The surgery of conception
From Primary Surgery
Contents |
Maternal Mortality
The next few chapters describe the diseases peculiar to women. Women produce more than half the food in the non-Muslim parts of India and Nepal, and up to 80% of it in Africa. Yet their health has been much neglected. Half a million of them die in childbirth each year, 99% in the developing world. The chances of this happening depend on how often a woman becomes pregnant (the concern of this chapter), and how dangerous each pregnancy is, as measured by the maternal mortality ratio (MMR). This is the number of maternal deaths expressed per 100,000 live births. A maternal death is: 'The death of a woman while she is pregnant, or within 42 days of the termination of pregnancy, irrespective of the duration and site of her pregnancy, from any cause related to, or aggravated by her pregnancy, or its management, but not from any accidental or incidental causes'. (ICD–9) In the Maternal Mortality Rate, which is not discussed here, the denominator is 10,000 women in the 15–49 reproductive age group.
The MMR varies widely. It used to be high all over the world. In some communities in Africa it is still 1000 or more, which means that a mother has a 1% chance of dying from pregnancyrelated causes, or a 10% chance if she has 10 pregnancies in her lifetime. In the developing world as a whole it is about 450, but in the developed world it has fallen to 30. The result is that a mother who delivers in Bangladesh has a 400 times greater chance of dying than a mother in Scandinavia.
The deaths of mothers are more difficult to prevent than those of their children. Apart from family planning, there are no simple ways of preventing a mother's death in the way that oral rehydration and immunization can save a child. Mothers die from abortions and ectopic pregnancies, eclampsia, anaemia, haemorrhage, obstructed labour, ruptured uteri, or sepsis, and often from more than one of these causes. Mostly, they either die at home, or present late in hospital as unbooked emergencies who have had no antenatal care. Tragically, those who need care are least likely to get it. Saving their lives requires improved education for women and services at three levels: (1) In the community. (2) In clinics and health centres. (3) In adequately equipped and staffed district hospitals. Especially, it needs plenty of well-trained midwives. Establishing all this needs political will. To raise this you will need to know your local MMR. Here is a simple new way of measuring it. Ask adults what happened to their adult sisters and whether or not they died in childbirth. Their mortality experience will be a measure of that of the community as a whole.
SAMPLE SIZE is important, and depends on the expected level of maternal mortality, the average number of 15+ sisters that respondents will have, and the amount of error you are willing to tolerate. If the expected level of maternal mortality is high (an MMR of about 1000), and most respondents come from large families, you will probably be able to get a reasonable estimate from 2000 respondents, which is the absolute minimum, and is only applicable for least developed rural areas. 4000– 6000 is suitable for most other situations, but you will need at least 8000 for urban populations in more advanced developing countries. In the developing world, each household often has three adults who can be interviewed, so that to find 2000 respondents, you may only need to visit 667 households (2000/3).
TOTAL FERTILITY RATE (TFR). You will need this to calculate the MMR. It is the average number of live births that a mother could expect to have in her lifetime if she experienced the same age-specific fertility rates as mothers now living. You can get it from the UN Demographic Yearbook, or from your Central Statistical Office. Or, much less satisfactorily, you can work it out. You can ask women aged 15–49 how many live births they have had in the last 12 months, and work out the TFR as described below. Alternatively, you can use a range of TFRs, from 4 to 7, which will cover most developing-country populations, and see what answers you get.
PRESENT AND PAST FATALITY AND FERTILITY. The older your respondents, the longer ago their sisters will have died, the longer ago they will have had babies, and the less up to date' your estimate. By using the information from all your respondents aged 15–45, you will get an estimate which reflects the level or maternal mortality over the last 10–12 years. This estimate is likely to be similar to the current one, because in the populations in which this method is used, the MMR is unlikely to have changed much over the previous decade.
THE SISTERHOOD METHOD FOR DETERMINING THE LEVEL OF MATERNAL MORTALITY
You will need some interviewers and a calculator. Carefully translate the questions into the local language, and stencil them with separate answer boxes for each respondent. You should be able to get all the answers for each household on a sheet of A4 paper. Use interviewers with a reasonable level of literacy and numeracy. Pupil nurses are ideal; make the survey an educational project for them. They will need to question at least 2000 respondents (see above), so it will take them several days. Take them into a classroom and explain the method. Then, ask them to visit a reasonably random selection of households, which you think will reflect the population in your district. In each house ask the head of the household to list all adults aged 15+; then question each in turn. Try to talk directly to all adults over 15, rather than using another household member to respond on his or her behalf.
a) How old are you? Or, What is your date of birth? Interviewer: check that the respondent is over 15 years old.
b) Interviewer: What is the sex of the respondent? If the respondent is female, and you are going to calculate the TFR, ask question (c):
c) How many live births have you had in the last 12 months, even if the baby is no longer alive?
d) For all respondents, male and female ask: How many sisters have you ever had who were born to your mother?
e) How many of these sisters ever reached the age of 15, including those who are now dead?
f) How many of these sisters, who reached the age of 15, are alive now?
g) How many of these sisters are dead? Interviewer: Check that the sum of (f) + (g) = (e), and sort out any discrepancies. (e) should be equal to or less than (d), it cannot be greater than (d).
h) How many of these dead sisters died while they were pregnant, or during childbirth, or in the 6 weeks after the end of pregnancy?
For practice, do a pilot study on about 10 households, and adjust your questions as necessary.
THE TFR based on question (c) above, can be derived from the age-specific fertility like this:
1) Group the female respondents aged 15–49 by 5-year age group, that is 15–19, 20–24, …, 45–49.
2) For each 5-year age-group, divide the number of live births in the last 12 months by the number of all women for that age (not just those giving birth). This will give you an estimate of the agespecific fertility rate for each age-group as a proportion.
3) Add the proportions together and multiply the total by 5 (for the years in each age-group) to get the TFR, which will probably be between 4 and 7.
MMR. Work out a table like that in Table 15-1. You will need to make two corrections:
(A) Respondents in the age-groups 15–19, and 20–24, can expect some more sisters to reach the age of 15. So work out the average number of sisters reaching age 15 for the respondents over 25. In Fig. 15-1 this was 1.54, that is each respondent above the age of 25 had 1.54 sisters reaching age 15. Multiply the number of respondents in the age-groups 15–19 and 20–24 by this figure to fill in the first two entries in column (3). These have been marked with a star. For example, in Fig. 15-1 there were 320 respondents aged 15–19. When questioned they said they had 325 sisters who reached age 15. They could however expect some more, so 320 was multiplied by 1.54 to give 493, the first figure in Column (3).
