The surgical approach to fallopian tube reconstruction is discussed in 3 parts according to the anatomic location of the obstruction:
(1) the proximal portion of the tube.
(2) the distal portion of the tube.
(3) the mid portion of the tube.
Occlusion of the proximal portion of the fallopian tube:
Proximal occlusion of the fallopian tube can be of 2 types: intramural/interstitial and isthmic.
Intramural/interstitial obstruction
In the past, intramural/interstitial obstruction was surgically treated with tubal reimplantation through the uterine wall. This procedure is mentioned for historical interest because, in terms of achieving lasting tubal patency and subsequent pregnancy, the results are so poor that the procedure should be abandoned. Today, other more successful therapeutic options, such as IVF, are indicated.
However, intramural obstruction can be approached via hysteroscopic cannulation. The patient undergoes concurrent laparoscopy and hysteroscopy. The procedure may require 2 surgeons. The laparoscopy is performed to exclude disease in the distal portion of the fallopian tube(s). If the distal fallopian tube(s) is healthy, the surgeon can proceed to hysteroscopic cannulation.
A number of commercial cannulation kits are available for this procedure (eg, the Novy Cornual Cannulation Sets, Cook Ob/Gyn; Spencer, Ind). The tubal ostia are visualized in the endometrial cavity with the hysteroscope. A small wire is inserted through the os into the intramural portion of the tube, and a small catheter is threaded over the wire. Patency can be confirmed when dye introduced through the small catheter in the intramural portion of the tube is visualized extruding through the fimbria via laparoscopy.
Proximal tubal disease is commonly caused by salpingitis isthmica nodosa (see the image below). It is commonly diagnosed when firm nodules are found on the fallopian tubes. The diagnosis is confirmed by histopathology. The hallmark of salpingitis isthmica nodosa is the presence of diverticula or outpouchings of the tubal epithelium, which are surrounded by hypertrophied smooth muscle. The diagnosis can only be confirmed by histology. It can be suspected by hysterosalpingography if proximal obstruction is present or by a stippled appearance indicating contrast medium in the diverticular projections. It is commonly bilateral and often found in fertile women. The cause of salpingitis isthmica nodosa is not known. Salpingitis isthmica nodosa is found in 0.6–11% of healthy fertile women and is almost always bilateral. There have been moderate success rates with microsurgical excision of affected areas and anastomosis of tubal segments.
Isthmic occlusion
Isthmic occlusion can be repaired by performing an isthmic-cornual or an isthmic-isthmic anastomosis as appropriate. The damaged portion of the tube is transected perpendicular to the axis of the tube. The occluded portion of the tube is resected 2 mm at a time, initially proximally and subsequently distally, until the tubal lumen is visualized.
Proximal patency is confirmed using retrograde chromopertubation through a cannula in the uterine cavity. Distal patency is confirmed by threading a piece of thin suture material from the fimbrial end toward the area of anastomosis.
An anchoring suture is placed in the proximal and distal mesosalpinx (isthmic-isthmic repair) or from the cornu proximally to the mesosalpinx distally (cornual-isthmic repair) to bring the 2 portions of the tube being anastomosed in proximity. Four interrupted sutures are placed at the 12-, 3-, 6-, and 9-o’clock positions, parallel to the axis of the tube, first within the muscularis and subsequently on the serosa, to bring together the proximal and distal portions of the tube.
Occlusion of the distal portion of the fallopian tube
Distal tubal occlusion can be surgically repaired by laparotomy or laparoscopy. Both surgical approaches achieve similar results.
Proximal patency of the tube must be confirmed with a preoperative hysterosalpingogram. Filling the fallopian tube with dilute dye at the time of surgery (via a cannula in the uterine cavity) facilitates identification of the entrance point in the distal, peritoneal surface of the tube that opens into the tubal lumen.
The distal occluded tube is opened using laser energy, a needlepoint unipolar electrode, or microscissors. The mucosa is everted without tension and is sutured to the serosa of the tube with a few interrupted sutures.
Occlusion of the mid portion of the fallopian tube
Midtubal occlusion is the most frequent cause of tubal sterility. In appropriate cases, anastomosis of the mid portion of the fallopian tube holds the greatest promise of success. The anastomosis can be isthmic-ampullary or ampullary-ampullary. The success of the procedure is directly correlated to the length of the tube following anastomosis.
Midtubal anastomosis can be performed via laparotomy or laparoscopy with equivalent rates of success. The procedure is similar to that described for isthmic-isthmic anastomosis. The occluded portion of the tube is resected. Portions of occluded tube (in 2-mm sections) are repeatedly resected, first proximally and then distally, until the tubal lumen is identified in the proximal and distal stumps. Patency of the stumps is confirmed with retrograde chromotubation (proximal stump) and by threading a piece of thin suture from the fimbrial end toward the area of anastomosis (distal stump).
An anchoring suture is placed in the proximal and distal mesosalpinx to bring the 2 portions of the tube being anastomosed in proximity. Four interrupted sutures are placed at the 12-, 3-, 6-, and 9-o’clock positions, parallel to the axis of the tube, first within the muscularis and subsequently on the serosa, to bring together the proximal and distal portions of the tube.
Preoperative Details
Candidates for tubal reconstruction are young women of reproductive age. In most cases, these women are healthy, and a preoperative CBC count and a serum pregnancy test are all that is required. Other preoperative evaluation is dictated by the patient’s medical history and needs. The use of perioperative prophylactic antibiotics to prevent infection and corticosteroids or antiprostaglandin agents to decrease adhesion formation is controversial.