Essay 295 - Sterilisation

a. Clinical assessment would include a history, examination and appropriate investigations.  History would include reasons for wanting sterilisation, number of children and mode of delivery.  Along with past gynaecological history and smear test results and current contraception use.  Past medical history and past surgical history to assess suitability for a general anaethesia and laparoscopic approach to the sterilistion.  Examination would include an abdminal examination and a speculum and bimanual examination to assess for gynaecological pahology like fibroids or adnexal masses.  If the pelvic examination was abnormal I would arrange a transvaginal ultraound to ensure no gynae pathology such as ovarian cysts that need appropriate consent and treatment at the time of the operation.  Other investigation would include a pregnancy test to ensure not currently pregnant and to be repeated on the day of surgery and an FBC to check for anaemia and G and S preoperatively.

b. The key issuses include explaining that there is a failure rate of approximately 1 in 200 laparoscopic sterilsations reulting in unintended pregnancy, this pregnancy may be ectopic.  Laparoscopic sterilsation is  a permanent form of contraception and reversal is not available on the NHS and is rarely successful due to scarring of the tubes, therefore the woman must be sure that her family is complete.  Other methids of contraception should be explored such as long acting reversible contraception, such as the mirena IUS as these have a failure rate equal to laparoscopic sterilisation and can also be helpful in treating menstrual disorders like menorrhagia, and avoid the risks of surgery.  There is risk of conversion to open surgery (laparotomy) if surgery is unable to be completed laparoscopically due to surgical difficulties such as adhesions, injury to viscera.  The surgical risk need to be explained such as bleeding, though blood transfusion is rarely required, Infection and venous thrombosis are also rare risks.  Damage to bladder, bowel, major blood vessels are rare, but can result in extensive complications and conversion to laparotomy. If there are no complications then it is usually performed as a daycase procedure and the woman can go home the same day with simple analgesia.

c. Careful positioning of the patient in modified lithotomy position with 45 degree hip flexion is important to allow manipulation of the surgical instruments without the legs causing obstruction.  The bladder should be emptied with an in-out catheter in the case of laparoscopic sterilstation, or if longer more complex surgery required then an indwelling foley catheter should be inserted, to keep the bladder empty and decrease the risk of bladder injury.  The method of creating a pneumoperitioneum is dependent on the surgeons experience and preference.  The veress needle technique is commonly used and involved blind insertion of a veress needle, the angle of insertion is important to avoid visceral injury and in normal BMI patients it is inserted intraumbilical and aiming at 45 degrees towards the pelvis, a high BMI neccesitates an angle closer to 90 degrees to the skin.  The veress needle is spring loaded and two clicks should be heard and indication entry to the peritoneal cavity.  There are some safety tests such as aspirating the needle to check for blood or bowel contents and the water drop test to see if water freely falls down the veress needle implying negative intrabdominal pressure and correct placement.  These tests have not been shown to decrease visceral injury.  Once the gas is connected it is most important to check that the abdominal pressure is less than 10mmHg, the flow rate is high and gas distension is equal, these all imply correct placement.  A pressure of 20mmHg is required before inserting the primary trochar and then the camera should be inserted to check position and abdomen.  The patient can be positioned head down to encourage the bowel to move out of the pelvis. The subsequent ports must be inserted under direct vision, and the inferior epigastric artery visulaised and avoided.  At this point the pressure can be dropped to 15mmHg. When operating it is important to keep all instruments in view to avoid inadvertant organ damage.  The ports should be removed under direct vision to ensure no occult haemorrhage and to avoid bowel herniation.  Port sites over 10mm should have the rectus sheath closed to avoid herniation.

(A)

A history emphasising on parity & type of deliveries, previous abdominal surgery, history of infection and understanding of procedure and future fertility intent should be checked. Abdominal and pelvic examination should identify previous scars, hernia and bimanual should exclude fixed uterus or pelvic mass. BMI, weight and height should be calculated. Current relationship, health of existing children and reasons for request are important factors.

(B)

Exaplanation of planned procedure, the use of clips or ligation of fallopian tupes and laporoscopy should be given. Inherent risks of visceral injury, failure to enter abdominal cavity, conversion to laparotomy and need/risks of GA should be discussed.

She should be counselled about Irreversability of the procedure despite a 1:200 failure rate in women years with increased risk of ectopic pregnancy in a subsequent pregnancy. Alternatives such as hysteroscopic tubal occlusion, requiring specialist skill and f/u HSG to confirm occlusion, LARC methods like cu-IUD, Mirena, implant and the appropriateness of male vasectomy for her partner should be discussed.

Effective contraception should be continued till the period following the procedure and pregnancy should be excluded prior to starting the procedure. Post op expectations should include mild pain or discomfort and the presence and location of scars.