(B) Column (5) is an adjustment factor based on a typical developing- country population model. Respondents aged 50, or more, will be referring to sisters who will have been subjected to the full risks of a lifetime of childbirth. Younger respondents will be referring to sisters who have only been exposed to part of that risk, so a correction has to be made to the reported number of sisters reaching the age of 15 to calculate 'sister units of risk exposure' in column (6). To get column (6), multiply column (3) by column (5). Column (5) is 'given' and is always the same. Sum column (4), which is the total number of maternal deaths reported by your respondents, and sum column (6). Divide the sum of (4), by the sum of (6), to give you the total lifetime risk of maternal death. It was 0.048 in Fig. 15-1, which means that a woman reaching the age of 15 has nearly a 5%, or about a 1 in 21 (1 21 = 0.048) chance of dying of pregnancy related causes during her reproductive life.
To calculate the MMR divide the estimate of the total lifetime risk of maternal death by your estimate of the TFR, and multiply by 100,000.
For example, the TFR for the population in Fig. 15-1 was 6. So, 0.048/100,000 = 800. The MMR calculated by this method is therefore about 800. As noted above, strictly speaking, this figu-re refers to period 10–12 years before the data were collected. However, in situations where this method is used, it is unlikely to have altered significantly.
Try to publish your findings somewhere. Inform the appropriate government office about your results, and include details of your study design, sample size, the questions you used, and any problems you found.
DIFFICULTIES IN MEASURING THE LEVEL OF MATERNAL MORTALITY
If a RESPONDENT IS UNAVAILABLE, ask the household member who is most likely to know about the respondent's sisters. Alternatively, omit missing respondents, and visit more households to collect the number of respondents you need. But make sure that the time of day you call would not exclude certain groups, such as women working in the fields.
If for any reason you CANNOT GET AN ADEQUATE SAMPLE, consider carrying out the study jointly with a neighbouring health unit.
If a HOUSEHOLD SURVEY IS IMPRACTICAL, consider questioning adults attending a fixed health facility, such as mothers attending an immunization clinic. They will be a selected group, but their sisters will probably be less so.
If questions on pregnancy-related matters are CULTURALLY SENSITIVE, confine your questions to female respondents aged 15+.
If you are worried about the RELIABILITY of your data: (1) Calculate MMR separately for males and female respondents. It should similar. If it is not, the sample may be too small, or the responses may be biased between the sexes. Women may be better informed about the circumstances of the death of their sisters than men. (2) Compare the MMR for the 15–49 age group (who will younger and better able to remember past deaths) with that for 15+ respondents. The figures should not be very different. The higher of the two is likely to be nearer the truth. The figure from the 15–49 age group will probably be the most reliable, provided more than ¾ of your respondents are in this age group. Try to at least half your sample between 25–49, without too many <25 >50.
Graham W, Brass W, Snow R, 'Estimating maternal mortality in developing
countries', Lancet 1988;i:416–7.
Graham W, et al. 'Indirect Estimation of Maternal Mortality; the Sisterhood
Method'. Centre for Population Studies. The London School of Hygiene
Tropical Medicine. London WC1E 6AZ.
Graham W, and Airey P, 'Measuring the maternal mortality, sense
sensitivity'; Health Policy and Planning 1987 (2);4:323–333.'
Obstetric aims and priorities
Mothers die from the diseases listed in the previous section. Between 5 and 10 per cent of their babies die in the perinatal period (from 28 weeks of pregnancy to 7 days after delivery). When they die in utero their deaths are often unexplained, but preventable causes include malaria, syphilis, and obstructed labour. Most perinatal deaths in Africa are of normally formed, normal weight babies who die avoidably from trauma, asphyxia, or infection. Many neonatal deaths occur in babies whose low birthweight is due to their being born too soon (prematurity), or to not having grown normally before birth (intrauterine growth retardation, or IUGR). The deaths of both mothers and babies are mostly due to the material and social conditions under which they live. Here we are concerned with the obstetric causes of their deaths.
Obstetrics differs from surgery in that there is no surgical equivalent of the midwife. This is because birth is usually sufficiently routine for most obstetrics to be done by non– doctors, whereas all but the the most minor surgery has to be done by doctors. The surgery in these manuals is therefore for doctors. Obstetrics, on the other hand can be divided into: (1) The more difficult and less commonly needed procedures, which are normally only done by doctors, and which are assembled here. (2) The easier, common procedures which can be done by doctors, or by midwives. These are in the fourth volume in this series — Primary Mother Care, which is a manual of 'paramedical obstetrics and gynaecology', rather than traditional midwifery (In preparation 1989). The distinction between what only doctors can do, and what both doctors and midwives can do, is however somewhat arbitrary. There are, for example, some midwives and many medical assistants who can do a Caesarean section. The next few chapters and Primary Mother Care form a whole, so that unless you can refer to Primary Mother Care, what you read here will be incomplete. For example, you may wish to look up the selection of cases for hospital delivery (M 5.3), the management of normal labour (M 18.11), vacuum extraction (M 22.3), outlet forceps (M 22.6), or the closed method of symphysiotomy (M 22.7). Some conditions, such as postpartum haemorrhage, are managed differently by a midwife in a clinic and by a doctor in a hospital, so these are described twice, but from different perspectives. Primary Mother Care describes methods of terminating pregnancy early, including menstrual regulation. Following the wishes of one of our contributors we have not included methods of termination later in pregnancy here.
THE NEXT FEW CHAPTERS ARE NOT COMPLETE WITHOUT 'PRIMARY MOTHER CARE'
Despite the challenges of pregnancy and childbirth, the most important task in many communities is to reduce the frequency with which pregnancy occurs. The priority of priorities is likely be a national population policy — most countries in sub- Saharan Africa don't yet have one. Populations there, and to lesser extent those elsewhere, are growing so fast that they are causing acute pressure on land, on food, on the wood to cook it with, on jobs, on education, and on the health and other social services. In some areas this population pressure is already finding its expression in desertification and starvation, in abject poverty and in civil disorder. Your own community may not have reached this point yet, but is it already exerting such pressure on environment that 'ecological collapse' is not far away? If it occurs your community may become 'ecological refugees', if indeed there is anywhere to flee to. If birth rates don't fall, death rates may rise to their old values or higher, with a much larger population in a much impoverished environment ('the demographic trap'). Part of the answer is to make sure that family planning services are available at all health units. Many families who would like to use them still don't have access to them.
Because so much obstetrics has to be delegated, the instruction and supervision of those to whom you delegate it is critical. Some mothers will be delivered in hospital, and some by midwives in health centres. Most of them will probably be delivered at home, attended either by their families, or by traditional birth attendants (TBAs), such as the dais of India. One way to reduce the maternal and perinatal mortality in your district may therefor be to start with the TBAs, to concern yourself with what they do, and to retrain them where you can. If a specialist group TBAs are at work in your area, each of whom delivers several mothers every year, try to run retraining courses for them.
STETHOSCOPE fetal, plastic, three only. These don't bend so easily as aluminium stethoscopes.
DOPPLER FETAL HEART DETECTOR, 'Sonicaid' pattern equivalent, one only. This is comparatively inexpensive about $250) and very useful.
SPECULUM, vaginal, Sims', double-ended, medium size, 27.30 mm, three only. This is the most generally useful vaginal speculum.
