Fimbrioplasty for tackling infertility

Fimbrioplasty is one of the several procedures for reforming the Fallopian tubes aimed at correcting infertility in females.

The fimbrioplasty procedure is more favored than the simply opening salppingostomy procedure performed on the Fallopian tubes as the latter does not tackle the vital role of fimbriae. Reforming the delicate fimbriae and preserving it of utmost importance for achieving a pregnancy. The surgery is not recommended till an inclusive infertility diagnosis of the concerned couple is carried out.

The objective of the surgery is to open the occluded Fallopian tube while salvaginging the fimbriae functions for smoothening the progress of entrapping and transporting the oocyte (egg).

Physiologic Changes:

Not only the fimbrae is restored, but also the Fallopian tubes are open.

Cautions:

Careful haemostasis is extremely necessary for the success of the procedure. The utmost care is required so that the tubal vascularity is not endangered by too much categorization of the mesosalpinx from the ovaries. Apart from this, needlepoint electrocautery, irrigation and suction are necessary for controlling homeostasis instead of fastening of bleeding vessels, clamping and sponging.

Technique

Before fimbrioplasty, the surgeon should perform a diagnostic laparoscopy.

For carrying out diagnostic laparoscopy, the patient is positioned in the posterior lithotomy with her hips bent at 45°, the knees at 90°, and the buttocks pulled out minimum 4” away from the operating table edge. The patient is consigned at about 15° Trendelenburg point.

As recommended under the laparoscopy procedure, the devices are introduced for a thorough investigation of the pelvis. In case of the presence of hydrosalpinx grossly or the Fallopian tubes are grossly damaged from both the sides, it is recommended to desert the procedure. The suitable patient for performing fimbrioplasty is the one, whose Fallopian tubes are normal excepting the fimbriae issue, which require agglutination or clubbing. The combined tubal end is somewhat distended by the indigo carmine solution injection into the uterus during the laparoscopy procedure. The laparoscopy devices are removed; the small pivotal (umbilical) opening is closed by applying 3-0 subcuticular stitch.

A Pfannenstiel (bikini) incision is usually preferred in such cases. Dye inscriptions are placed for helping the abdominal area closing for giving a better cosmetic view.

For elevating the ovaries, the Fallopian tubes and the uterus into the incision, moist packs are introduced in the cul-de-sac (dead-end). For removing adhesions, a cautery having a microchip is used.  Visual intensification and an excellent light source are necessary for performing this step. The traction and countertraction rule is important on the structure for viewing the adhesions safely.

For elevating the serosal covering over the combined Fallopian tubes’ end,  fine forceps are used. Before opening the combined end of the fimbriae with an electrical cautery having a microtip, small vessels are thickened. When the scar tissues on the combined end of the tube are severed transversely, carmine dye is observed falling from the Fallopian tube.

As the tube is folded back after scarred serosal layer is opened of the combined Fallopian tube, the fimbriae comes out of the Fallopian tube.

The scarred serosa is stitched back to the Fallopian tube with the help of a microneedle and 7-0 Prolene stitches. It is done in such a manner that the fimbrea is set free while keeping the patency  of the Fallopian tubes intact.

A complete bimanual pelvic investigation is done

Two positions are used for performing fimbrioplasty. One is the dorsal lithotomy keeping the face upward, wherein the legs are kept inferior in  the gynecological stirrups so as to keeping the hips enlarged at 10°  instead of their flexing and the knees are being about 90°.

The legs are seized about 15°, revealing the perineum and the vulva. This position is preferred when a surgeon desires to introduce a cannula into the endometrial cavity or devices into the cervix during the method.  The position helps in injecting the indigo carmine liquid via the cervix through a cervical cannula. Apart from this, the uterus is elevated into the suitable operational location without using the traction stitches on the fundus or the cul-de-sac packing.

The abdomen is opened by making a Pfannenstiel incision. There is a probability of finding adhesions between the round ligament, ovaries and the Fallopian tubes. While the bladder is found on the right; the fundus is located in the middle. A blocked Buxton-type fastening is executed in the lower uterine section, and a 10 ml of indigo carmine liquid is placed via the fundus with a 21 gauge needle. The endometrial cavity gets packed with the dye. The dye is meant to flow into the Fallopian tubes swelling up the combined endings of the Fallopain tube requiring a fimbrioplasty.

After removing the adhesions completely, the combined end of the tube is identifiable and opened up with the help of a low setting cautery. Dazzling light and visual intensification may help the surgeon in doing this delicate work.

Extra fine scissors and forceps are used for picking up the star tissue and cutting transversely the serosal covering below the fimbrea. It is imperative to classify the blood vessels in the scarred layer of the fimbriae; the scarred serosa incisions are so fashioned that the minimum blood vessels are transected. Hemostasis is managed with the help of the microelectrode.

For separating the fimbriae and identifying the ampullar portion lumen of the tube, saline solution is used for irrigation.

For checking the Fallopian tubes patency, the lower uterine section is strained between the first finger and the thumb or is seized with the help of an atraumatic clamp. 10mL of indigo carmine is introduced in the endometrial cavity through the fundus, using a 21 gauge needle.  The dye is meant to load in the Fallopian tubes and flow out from the fimbriae.

  1. December 19, 2017

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