(C)

An adequately trained or appropriately supervised and skilled surgeon should perform the procedure with an MDT of theatre staff with training in the equipment, anaesthetists and recovery staff.

Correct site of entry, normally in the umbilicus but alternatives such as left costal margin should be considered if significant subumbilical scarring and adhesions are expected. Visiports, use of open procedure may reduce risk of visceral injury in selected patients but  the method preferred by the surgeon should be used. closed entry does not have higher risk of visceral injury compared to open methods.

Entry should be with the patient level, the bladder empty. excessive force should not be used, and the veres needle protected by grasping it appropriately. Low pressure on tested equipment should help confirm safe enbtry. Palmer's test or saline mapping may additionally help confrim safe entry.

Following safe entry, the head down position should be used to reduce risk of bowel injury. Other ports should be introduced under laparoscopic vision and instruments kept in view at all times. Use of filshie clips and non-sharp instrument will help reduce the risk of visceral injury. Ports should be visualised on removal.

Audit and risk management of adverse events should encourage a pro active, safe envornment by non-judgment reporting of any clinical incident.

A.

Obstetric history including number, mode and date of deliveries should be asked. Past abdominal surgeries and midline scars should be enquired. Menstrual history especially LMP to rule out possible pregnancy should be asked. Gynaecological history regarding dysmenorrhoea, dyspareunia and chronic lower abdominal pain should be elucidated. Abdominal examination to rule out prior scars is mandatory. Pelvic examination to rule out masses and tenderness to be done.

B.

She should be informed that tubal sterilisation is permanent non-reversible technique. Many patients feel regret after sterilisation. Reversal of sterilisation is not refundable and success rate pregnancy is 70%.  There alternative methods of contraception that are long acting, effective and revisable she can use instead. Male sterilisation is easier, safer and more effective with failure rate 1 in 2000 is an alternative option. Failure rate of tubal sterilisation is 1 in 200, and ectopic pregnancy reaches up to 20% if she gets pregnant. Risk of anaesthesia and laparoscopy should be discussed, visceral and bowel injury although small 3-5 in 1000 should be explained. Also failure to gain entry and possible laparotomy should be explained. 

C.

Preoperative bowel preparation to reduce visceral injury is preferable. Abdominal palpation under anaesthesia should be undertaken to localise bifurcation of aorta and rule out pelvic mass. If the closed entry is used, subumbilical incision and patient should be on horizontal position. Veress needle spring-loaded should be tested before insertion. Veress needle enter abdomen in 60 degree towards the pelvic cavity once double click felt no more advancement of needle. Injection of 10 ml saline and re-aspirate to make sure intra-peritoneal placement. If she has prior abdominal scar open Hasson entry can be used although it does not eliminate risk of injury. As the woman is slim Palmer point entry may be suitable for her as well as in prior scar. Pneumperitoneum should be raised to 20-25mmHg prior primary and secondary trocar entry making sure that the patient is in horizontal position meanwhile.   

A.

Menstrual history for last menstrual history and regularity to rule out pregnancy.Previous obstetric history including mode of birth, last child birth,previous abdominal/pelvic surgeries to anticipate adhesion /contraceptive history and any issues with them  and drug history including allergic history is asked.Blood pressure checked.Abdominal examination done for any scar and mass to decide route of surgery.pelvic examination to rule out pelvic mass.

B.I would explain the nature of sterilization that it is a permanent method of contraception.It involves blocking of fallopian tubes to prevent sperm transport and fertilization by clips/falope rings/ segmental resection /tubal cannulation and placing intrafallopian implants if by hysteroscopy.It is a day care procedure done  under regional/General anesthesia.It can be done by laparoscopy/minilaparotomy/hysteroscopy. Laparoscopy involves putting in laparoscope per abdomen and  Hysteroscopic sterilization involves vaginal approach -total blockage of tubes has to be confirmed after  3 months by HSG and need to have alternate contraception  meanwhile—long term effectiveness data limited.sterilisation can ha ve frequent risks like abdominal pain an d discomfort, shoulder pain and serios risks like injury to viscera –ureter/bladder/bowel /great vessels and haemorrhage , VTE  which are rare.  Its failure rate is 1 in 200 procedures with more  chance of ectopic conception. Additional procedures like repair of injured viscera may be needed.Alternative contraception like barrier contraception, Oral pills(COCP,POP)long acting reversible contraception- LNG-IUS, Injectable progestogen explained with their risks ( breast pain, head ache ,mood changes, compliance issues  and benefits (reversible).Male  sterilization-vasectomy explained with its least failure rate 1 in 2000 and least morbidity –done under local anaesthesia.reversal of sterilization is possible ,however needs surgery and success ful intrapregnancy rate is around 25% with higher chance of ectopic conception.I would document the discussion and provide written information leaflet.