SPECULUM, vaginal, Cusco's, duckbill, small and large,stainless steel, three of each size only. These specula open like the beak of a duck, and in doing so enable you to examine the cervix.
SPECULUM, vaginal, weighted, Auvard's, chromium-plated, one only. The weight on this speculum presses it downwards, and so keeps the vagina open.
FORCEPS, uterine vulsellum, curved, 1×2 teeth and 3×4 teeth, box joint, 230 mm, one only of each size. Use these to grasp the non–pregnant cervix when you curette it. In pregnancy, ring (sponge) forceps are better.
SOUND, uterine, malleable, metric, graduated shaft, two only. Use this to measure the depth of the uterus before inserting dilators. A sound is a dangerous instrument in a pregnant uterus, because you can easily perforate it.
DILATORS, cervix, double-ended, Hegar's, 222 mm, set of 12 sizes, 1/2 mm to 23/24 mm, one, or preferably two sets only. Use these to dilate the cervix before curetting it. You are likely to have several patients needing dilatation and curettage on the same list, so two sets of dilators will be useful.
MANIPULATOR, uterine, one only. Use this to bring the uterine fundus up against the abdominal wall when you do a minilaparotomy.
FORCEPS, ovum, curved, screw joint, McClintock 250 mm, one only. Use this to remove the products of conception from an incomplete abortion, after you have dilated the cervix. If you don't have them, use sponge-holding forceps.
CURETTE, uterine, double-ended, blunt and sharp, 8 mm and 5 mm, two only of each size. The great danger with a curette is that you may push it through the wall of the uterus, especially a pregnant uterus. Opinions differ as to whether a blunt curette is more dangerous than a sharp one. Let a curette lie gently in your fingers, so that you can 'feel' the wall of the uterus — don't grasp it firmly.
CURETTE, suction, stainless steel, reusable, sizes 8 and 10 Hegar, one only of each size. Use this for evacuating moles (it causes much less bleeding than dilatation and curettage), and for terminating a pregnancy which has lasted less than 12 weeks.
CURETTE AND SYRINGE for menstrual regulation, sterile, plastic, disposable, five hundred only. You will only need these if you intend to introduce menstrual regulation as part of your family planning activities.
CATHETER, Drew–Smythe, one only. This is useful for rupturing the membranes if the head is high, especially if there is polyhydramnios, to control the gush of fluid and to prevent prolapse of the cord (19.13).
CANNULA, cervical, Leech Wilkinson or Miller, one only. This is for doing a salpingogram.
SCISSORS, episiotomy, Vant, one only. These have straight blades and round points.
VACUUM EXTRACTOR, Bird's modification of Malmstrom's, complete with 3 suction cups 40, 50, 60 mm, one posterior cup, traction handle, vacuum hand pump, chain, spare vacuum bottle and spare baskets, one only. Bird's modification is better than the original Malmstrom extractor, and is quicker and easier to assemble. The anterior and posterior cups are not really necessary. Some workers advise the 50 mm cup only.
FORCEPS, outlet, Wrigley, one only. Outlet forceps are the only safe ones for anyone but an experienced obstetrician.
FORCEPS, obstetric, Neville Barnes, one only. You will need these for the aftercoming head of a breech delivery, for which Wrigley's forceps do not have long enough handles. For the uses and dangers of forceps, see Section 18.1.
FORCEPS, haemostatic, straight, Green-Armytage, 203 mm, six only. Optional. Use these for clamping the cut edges of the uterus during a Caesarean section, and for repairing a ruptured uterus.
BREECH HOOK and CROTCHET combined, one only. Use this to deliver a dead baby presenting by his breech.
PERFORATOR, Simpson's, one only. This is the standard instrument for opening the skull when doing a destructive operation.
RETRACTOR, Doyen's, one only. Use this for Caesarean section, it has a curved lip which fits over the lower end of the wound and keeps the bladder out of the way of the operation.
RETRACTOR, Kirschner, one only. This gives an excellent exposure for laparotomy, with a good view for operating in the pelvis.
SCISSORS, embryotomy, Queen Charlotte's pattern, one only. These scissors were specifically designed for destructive operations.
SAW, decapitation, Blond–Heidler, complete with ring, thimble and blades, one only. Use this for decapitating a dead baby when labour is obstructed by a transverse lie. It is a piece of wire with teeth on it, hooks at each end to fit handles, and pieces of tubing to prevent it from cutting his mother. It also has a thimble you can push round his neck to fix the saw to. Alternatively, you can use large scissors, preferably the embryotomy scissors described above.
Infertility
Infertility causes much distress, particularly in those districts of Africa where as many as 30 per cent of families are childless. Primary Mother Care describes what health centres can do for it (2.3), and if they have done their job properly, there is little more that you can do in a district hospital. You may decide that you have other priorities, and that infertility is so unrewarding that you are not going to try to treat it. If you do decide to do so, make it part of your family planning activities and promote an integrated 'fertility service', which is concerned with both too much and too little fertility.
Typically, about 60 per cent of infertility is caused by the adhesions that follow PID (pelvic inflammatory disease). Repairing tubes that PID has blocked is an expert's task, and even then the success rate is low, so you may decide that there is little point in investigating or referring these patients. If you decide to do so, you can: (1) Do a hysterosalpingogram which will tell you where a block is. Many district hospitals find these too expensive and time-consuming. (2) Insufflate the tubes, which is cheaper, but gives less reliable information. Also, the instrument often leaks, and you can make mistakes. (3) Do a laparoscopy which again is expensive and time-consuming.
Some couples will be childless because the wife is not ovulating. You can find this out by: (1) Taking her history. If she has regular cycles, she is almost certainly ovulating. Failure to ovulate is typically associated with irregular cycles or amenorrhoea. (2) Dilating and curetting her during the second half of the cycle, and sending the scrapings for histology. (3) Asking her to keep a temperature chart, as described in Primary Mother Care. She may be sufficiently intelligent and motivated to do this, particularly if she is a member of the hospital staff or a teacher. A regular 0.5°C temperature rise 14 days before the start of menstruation is good evidence that she is ovulating. Lack of this rise, especially if her periods are irregular or scanty, is strong evidence that she is not doing so. (4) If you are fortunate enough to have a laparoscope or laprocator, you can examine her ovaries 15.4), to see if they are scarred, showing that she has ovulated. At the same time you can test the patency of her tubes, by injecting a blue dye though her cervix, and seeing if it appears in her peritoneal cavity.
If she is not ovulating, refer her. If you cannot refer her, you may be justified in inducing ovulation with clomiphene, which is comparatively safe, if she can afford it. One contributor considers it has no place in this manual. Only an expert should give her bromocriptine or the gonadotrophins. Use a temperature chart to monitor your success.
A very occasional patient is sterile as the result of tuberculous endometritis; sterility is its most common presentation. Treating tuberculosis is not difficult, but it is unlikely to make her fertile — she has about an 8 per cent chance of conception, but only a 2 per cent chance of a live child. She also runs an increased chance of an ectopic pregnancy.
