Chapter 38 Robot-Assisted Tubal Anastomosis

Sejal Dharia Patel, Nora Alghothani, Olga A. Tusheva

Worldwide, more than 153 million women have chosen sterilization as their contraceptive method. As many as 20% will subsequently regret their decision because of a change in family circumstances such as the death of a child, improved economic situation, or change in marital status. Of these patients, 1% to 5% will express interest in sterilization reversal. Tubal anastomosis is a surgical approach to sterilization reversal and can be performed with robotic assistance. Robotic technology combines the benefits of open microsurgery with a laparoscopic approach. This chapter describes the evolution of robotic technology, instrumentation, essential components of the system, and technique of robotic tubal anastomosis.

Operative indications

The ideal candidate for tubal reversal has normal ovulatory function, intrauterine anatomy, and seminal parameters (in the partner). In vitro fertilization (IVF) is a nonsurgical option for couples desiring fertility after tubal ligation. Surgical reversal of tubal ligation with tubal anastomosis can be performed by laparotomy, by laparoscopy, or with robotics.

In Vitro Fertilization

IVF is an alternative procedure to surgical tubal anastomosis. It requires medication to recruit the development of multiple follicles. Once the follicles are of a certain diameter (as determined by serial ultrasound and serum estradiol), medication is given to induce ovulation. Before ovulation, the oocytes are harvested from the follicles through a transvaginal ultrasound-guided oocyte aspiration. The aspirated oocytes are incubated with sperm, and fertilization is assessed 17 to 25 hours later. These fertilized oocytes are monitored for growth and development. Of the resulting embryos, the most functional ones are transferred. Pregnancy rates have varied based on maternal age. For a good-prognosis patient younger than 35 years, the IVF pregnancy rate in our clinic (reported to the Centers for Disease Control and Prevention in 2009) is 58.6%, if the patient underwent a blastocyst transfer. One advantage of IVF includes correction of concomitant infertility factors. In addition, use of IVF avoids a major surgical procedure and does not require the patient to address contraception after delivery. IVF reduces the risk for ectopic pregnancy to that of the general population. IVF does involve, however, a defined cost per cycle, as well as the risk for twin gestation if more than one embryo is transferred.

Laparotomy

The first report to document microsurgical technique for tubal anastomosis was published in 1977. Pregnancy outcomes were improved compared with macrosurgical techniques. The reported pregnancy rates were 30% to 63% at 6 months and 53% to 80% at 12 months. Subsequent microsurgical tubal anastomosis by minilaparotomy yielded pregnancy rates of 72% to 78%.

Laparoscopy

Early laparoscopic unilateral sterilization reversal used biologic glue with intraluminal guidance and resulted in low pregnancy rates. In 1992, Charles Koh applied the principles of microsurgery to laparoscopic tubal anastomosis, resulting in improved pregnancy rates over time (up to 83.3%) at 18 months. These results were comparable to those achieved by open microsurgery.

Several laparoscopic surgical techniques have been described for laparoscopic tubal anastomosis. Many authors reapproximate the muscularis layer with four interrupted sutures at the 3-, 6-, 9-, and 12-o’clock positions and close the serosa with two or three interrupted sutures. Others prefer a one-stitch, two-stitch, or three-stitch technique, closing both muscularis and serosal layers. Regardless of the anastomotic technique, laparoscopic tubal anastomosis does offer the benefits of minimally invasive surgery. This approach is limited, however, by the absence of stereoscopic vision and the difficulty of handling fine suture with laparoscopic instruments.

Robotic Approach

The feasibility of robotically assisted tubal anastomosis was demonstrated in 1998 in animal models using the Zeus system and then followed by a pilot study in women. The procedure was successfully completed in all patients without complications. Subsequent studies have confirmed the feasibility of this technique.

Preoperative evaluation, testing, and preparation

Patients who desire robotic tubal reversal must show documentation of a competent oocyte, partner sperm, and a patent uterine cavity. Each patient has serum progesterone measured in the luteal phase to document evidence of ovulation. The partner must undergo a semen analysis showing adequate sperm (moderate oligoasthenoteratozoospermia is permitted). Finally, the patient undergoes a hysterosalpingogram to confirm a normal uterine cavity and to rule out isthmic or ampullary obstruction. If there is evidence of distal ampullary or fimbrial obstruction, the patient is not offered a robotic tubal reversal.

Patient positioning in the operating suite

The patient initially is placed in the supine position with the buttocks at the table break and the arms tucked to the sides. The caudal end of the table then is removed, and the legs are then placed into Allen stirrups (Allen Medical Systems, Acton, Mass.), with the knees flexed and lowered (Fig. 38-1). Gel pads are placed under the patient to minimize trauma at pressure points. The patient is held into position with a desufflated “bean bag” (Olympic Vac Pac, Olympic Medical, Seattle, Wash.). The elbows, shoulders, and chest are cushioned before the patient is taped to the table to prevent movement in steep-Trendelenburg position. A uterine manipulator is inserted to facilitate performance of chromopertubation during the anastomotic construction.

FIGURE 38-1 Patient positioning for a robotic tubal anastomosis.

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