c.

patient is positioned flat after emptying bladder . Good functioning and Appropriate sized instruments  as per patients  body habitus  s elected  white balance,checked.  Entry  of  primary port  is sited at umbilicus as it is the thinnest part of anterior abdominal wall and helps in easy entry.Alternate entry selected at palmers point in case of midline scar .Closed entry with Verres needle  is done directing its tip to hollow of sacrum to prevent great vessel injury and by splinting the abdominal wall .Its position is checked by double snap/palmers test without rotating it inside to avoid extension of injury if at all occured.Abdomen insufflated with CO2 at a rate of 5-6L/mt  at 20 -25 mm of Hg.Pneumoperitoneum checked by liver dullness and visual impression. Primary trocar is inserted pointing toward centre of pelvic cavity to avoid visceral injury  .Laparoscope is inserted visualizing the point of entry for any vessel i/bowel injury and patient is positioned in head down position. Bowel and omentum removed from surgical field for avoiding injury and for better visualization.Pelvic anatomy checked and any distorsion ruled out.uterine manipulation done carefully to avoid perforation. Fallopian tube identified and secondary ports made  and grasper inserted under direct vision avoiding inferior epigastric vessel .clips put. Minimal handling done .limited cauteries used if needed.Instrument removed under vision after keeping it closed.

Sterilizaton essay

i am not able to send the corrected essay,kindly help

A)DISCUSS YOUR CLINAL ASSESSMENT ?

The women is enquired about her parity, mode of delivery(as caesarean sections increase the risk of adhesions),post abortion , nulliparity  ,as these women may regret later. Her last menstrual period is noted ,her contraceptive history is elicited, recent paps  smear report is documented, partner support and social factors (risk of coercion) are accounted for, as this is a permanent procedure a steady partner and the knowledge of the availability of male sterilization is assessed.  On examination her blood pressure and Cardiovascular and respiratory systems are examined, abdomen is examined for masses and tenderness,speculum examination is done to exclude any suspicious lesion, and a Paps smear is taken if due.a vaginal examination is done to notice the mobility of the uterus,tenderness and if fornices are free. FBC,Urine pregnancy test is done (luteal phase pregnancy cannot be excluded),USG : is required if indicated by history or examination.

B)Discuss the key issues to be explained to the women before sterilisation is undertaken?

This women should be explained that sterilization is intended to be a permanent procedure,however it can be reversed and the success rate is about 31-92 %,with expertise and that reversal may not be available under the NHS scheme. She should be explained  that there are other long acting reversible contraception available, their risks and benefits are highlighted. She should be explained that male sterilization has reduced risks of the procedure, and the failure rate is 1 in 2000,this is compared to the risks of female sterilization procedure and the failure rate is 1 in 200,the importance of continuing the contraceptive measure (if she is using one) even after the procedure, is conveyed, this is to reduce the luteal phase pregnancy which may not be picked up by a urine pregnacy test. The risk of ectopic pregnancy after sterilization procedure is about 4.3 to 76%.,and all procedures can fail.

She should be explained that sterilization is  a day case procedure,the procedures available are laparoscopy or minilaparotomy ,or hysteroscopic tubal occlution (essure)(available only  if there is expertise).These are done under general anesthesia (in u.k.)or under local anesthesia ,Her choice is documented after explaining the procedures and after their risks are explained.

She should be explained that, Laparoscopic surgery is done with a small incision of 1 cm at the base of the umbilicus .FILCHIE CLIPS are used to occlude the tubes,the failure rate is about 2-3/1000 in 10 years.

The major disadvantage of the procedure is  that she may require  a  laparotomy, when there is a major complication ,especially a bowel, bladder or urological injury, over all complication rate being 1.4/1000 procedures. Advantages of laparoscopic procedure are that the time required is less, less post operative pain, quicker recovery.

In minilaparotomy a 2 cms incision is taken about 2 cms, above the pubic bone and the tubes are identified under direct vision, cut and ligated  (pomeroys technique) on either side, the failure rate of this procedure is 7.5/1000 procedures in 10 years.There is an increased risk of post of pain and incisional hernia at the site. Local xylocaine infiltration reduces the post operative pain scores.

In hysteroscopic  tubal occlution  (essure), the expertise needs to be available, it is an office procedure about 10 minuites time is required for the procedure,  it involves occluding the fallopian tubes with inert materials. Success rates are higher about 99.7 % .Risks of the procedure are tubal injury, perforation, tests are done( HSG), after 3 months of the procedure to confirm sterilization, until then a reliable contraception needs to be used, other than intrauterine contraception.