INFERTILITY
The health centre staff should have taken a history, examined both partners, and sent the husband's semen for examination. If their workup is incomplete, complete it (M 2.3).
HUSBAND. His seminal fluid must be examined within 2 hours. It is normal if: it has a volume of 2 ml to 6 ml, it is liquid after 30 minutes, it has 60% of motile sperms, and if it has 20 million sperms or more per ml, less than 15% of them being abnormal. If he has a low sperm-count, suggest they abstain from sex until the 12th to 14th day of the cycle, to increase his sperm-count at the time of ovulation. If he has pus cells in his ejaculate, treat his infection.
WIFE. Curette her late in the second half of her cycle. Either: (1) Use a microcurette of the Novak or similar type, as an outpatient. Or, (2) dilate and curette her under anaesthesia. Put half the curettings into formol saline for histology, and the other half into a sterile bottle for culture and, if possible, for guinea pig inoculation for tuberculosis. Indicate on the request form for histology that you want to know if she is ovulating. Remember not to overload a pathology service which is overloaded already.
HYSTEROSALPINGOGRAM
CAUTION! (1) Before you start, do a pelvic examination to exclude pregnancy and active pelvic infection. (2) Do a hysterosalpingogram within 10 days of the patient's last period, and not in the premenstrual or active menstrual phases of the cycle. (2)Wear a lead apron.
EQUIPMENT. An intracervical cannula, preferably of the Leech Wilkinson screw-in type. A Miller cannula causes less trauma to the cervix, but does not make such a good seal with it, unless she is under general anaesthesia, which allows you to use more force. A 20 ml syringe filled with a water-soluble contrast medium such as 'Urografin'. Avoid oily contrast media.
ANAESTHESIA. No anaesthesia is usually needed, but if she is very anxious, premedicate her with diazepam 30 minutes beforehand and do a cervical block.
METHOD. You can do a salpingogram in the X-ray department. If possible, screen her during injection of the dye. If not, lie her on her back on the X-ray table with her hips and knees flexed, and the plate under her pelvis. A tube–plate distance of a metre is satisfactory and no grid is needed.
Insert Cusco's speculum and clean her cervix with cetrimide. Hold her cervix gently with a single-toothed tenaculum, lightly closed to the first ratchet; she should feel little pain.
Expel all air from the syringe and cannula, inject 20 ml of contrast medium firmly into her cervix, and take a film. If she has a cornual block, 20 ml will not go in. If possible, take a second film some hours later. The dye should have spread into her peritoneal cavity. If it remains loculated, this suggests adhesions and impaired fertility.
TUBAL INSUFFLATION
INDICATIONS. Although theoretically simple, false results are not uncommon. If insufflation is the only method of investigation you have, this suggests that expert tubal surgery is unlikely to be available, which should make you question the value of insufflation.
EQUIPMENT. An insufflator, a source of a carbon dioxide, and preferably a device for recording the pressure graphically. If necessary you can use air.
METHOD. Give her a general anaesthetic and put her into the lithotomy position. Insert a Sims' speculum. Insert the insufflator into her cervix and fill her vaginal canal with fluid, so that the cannula is submerged, and you can see if there is a leak. Discharge some carbon dioxide, and listen over her lower abdomen for the sound of it bubbling out of her tubes. Measure the rise in pressure of CO2 before free flow occurs. If her tubes are patent, pressure will peak, and flow occur below 40 mm Hg. If they are blocked it may rise as high as 160 mm. If you are using air, use a maximum of 250 ml, and don't go above 100 mm Hg, because of the risk of air embolism.
LAPAROSCOPY AND DYE INJECTION
Under general anaesthesia insert a Miller cannula into her cervix. Insert a laparoscope, as for tubal ligation (15.4), and tilt her head down until you see a good view of her pelvis. If you cannot see clearly, insert the Verres needle (with the valve closed) in the midline suprapubically, and use this to manipulate her tubes. Inject 10–20 ml of methylene blue dye diluted 1:10 in sterile water, and look for dye spilling from the ends of her tubes.
Normal tubes Her fimbriae look healthy and the dye spills through easily. It may spill on one side only, but if both tubes look healthy, they are probably both patent.
Cornual block No dye enters her tubes. As your assistant injects the dye, the region of their insertion into her uterus blanches slightly.
Fimbrial block Her tubes are often distended; their fimbriae are clubbed and sealed over the ostia, and may be adherent to her ovaries. As you inject the dye, the thin walls of her tubes allow you to see it entering them. Usually, no dye spills out. Sometimes fimbrial block is partial, so that only a little spills.
ANOVULATORY INFERTILITY
CLOMIPHENE is only indicated for anovulatory infertility. If you cannot refer her and can afford it, consider giving her clomiphene. Warn her of the increased incidence of multiple pregnancies. Unless she is also receiving gonadotrophins, this risk is small. Give her 50 mg daily from the second to the sixth day of her menstrual cycle, or at any time if cycles have stopped, to a maximum of courses. Monitor ovulation with a temperature chart. If she does not ovulate increase the dose by 50 mg amounts each month, to maximum of 200 mg daily for 5 days.
CAUTION! (1) Only give clomiphene to adequately investigated patients with patent tubes and fertile husbands. Don't use it randomly on all infertile patients. (2) It is contraindicated in hepatic disease, ovarian cysts, pregnancy, and abnormal uterine bleeding. (3) Side-effects include visual disturbances, ovarian hyperstimulation (very rare unless it is used with gonadotrophins; if occurs stop treatment), hot flushes, nausea, vomiting, depression, insomnia, breast tenderness, weight gain, rashes, dizziness and hair loss. It may make her ovaries tender, and simulate an acute abdomen.
Tubal Ligation
This should be the most common operation you do, and the most important one. It is chosen after careful consideration of the alternatives, so it must be as safe and as painless as it can be. Try not to keep a mother waiting too long for surgery, or she may become pregnant meanwhile!
Large numbers of mothers need their tubes tying, and if you take the trouble to encourage them, many will be willing to accept it. But however many ligations you do, you will probably be only able to satisfy a small fraction of the community's need. You can: (1) Tie a mother's tubes at the same time that you do a Caesarean section (18.9). (2) Do a 'minilap', which is a laparotomy through a very small incision. (3) Do a standard laparotomy — but this should seldom if ever be necessary. (4) Tie her tubes through a laparoscope, or a laprocator (15.4).
Tying a mother's tubes immediately after delivery has several advantages: (1) They are easier to get at when her uterus is still enlarged. (2) You already have her in hospital, whereas if you send her out and ask her to come back, she may never return. (3) Immediately after a normal delivery she will tolerate the minimal additional trauma of sterilization particularly well. (4) If you have already opened her abdomen for some other reason, such as Caesarean section, tying her tubes is easy. But there are some minor disadvantages in doing it at this time: (a) She is more likely to change her mind later. (b) You have little time to examine the baby and exclude any abnormality before you tie them. Local anaesthesia has many advantages, and if you follow the methods described here carefully, complications should be few and easily managed. Finding a tube and bringing it painlessly up into a small incision needs gentleness, skill, and practice. Carefully trained theatre sisters and assistants can tie tubes, but you should examine all patients first, and be at hand in case there are difficulties. Tubes can also be tied on a large scale in special 'camps'.
