250 mg of thiopentone sodium mixed in the same syringe, intravenously, slowly, just prior to the operation.
c) The remaining patients were operated upon under controlled general anaesthesia.
The patients found out to be pregnant were not entertained for laparoscopy in the camp. In patients who presented postmenstraually, the laparoscopy was carried out directly. When the patients presented premenstrually, dilatation and curettage were done in addition to laparoscopy. Some patients also had puerperal laparoscopic sterilization. Suction evacuation and second trimester abortion, in addition to laparoscopy were not performed in the camps but were undertaken in the K.E.M. Hospital
Both single puncture and double puncture operative techniques were employed. Carbon dioxide was the gas most commonly used to induce pneumoperitoneum. When it was not available, as in the camps, air was used. Tubal occlusion was achieved with silastic bands, Filshie clips or unipolar cautery (done at the K.E.M. Hospital) as suitable. The silastic bands were used for interval cases with normal tubes. Filshie clips or unipolar cautery was used when the tubes were thickened due to oedema or chronic infection.
After an uneventful operation, the patients were discharged on the same day. With development of any complication, they were treated appropriately and kept under observation till such time as it was deemed safe to discharge them.
All the patients were followed up for detecting late complications and failure of sterilization procedure. The failed cases were subjected to medical termination of pregnancy and re-sterilization.
All the patients in the camps were in the reproductive age group. Their parity varied from second to seventh. In the K.E.M. Hospital, the average age was 30 years, and average parity 3.
[Table - 1] shows the details of the procedure performed at camps and at the K.E.M. Hospital. Ninety-five per cent patients undergoing sterilization at camps were interval cases, compared to 17.47% in the hospital. Of the K.E.M. patients, 38.31% were with first trimester abortions. Silastic bands were used in majority of the cases at both camps and K.E.M. Hospital. In the camps, 80% cases were operated upon through a single puncture and 20% through a double puncture. In the K.E.M. Hospital, 95% were performed through a single puncture and 5% through a double puncture.
Various operative complications encountered are shown in [Table - 2]. No patient in the camp required exploratory laparotomy for management of the laparoscopy complications, but all got well with conservative treatment. In the hospital group, 4 patients with tubal transection and 3 with bowel burns required an exploratory laparotomy. Those with tubal transection were managed by ligation of the cut ends and had an uneventful recovery. Out of 3 patients with accidental bowel burns, two recovered after resection of burnt bowel and anastomosis, but the third ore expired due to generalized peritonitis following resection anastomosis operation.
The mean stay in the camp was half to one day. About 1% required an overnight stay. In the K.E.M. Hospital, after silastic band application, the duration of hospital stay was 1 day, after the use of unipolar cautery 4 days, with minor complications 2 days and major complications 7-15 days.
There were 3 failures out of 5584 (0.05%) in camps and 6 out of 830 (1.14%) in the K.E.M. Hospital.
In camps, 2 patients had pelvic adhesions and 2 had gross obesity, making sterilization difficult, which was however carried out in all 4 cases. At the K.E.M. Hospital, 5 patients needed minilaparotomy for tubal occlusion due to peritubal adhesions.
Eighty per cent of our population lives in the villages where less than 20%, of the doctors practice; only a few of them are capable of performing sterilizations. The need for family planning in rural areas is made evident further by the difference in the number of sterilizations performed5584 in rural camps over 3 years and 830 in the K.E.M. Hospital in the city of Bombay over 9 years.
The relatively greater incidence of complications in our hospital group of patients, including one death, and the higher failure rate in the hospital patients were to a great extent related to surgeons in training. Another factor was that 95% of the sterilizations in the camps were interval procedures. Post-abortal and puerperal sterilizations are always associated with greater number of difficulties and more frequent complications.
The use of unipolar cautery in the earlier days nurtured lot of complications; it was replaced in due course with bipolar cautery and endothermal cautery. However, we advocate only mechanical methods of tubal occlusion at camps. The transit from the use of cautery to the use of mechanical means-silastic bands and clips-indicates the changing trends in Laparoscopic sterilization, and this should expel any fear regarding the high complication rate encountered with the use of cautery coagulation.
Laparoscopic sterilization by silastic bands is getting more and more popular in our country. A camp approach is the best way of managing large number of women requiring sterilization in rural areas.,, Camp organization by a person experienced in laparoscopy and management of any complications that may arise makes the camps safe.
We thank the Dean, Seth G.S. Medical College and K.E.M. Hospital, Bombay, for permitting us to report the hospital data.