An attempt should always be made to acquire the operative and pathology reports from the tubal ligation. If the procedure was performed in a way that would not provide sufficient tubal length for repair, or significant pelvic disease was noted, the patient should be counseled to go directly to IVF. If the operative report indicates that the pelvis was normal and the tubal ligation was performed with Fallope rings or Filshie clips, or a postpartum ligation was performed with only short segments of excised tubes measured on the pathology report, tubal anastomosis can be performed without a prior diagnostic laparoscopy. In all other cases, diagnostic laparoscopy should be performed just prior to the anastomosis as 3.8–27% of patients who desired tubal anastomosis did not have repairable tubes [20–22].

Although a preoperative HSG is useful for revealing intrauterine pathology, a diagnostic hysteroscopy can be performed just prior to the tubal anastomosis without putting the patient through a painful HSG procedure. A semen analysis is always advised prior to scheduling tubal anastomosis as IVF is the procedure of choice if a significant male factor is present. For women 35 years of age and older, day 3 FSH and estradiol levels, a Clomid challenge test, anti-mullerian hormone level, or antral follicle count can be performed to rule out diminished ovarian reserve which may indicate a poorer ­prognosis for success with both tubal anastomosis and IVF.

Our standard approach to microsurgical tubal anastomosis is by minilaparotomy as an outpatient procedure, though it may not be feasible in obese patients. The patient is placed in modified lithotomy position. After diagnostic hysteroscopy is performed, a uterine manipulator is placed to help elevate the fundus to the incision as well as to perform chromotubation. Diagnostic laparoscopy is then performed if indicated.

A 5 cm transverse incision is made about 2 fingerbreadths above the symphysis through the skin and subcutaneous fat to the level of the fascia. The fascia and peritoneum are incised vertically in the midline. A Mobius abdominal retractor (CooperSurgical, Trumbull, CT) is then placed through this cruciate incision. This single-use device provides excellent exposure and protects the wound edges without the risk of nerve compression injuries associated with metal retractors. Packs and sponges are not used and frequent irrigation is performed with Lactated Ringer’s with 5,000 units of heparin per liter to reduce postoperative adhesion formation. Hemostasis may be achieved with micro-bipolar forceps or ophthalmic cautery.

The uterine fundus is delivered to the incision and the tubal segments are identified. Dilute vasopressin (20 units/100 ml of injectable saline) is infiltrated in the mesosalpinx beneath the occluded ends. The operating microscope is draped and brought into the operative field. The tubes are then mobilized using the unipolar microneedle. The occluded ends are opened with iris scissors. Transcervical chromotubation is performed by injecting indigo carmine through the uterine manipulator to demonstrate patency of the proximal tubal segments. Successive thin slices may be made with the iris scissors until free flow of dye is noted. A Beaver blade may be used instead in cases of cornual occlusion. Patency of the distal segments is documented by retrograde injection of dye using a 14 gauge angiocath (with needle removed) through the fimbria.

A single interrupted 6-0 Vicryl suture is placed through the mesosalpinx to align the tubal ends and take tension off the actual anastomosis. The anastomosis is performed with interrupted 8-0 Vicryl sutures placed such that the knots are tied extraluminally. There are no data to indicate that it makes a difference whether or not the tubal lumen is included. The first stitch is placed by the mesosalpinx (6:00 position). Additional stitches are then placed at 3, 9, and 12:00. It may be preferred to tie the knots after the stitches have been placed if visibility of the lumens is limited. Transcervical chromotubation is again performed to assess tubal patency. It is not necessary for the anastomosis to be watertight as long as spill of dye is seen through the fimbriated ends. Additional stitches may be required if there is an anastomotic leak but no distal spill. Finally, interrupted 8-0 Vicryl sutures are used to reapproximate the tubal serosa. Most patients are discharged within two hours.

The quest for an even less invasive approach led to the first published reports of tubal ligation reversal by laparoscopy in the 1990s. However, the results were poor until proper instrumentation was available. Recent publications with conventional laparoscopy show excellent outcomes using a standard two-layer anastomosis. This approach was not widely adopted because of the great technical difficulties in learning laparoscopic microsurgery. Modifications of the technique were introduced such as the use of a one- or two-stitch repair with good results. A robotic approach was initially reported in 1999 with the ZEUS (Computer Motion Inc) robot, which is no longer available [23]. Robotic tubal reversals are now solely performed with the daVinci robot (Intuitive Surgical Inc, Sunnyvale, CA).

If a minimally invasive approach is chosen, we prefer to use robotic-assisted laparoscopy rather than conventional laparoscopy because the robotic system eliminates the fulcrum effect and the motion scaling reduces tremor. This is critical when working with fine sutures. Furthermore, the physician is comfortably seated with elbows placed on the resting area with robotic surgery. The only motion is at the wrist, which is the standard microsurgery approach. Robotic microsurgery’s main limitation is the lack of haptic feedback that leads to needle bending and suture breaking. Visual cues are typically used to gauge the appropriate movements. This procedure requires experience to minimize these limitations.

The components of the daVinci surgical robot include the surgeon’s console, a video cart, and a surgical cart or tower. The surgical tower has four robotic arms that attach to specifically designed robotic trocars. The trocars that are used for tubal ligation reversal are 8 mm for the surgical instruments and 12 mm for the laparoscopic port. The console, placed anywhere in the operating room, provides the surgeon a three-dimensional vision of the operative field, as well as the ability to move the camera and manipulate surgical instruments (Fig. 12.2). The console settings should be adjusted to provide fine movements and extra magnification. Magnification can be easily adjusted and scaling is usually set at very fine (1:3). The surgeon’s arms are placed comfortably on the arm rest so that only the wrists and fingers are moving (Fig. 12.3). The main advantage of the robot over conventional laparoscopy is the seven degrees of freedom of wrist movement.

The patient is placed in dorsal lithotomy position in Allen stirrups and a RUMI uterine manipulator is placed transcervically. The robot tower is “side docked” to allow access to the vagina and cervix for possible adjustments of the uterine manipulator or for performing a hysteroscopy (Fig. 12.4). Furthermore, it provides more space for an assistant to sit and manipulate the uterus comfortably. After establishing a pneumoperitoneum, a 12 mm port is placed in the umbilicus. The proper placement of accessory trocars for robotic surgery is critical so as to avoid collision. We typically use three accessory robotic ports and one accessory conventional port for the introduction of needles, suction–irrigation, and other conventional laparoscopic instruments. The robotic ports need to be placed 8–10 cm away from each other. The conventional accessory laparoscopic port is placed in the lower quadrant, usually on the right side. A 12 mm port is typically used as the small needles can get stuck in smaller ports. It is important that needles are visualized as they enter and leave the trocar since it is easy to lose one of these fine needles.