OPERATING IN A HEALTH CENTRE. Grand multips with large families don't like going to a remote hospital to have their tubes tied, but they may be pleased to have this done at their local health centre, if you can visit it and do a list there. Operating in a health centre is not easy, but it extends the benefits of this most necessary operation to those who need it most — if the health centre has a theatre (2.2a).
Ask the staff to prepare a list of all the mothers in the district who want their tubes tying. Often only a few will come the first time, but more will come later. If you plan ahead, you can work without an autoclave on the site, or you can combine antiseptic methods (2.6) with aseptic ones. Bring sterile packs of drapes and gowns, and use the same gown for several patients; for gloves see Section 2.3. Use a single square drape with a 12×12 cm opening for each patient. If necessary, this can be a plastic sheet sterilized between patients in an antiseptic fluid. Boil instruments between cases. Some workers give each patient a gram of chloramphenicol intravenously at the start of the operation (2.6).
Barss P, 'Tubal ligation with local anaesthesia', Tropical Doctor 1985;175– 178.
MINILAP
CAUTION ! (1) Before you tie anyone's tubes, make sure you know what the local cultural attitudes to it are. (2) Always get consent from the patient and her husband, and if necessary her mother. (3) Don't try to press for consent during labour. (4) This operation has a mortality of the order of 5/100,000 from anaesthesia (the major risk), tetanus and haemorrhage, so take the appropriate precautions.
INDICATIONS. (1) Mothers who are sure they want no more babies. (2) Medical diseases contraindicating pregnancy, particularly severe heart disease, renal failure or severe diabetes.
CONTRAINDICATIONS. (1) Extreme obesity (see below). (2) Excessive anxiety. (3) A history of pelvic sepsis (PID) immobilizing the uterus of a non-postpartum patient make a minilap under local anaesthesia difficult. She needs subarachnoid or general anaesthesia, and she will probably be infertile anyway. Dense adhesions are unusual immediately postpartum in multips. (4) A chronic cough will increase the risk of an incisional hernia later. (5) Pregnancy. (6) Refusal of the patient or her husband to sign a consent form.
ARRANGEMENTS. You can do a minilap as a day case, but if you admit her the night before, she is more likely to be present when the list starts.
THE EQUIPMENT includes two long narrow, 13×44 mm Langenbeck retractors, a scalpel, a needle-holder, ovum (ring) forceps, a circular cutting needle, chromic catgut, and monofilament. A special manipulator is listed above, which you can use to press a patient's fundus against her abdominal wall, and bring it into a small minilap incision. This is unnecessary immediately postpartum, but if you are inexperienced, it makes the tubes easier to find in a non-postpartum patient.
ANAESTHESIA. Take all the precautions for an abdominal operation (9.1), and be sure to starve her. There are several alternatives: 1) A method of local anaesthesia is described below with the surgery. Use 100 ml of 0.5% lignocaine with adrenalin. This is the maximum dose (A 5-1). Premedicate her with pethidine 25 mg and diazepam 5 mg intravenously. Double this premedication if she is large or anxious. The minimum intravenous premedication will enable her to get up and walk away immediately afterwards. 2) Local infiltration as in A 6.7, with a paracervical block (A 6.14) for the dilatation and curettage, if you do one (see below). (3) Ketamine (A 8.1). (4) Pethidine with diazepam (A 8.8). (5) Subarachnoid or epidural anaesthesia are convenient. (6) If she is obese, you may need general anaesthesia with muscle relaxation.
CAUTION! (1) Local anaesthesia, properly used, is the only safe anaesthetic for a national sterilization programme. (2) Avoid large intramuscular doses of pethidine. Instead, use small intravenous doses, followed by intravenous diazepam as in A 8.8.
METHOD. Immediately before the operation ask her to pass her urine, or catheterize her, to prevent you cutting into her distended bladder. Do a careful bimanual examination to make sure that she is not already pregnant. Put her into the semilithotomy position, with her thighs flexed to 45° and moderately abducted, her knees flexed, and her lower legs horizontal. Use Lloyd Davis stirrups, or, cheaper, 'Chogoria supports' (15-4).
Clean her abdomen, perineum, and vagina, empty her bladder with a catheter, and cover her with an abdominal sheet. Pass a Sims' or Auvard's speculum.
If more than 10 days have elapsed since the first day of her last period, consider doing a 'D and C' (20.3), to prevent implantation in this cycle. If you are operating under local anaesthesia, you will have to do this under a paracervical block (A 6.14). Many surgeons consider this unnecessary interference, and point out that it is not sure to prevent implantation.
THE INCISION depends on the position of her fundus. If she has delivered within the last few days, and her uterus is at her umbilicus or can easily be pushed there, make a 2 cm horizontal incision in its inferior fold. This is good cosmetically, and avoids the need to shave her.
If her uterus has involuted, or she is not postpartum, make a short transverse incision just above her pubic hair. One contributor always makes a suprapubic incision, even if her uterus is enlarged; you can always find her tubes down beside it.
If you are using a uterine manipulator, insert it and move to her abdomen. Ask your assistant to raise her fundus against her abdominal wall until you see and feel a bulge. Make a 5 cm midline incision over this.
Tilt the table moderately head down to let her gut fall away from her uterus. Prepare her skin widely with iodine. Drape her abdomen, leaving a large area exposed. Use a 0.4 mm needle to raise bilateral skin wheals, just lateral to her rectus sheath and about 4 cm above the proposed incision. Push a long 1 mm subarachnoid (spinal) needle through the wheal, and inject a track of anaesthetic along either side of the proposed incision, extending well above and below it. Inject 10 ml on each side. These injections just lateral to the rectus sheath block a wide area. Use a shorter 0.7 mm needle to inject another 10–15 ml into her skin and subcutaneous tissue at the site of the incision. Inject each rectus muscle through its anterior sheath about 2 cm from the midline. Inject 5 ml at three levels on each side, above, at the level of, and below the planned incision. Expect to find the rectus muscles further apart in multips. A total of 30 ml gives good muscle relaxation.
If you are going through her umbilicus, inject above and below it on both sides so as to infiltrate it completely. Stretch it and make a 2 cm horizontal incision in its inferior fold. Spread the subcutaneous tissue vertically with scissors until you see the fascia. Insert two small narrow right-angled retractors, one towards her head and the other towards her feet, and pull them apart. Pick up the fascia between two haemostats, and inject another 10 ml of lignocaine at a few points just beneath the fascia to anaesthetize her peritoneum. Open the fascia vertically with a knife. You will find it and and her peritoneum almost fused, and will enter her peritoneal cavity bloodlessly. Enlarge the incision in the fascia to admit your index finger. Her skin will stretch, so you can make the skin incision shorter than the fascial one.
If you go through her suprapubic area, do so in the exact midline between her rectus muscles. Spread them carefully to avoid bleeding. Spread the fat with scissors until you see her peritoneum. Pick it up, open it, and secure it with haemostats. Optionally, inject 10–20 ml of lignocaine over her pelvic organs for a topical effect. Feel for her fundus with your index finger. Feel behind it laterally to the point where each ovary is attached. Her tubes lie just anterior to them. As you hook a tube towards the incision with your finger, rotate her uterus to bring its cornua close underneath it. Next, insert two long Langenbeck retractors at right angles to one another. Use the upper one to pull gut and omentum away, and the other to pull laterally, so that you can see the tube. Grasp it with ovum forceps. If it is difficult to find, go to the cornua of her uterus, and follow the tube from there to its fimbriated end. Deliver a tube into the wound. If it is difficult to deliver, try lowering the head of the table. Look for its fimbrial end, to make sure that it is her Fallopian tube, and not her round or ovarian ligament. Either, (1) apply two clamps, 2 cm apart, cut out a piece of tube between them, and tie each end. Or, (2), alternatively, tie catgut (not monofilament, you want to cause a mild inflammatory reaction) round a loop of tube, and excise it as in Fig. 15-3 (Pomeroy tubal ligation). Does the tube you cut have a lumen? If not, it is her round ligament! There is no need to bury the stumps. Do the same thing on the other side.
CAUTION! Be sure to use catgut, which is more reliable for this particular purpose than other materials. Check carefully that there is no bleeding, cut the sutures on the tube, and then operate on the other tube in the same way.
CLOSING HER ABDOMEN. Close her peritoneum and fascia with a suture of 2/0 monofilament. Close all dead space to minimize oozing when the vasoconstrictor effect of the adrenalin wears off. Sit her up, dress her, and let her walk back to the ward. If you have had to give her extra sedation, she will need help. If she lives close she can go home the same day. If she comes from a remote village, don't discharge her until her sutures have been removed, and her wound has been carefully inspected and palpate — she must not develop a wound infection at home.
DIFFICULTIES WITH A MINILAP
CAUTION! If you are not operating in a hospital, and there are any complications, treat her as best you can and immediately refer her for admission.
If she complains of PAIN when you are injecting the local anaesthetic, give her intravenous pethidine. A wide area of local anaesthesia should prevent this. She is starved, and if you have great difficulty pulling her tubes into the wound, give her ketamine 2 mg/kg and atropine 0.6 mg intravenously.
If she is OBESE, it will be difficult to pull her tubes into view through a layer of fat. Enlarge the incision and apply more head-down tilt. An umbilical incision may be easier than you expect, because there is less fat around it.
If you CANNOT FIND HER TUBES, (1) the incision may be too far above her fundus; it should be slightly below it. Turning her uterus with your finger behind it helps. If she is is postpartum, and her uterus is large, try manipulating it through her abdominal wall. You may find it helpful not to release the first tube, until you have moved across her fundus and found the other one. Try passing Cusco's speculum through the incision to help you look around. (2) Her uterus may be stuck down with adhesions. A careful initial pelvic examination should have excluded this.
If you find ADHESIONS, you may be able to divide fine ones. Dense ones need general anaesthesia. If her tubes are adherent to her uterus or her pelvis, you may have to make a standard incision, or abandon the operation. This is particularly likely to happen if she has adhesions following Caesarean section.
If you find any CYSTS on her ovaries, leave them if they are small (<5cm). All normal ovaries have some physiological cysts. If a cyst is larger, collapse it by draining it with a syringe and needle, pull it into the wound, and if you don't think it is malignant (20.7), excise it.
If you OPEN HER BLADDER (rare), close it with 2/0 absorbable sutures in two layers, and leave a catheter in for 10 days. Prevent a full bladder by having her empty it just before she enters the theatre. If you find it full at surgery, empty it with a needle and syringe.
If you OPEN HER GUT (rare), close it in two layers transversely, 'suck and drip' her for a few days, and observe her closely.
Using a laprocator
A standard laparoscope is a 1 cm tube, which you insert through a tiny incision near a patient's umbilicus, and which you can use to inspect her abdomen. You can also do a variety of minor operations through it, including tying her tubes. Because a standard laparascope with its associated equipment costs about $3000, and is fragile, a simpler and more robust instrument, the 'Laprocator', has been extensively used by the JHPIEGO programme (Johns Hopkins Program of International Education in Gynaecology and Obstetrics), and is specially adapted for use under the difficult conditions of the developing world. It is only suitable for tubal ligation and diagnostic inspection of the peritoneal cavity, and not for the other procedures which are possible with a standard laparoscope. Unfortunately, like a standard laparoscope, it also needs special training, which is usually given at the JHPIEGO courses, a laprocator being given free to all those who pass the course, and who can demonstrate that they have adequate facilities. It is described here, so that it becomes more widely known. One contributor comments that a standard laparoscope with a separate ring applicator is smaller, safer, and easier to use than a laprocator, the only advantage of which is that JHPIEGO provides it free!
A laprocator is robust, reliable, and relatively inexpensive, and is popular with patients. It has a bulb, not a fibreoptic light source; and you can use it with local anaesthesia, but you will find it more convenient with general anaesthesia. You will need a cylinder of carbon dioxide, but if you can get oxygen, you should be able to get this too.
If you are skilled and have a good team, laparoscopic ligation is quick, and safe, and can be done on outpatients. The incision is so small that it soon becomes almost invisible. If you use carbon dioxide and not air, there is no risk of air embolism. If you use rings or clips instead of diathermy, you will not injure the gut. There are disadvantages. A laprocator is delicate, and the possible complications include burns, air embolism, and bleeding, and if you don't sterilize it properly, peritonitis.
You can introduce the laprocator through a small laparotomy incision, or you can use a special trocar called the Verres needle. If you are a beginner, start with the open laparoscopy method described below, which is safer and does not need a CO2 supply. The only disadvantage of the open method is that the skin incision is slightly longer, and needs two sutures instead of one. Laparoscopy has caught the imagination of doctors and patients. Illogically perhaps, possessing one is likely to increase your interest in sterilization. If you demonstrate it at at health education talks (M 7.1), you can be sure that some mothers will come forward afterwards to have their tubes tied.
• LAPROCATOR, JHPIEGO pattern (JHP), with Verres gas needle, and carbon dioxide supply, in case complete, one only.
USING THE LAPROCATOR
INDICATIONS. (1) For sterilization. (2) For the diagnosis of PID, endometriosis, and the exclusion of ectopic pregnancy.
CONTRAINDICATIONS. (1) Most lower abdominal scars. If you are experienced you can do a laparoscopy, if the scar was for a lower-segment Caesarean section, because it seldom causes adhesions between the gut and the abdominal wall. (2) A history of chronic PID with possible adhesions. (3) Extreme obesity. Mild obesity is an indication for laparoscopy, because the incision does not have to be larger if a patient is mildly obese, as it does in a minilap.
EQUIPMENT. A laprocator, with its carbon dioxide supply; a uterine manipulator. If possible sterilize it in 'Cydex', otherwise immerse it in aqueous 0.5% chlorhexidine changed weekly.
ANAESTHESIA. (1) General anaesthesia. (2) Pethidine with diazepam (A 8.8). (3) Ketamine (A 8.1). (4) Local infiltration (A 6.7).
PREPARATION. Put the patient into the semilithotomy position, as for a minilap. Clean her abdomen, perineum, and vagina. Empty her bladder. Pass a uterine manipulator and attach it to her cervix. Move up to her abdomen. Wait until she is relaxed and not coughing. Tilt her head downwards.
LAPAROSCOPY WITH THE VERRES GAS NEEDLE
If you are right-handed, stand on her left. Move your mask down your nose to prevent your breath clouding the lens. Hold her abdominal wall with your left hand, and insert the needle with your right hand. Hold it by the barrel, so that the blunt trocar is free to slide up and allow the cutting needle to enter. Make a nick in the lower border of her umbilicus, and insert the Verres needle through it almost at right angles to her skin, pointing it slightly towards her feet. Insert it firmly and feel it penetrate her rectus sheath and peritoneum.
Use the following methods to check that the end of the Verres needle is indeed in her peritoneal cavity: (1) You are able to move its point freely from side to side. Be careful as you do this, and don't use force, because you may tear adhesions. (2) When you lift up her abdominal wall, the pressure shown on the gauge falls, and a drop of saline, placed over the hub of the needle, is sucked in. (3) CO2 flows into her peritoneal cavity with little resistance. There will be a normal range of insufflation pressures for your machine, shown in green on the dial. If the pointer moves to the red area, the needle is probably in the wrong place. (4) A small volume of CO2 obliterates the normal dullness to percussion over her liver.
Let the CO2 flow into her peritoneal cavity. A multip who is being sterilized needs up to 4 litres (2 are usually enough). A nullip who is having a laparoscopy for diagnosis needs 2 or 3 litres. The insufflator does not measure volume, but carbon dioxide flows at the rate of a litre a minute, so allow it to flow for 2 minutes.
Remove the Verres needle, and enlarge the skin incision with a scalpel, until you have a 1.5 cm horizontal incision at the lower border of her umbilicus. Insert the trocar and cannula. Push it in almost at right angles to her skin, pointing slightly towards her feet. You will have to push quite hard, so keep the trocar sharp. A blunt trocar is dangerous, and much more difficult to control. Prevent it from going in too far by placing one finger alongside the cannula as a guard. When it is through her peritoneum, withdraw the trocar into the cannula, and insert the cannula fully. Withdraw the trocar fully and insert the laparoscope. Touch her gut to clear the objective lens.
Look for her tubes. Recognize them because: (1) They join her uterus at the cornua, whereas her round and ovarian ligaments join it below the cornua. (2) They are in the middle behind her round ligaments and in front of her ovarian ligaments. (3) They end in fimbriae. (3) You can pull them up to form a loop, much more easily than you can pull up a loop of her round or ovarian ligaments.
If you have difficulty manipulating her tubes, try inserting the gas needle in the midline 5 cm below her umbilicus. Turn the knob on it to prevent gas leaking. Use it to help you manipulate her tubes. Apply one ring or two clips to each tube. Withdraw the laparoscope. Open the valve to expel the CO2, and remove the cannula. Close her skin with one catgut suture or a skin clip.
OPEN LAPAROSCOPY WITH THE LAPROCATOR
INDICATIONS. (1) Beginners. (2) The absence of a CO2 supply.
METHOD. Apply two tenaculum forceps to the floor of her umbilicus, one towards her head and the other towards her feet. Pull on them to lift her umbilicus away from her gut. Make a horizontal incision with a scalpel through her umbilicus, her abdominal wall, and her peritoneum into her abdomen. All the layers of her abdomen are adherent here, so you will go through them as a single layer. Make the incision at least 2 cm long, and if necessary longer. When your are in her abdominal cavity, insert the laparoscope with its cannula, but without its trocar. Use two towel clips to tighten the skin around it and prevent gas leaking. Fill her peritoneum with two litres of gas. If necessary, you can safely use air instead of CO2, because there is now no danger of air embolism.
Proceed as if you were using a laprocator by the closed method above. The skin incision is a bit longer, and you may need two sutures.
Using air for the pneumoperitoneum. The laprocator control box has a small air reservoir which is filled by a rubber pump. Switch the gas tube to the patient from the carbon dioxide output to the air output, and fill her abdomen with air through the cannula. Air is only slowly absorbed, so take care to let it all out when you have finished.
If you use air through the Verres needle for closed laparo-scopy, remember the possibility of air embolism (uncommon). Also, if you allow air to get into the wrong place, for example into the extraperitoneal tissues, you will not be able to wait a few minutes and try again, because it takes hours to be reabsorbed.
DIFFICULTIES WITH THE LAPROCATOR
If CO2 GOES INTO THE EXTRAPERITONEAL TISSUES, it will take a minute or two to be absorbed. Wait until it has gone and then try again.
If there is EXTENSIVE BLEEDING, because you have damaged her mesenteric vessels (rare), do a laparotomy and tie them, taking the precautions listed in Section 66.10.
If you have DAMAGED HER AORTA OR VENA CAVA, do a laparotomy. This should never happen if you go in below her umbilicus and keep in the midline. But it has happened!
If you CANNOT SEE HER TUBES, abandon the procedure, or do a laparotomy.
If you mistakenly put a RING ON AN IMPORTANT WRONG STRUCTURE, you can usually pull it off again by catching its edge with one prong of the laprocator forceps. If this fails do a laparotomy.
If you PERFORATE HER GUT with the trocar, do a laparotomy, oversew the perforation with two layers of 2/0 catgut, and give her antibiotics (2.9). There is no need for a proximal colostomy, unless her gut is diseased.
If you PERFORATE HER GUT with the insufflation needle, give her antibiotics and observe her closely. Don't do a laparotomy unless she develops signs of peritonitis.
Vasectomy
Primary Mother Care explains what a couple should know about vasectomy (3.18). Although it is a simple operation, it must be done well, because its success as a family planning procedure depends on there being very few side-effects.
The normal vas is about 2.5 mm in diameter. When you pinch it between your finger and thumb, it has a characteristic firm feel, like partly cooked spaghetti. It is difficult to feel immediately behind a patient's testis, but between the upper pole of his testis and his inguinal ring you can feel it quite easily, and deliver several centimetres of it through a small incision in his scrotum. Rarely, it is double, which is one reason why vasectomy occasionally fails.
After you have incised his skin, you will meet his superficial fascia containing his dartos muscle. Deep to this lies the connective tissue which sheaths his spermatic cord. When you reach his vas, you will find that this also has a sheath of its own. Take care: (1) Don't injure the veins of his spermatic cord (the pampiniform plexus), which will bleed during the operation, and possibly afterwards also. (2) Don't tie his testicular artery, or his testis will atrophy.
• FORCEPS, vasectomy, two only. If you are going to do many vasectomies, get these.
VASECTOMY
THE CONTRAINDICATIONS to vasectomy as an outpatient include: a varicocele, a large hydrocele, a local scar, an inguinal hernia, genital tract infection, diabetes, recent coronary heart disease, and filariasis.
EQUIPMENT. Ideally use the special vasectomy forceps shown in Fig. 15-6. A No. 15 scalpel and blade, mosquito forceps, equipment for local anaesthesia, No. 0 plain catgut, 1% lignocaine.
PREPARATION. Ask the patient to shave his scrotum before the operation, and bring with him a tight-fitting undergarment to support it afterwards. Take careful aseptic precautions, scrub up, and wear a mask. There is no need for a gown. Either shave the relevant part of his scrotum just before you operate, or clip it. Prepare the skin of his scrotum.
CAUTION! Don't use iodine — it is painful on the scrotum.
FINDING AND ANCHORING HIS VAS. Stand on his right. Find his vas where it is easily palpable in his scrotum. Pull on his spermatic cord just above his testis, with the thumb and index finger of your right hand.
Use the thumb and fingers of your left hand to manipulate his cord, so as to push his vas upwards and medially into the anterior part of his scrotum close to its median raphe. Isolate his vas from the other structures, by squeezing them out laterally (A, in Fig. 15-7).
Hold his vas well above his testis with your thumb over it and two fingers underneath it. If his skin is thin you will be able to see it. Pulling on it will cause him some discomfort, and pain referred to his abdomen. This is a useful sign that you have indeed found it (B).
CAUTION! Make sure you have isolated and anchored it in the manner described. This is the critical step. Doing it without causing discomfort needs practice.
ANAESTHESIA. With his vas now anchored, find an area in his skin which is free of cutaneous blood vessels, and use 1% lignocaine to raise a small wheal. Then push the needle deeper and inject 1 or 2 ml of solution as close to it as you can, while holding it away from the other structures in his cord. If he has persistent discomfort while you are handling it, inject more solution into its sheath.
CAUTION! Don't infiltrate the other structures in his cord. This is unnecessary and dangerous, because you may injure his pampiniform plexus. If there is adrenalin in the anaesthetic solution, it will constrict the vessels, and make his testis temporarily ischaemic and painful. Pull his testis downwards, so as to tighten his spermatic cord. Carefully feel for his vas.
If you cannot feel his vas (rare), don't give up too soon. If you still cannot feel it, leave it, don't explore his cord. Proceed to operate on the other side. Very occasionally the vas is absent. If you have not been able to find it, you will know whether it is indeed absent, by examining his ejaculate later.
DELIVERING HIS VAS. While still firmly anchoring it, incise the skin over it vertically. Push the tip of mosquito forceps, or blunt dissecting forceps through the incision, and split his dartos vertically. Then push vasectomy forceps into the incision. Confirm that his vas has not slipped away by feeling it with these forceps. Open them just wide enough to grip it. Release your fingers, which are holding his testis and cord, and pull his cord gently into the incision (C).
CAUTION! Don't mistake his vas for thickened bands of cremaster muscle, thrombosed veins, thickened lymphatics, or calcified worms.
TO ISOLATE HIS VAS FROM ITS SHEATH lever the tip of the forceps upwards by lowering their handle. Use a No. 15 blade to incise the connective tissue over his vas vertically in line with it. Make sure that the connective tissue is completely divided by continuing the incision into the vas itself (D).
Hold a segment of his exposed vas with a second pair of vas forceps, or with a special vasectomy hook. Meanwhile, release the first forceps. If you have judged the site and depth of your incision correctly, you can now easily pull out his vas, leaving only a thin mesentery on its medial surface (E).
Use mosquito forceps to make a small window in a piece of the mesentery of his vas which is free of blood vessels. Isolate a 1 to 5 cm segment of vas between clamps. Tie its clamped ends with catgut, placing your ties beyond the clamped area (F). Excise the isolated segment (G).
CAUTION! (1) Don't put the ligatures over the crushed area. (2) Don't tie them too tight, or they will cut out. (4) To begin with, leave the ends of the sutures long, so that, if the cut ends of his vas bleed, you can pull them back into the wound. (5) Leave a reasonable length of vas above his epididymis. If a reanastomosis has to be done later, this will make it easier. Keep the ligatures away from his epididymis.
Pull on his testis to separate the ends of his vas. Inspect the wound. If it bleeds, pull out the ends of his vas, and tie any bleeders with plain catgut. Then cut the ends of the ligatures short and drop them back.
CAUTION! (1) Don't damage his pampiniform plexus. (2) Control all bleeding carefully. A small vessel can form a big haematoma later. He can also bleed from the skin edges, from the fascial sheath covering his vas, or from his pampiniform plexus. If the incision is less than 1 cm, the skin edges may come together without any sutures. If necessary, suture them with catgut, using a mattress suture if they need to be everted. Place a swab on the wound, and hold it with strapping.
Repeat the same procedure on the other side of his scrotum through a separate incision.
Alternatively it is not obligatory to wears gloves. If you choose not to wear them, handle his vas only with sterile instruments, using a strict no-touch technique.
POSTOPERATIVELY, the sutures will fall out by themselves. Ask him to rest after the operation, and not to do any heavy manual work for a day or two.
CHECKUP. Warn him that he may not become sterile for up to 3 weeks. He should continue to use a contraceptive: (1) until two examinations of his ejaculate have shown no sperm, or (2) until he has had 15 ejaculations after vasectomy.
To examine his ejaculate, ask him to produce a specimen by masturbation, or from a condom after intercourse. Put several loopfuls under a microscope, and examine them for sperm under the low power. There should be none.
DIFFICULTIES WITH VASECTOMY
If you CANNOT FIND HIS VAS, don't continue the operation under local anaesthesia as an outpatient.
If YOU LOSE THE CUT ENDS of his vas after sectioning them, try to recover them by systematically palpating his vas, and feeling for them with forceps. The ligature may have slipped, or you may have released the forceps holding his vas too soon, and let them be drawn quite a distance into his scrotum. Don't injure any blood vessels. If you cannot find the cut ends, the operation will still probably succeed. Tell him that you have had difficulty, and watch for haematoma formation. Check to see that his ejaculate becomes sperm-free.
If a HAEMATOMA FORMS, it may spread into his scrotum, his thighs, or his abdominal wall. If it is small, it will disappear spontaneously. If it is larger, you may have to admit him and evacuate it.
If his WIFE BECOMES PREGNANT, either vasectomy has failed, or he is not the father. If sperms are present in his ejaculate, you can reexplore his vas under general anaesthesia, and divide it again. Consider carefully what you should tell him! A more diplomatic alternative than testing his sperm count is to tell the couple that his vasectomy has presumably not worked, and to offer the wife sterilization.
HAEMOSTASIS MUST BE ABSOLUTE