An appropriate patient information leaflet is provided at this consultation.

C)Laparoscopy has a inherent risk of injury to the vicera (0.6/1000),mostly occurs during the entry. The steps that needs to be undertaken during the procedure to avoid the injury, are an experienced laparoscopic surgeon ,the equipment with disposable veeres needle/or a veeres needle with good spring action, guarded instruments, the correct procedure, i.e .under anesthesia with the patient   supine ,abdomen is examined for any masses bladder is drained, an open technique (Hassons )is followed, a small incision is made at the base of the umbilicus, with normal women without prior surgery the  bowel  is attached to the umbilicus in about 5 %,the Open method reduces only the vascular injury ,a verres needle is inserted at right angles to the abdomen, which is steadied with the other hand .Excessive lateral movement is avoided(to reduce a small needle rent into a bigger bowel injury),and 2 double clicks are audible on entry into the abdomen ,the pressure moniter will show a negative pressure and a Palmers test (not 100% accurate),is done , i.e a drop of saline over the needle is sucked into the abdomen ,if bowel contents are noted ,perforation is confirmed, and appropriate measures are undertaken .The abdomen is insuffalated with co2 /nitrous oxide at 1^st about 20-25 mm of mercury pressure is required ,i.e about 5.58 lts.of co2,for the primary trocar to be inserted safely,the primary trocar is inserted in a controlled manner at 90 degrees to the skin ,and stopped as soon as it enters the abdomen. The laparoscopy with preloaded filschie clips is directed towards the sacral promontry ,during insertion, the abdomen is surveyed to note any bleeding or contamination,and the felchie clips  are applied at right angles to the isthmus  2 cms from the corneal end of the tubes. When there is suspicion of bowel injury, a secondary port is inserted under direct vision and the primary port is visualized to exclude bowel injury.

a)

My clinical assessment would involve history and examination. Important points in her history would include her parity and modes of delivery and any history of previous abdominal surgery. I would ask about previous and current contraception and details about her menstrual cycle including any problems with heavy or painful periods and any history of endometriosis or significant pelvic infections. I would ask whether she was currently sexually active and in a long term relationship. I would establish why she feel laparoscopic sterilisation is her best option.

I would take her BP as if raised this may be postpone surgery until controlled and influence her suitability for alternative methods of contraception. I would perform a pelvic examination assessing for fibroids or a fixed uterus.

Unless history and examination revealed anything of concern I would not arrange any routine investigations.

b)

I would explain laparoscopic sterilisation is considered a permanent and irreversible method of contraception and therefore she needs to be completely sure her family is complete. Reversal of sterilisation is not performed on the NHS and if done privately it is associated with a high failure rate and increased rate of ectopic pregnancies.

I would explain the benefits of laparoscopic sterilisation. These are that it is highly effective, but does carry a 1:200 failure rate, with an increased rate of ectopic pregnancy in these rare cases. There is no ‘forgetting’ and therefore no problems with patient compliance. It is non-hormonal and therefore does not have unwanted side effects from oestrogen or progesterone. It is a day case proceedure only.

I would explain the risks of laparoscopic sterilisation which are of the procedure itself, mainly infection, injury to viscera (bladder, bowel), injury to blood vessels and significant bleeding and rarely the need to perform a laparotomy to repair any damage. I would explain the need for general anaesthetic. I would explain she may experience some discomfort after including shoulder pain. I would explain she would still have normal periods. If she has problematic periods, sterilisation would not help her symptoms and she should consider alternatives.

I would discuss alternatives to laparoscopic sterilisation, namely long acting reversible contraception and hysteroscopic sterilisation. Possible LARCs for consideration would be the Mirena, which is equally effective and significantly reduces menstrual blood loss or pain and she does not have to remember to take it and it can be in place for 5 years. The side effects are of a small systemic amount of progesterone that can cause mild side effects like breast tenderness or mood changes although this is unusual.  Alternatives would be Progesterone Depot or implant which are effective contraception but carry progesterone side effect like bloating, breast tenderness or mood disturbances and would need 3 montly or yearly replacement respectively. The copper IUD is another option of equal contraception efficacy and no hormonal side effects but she may experience slightly heavier periods. Hysteroscopic sterilisation is also a possibility if the service is offered which is as effective and less invasive surgery and also a permanent method of contraception. Finally, I would discuss the option of male vasectomy which is considered less invasive surgery.

I would explain laparoscopic sterilistation can be carried out any time in her cycle but would advise contraception is used until her next period after the procedure.

Finally I would discuss the different methods of laparoscopic sterilisation which are of clips (for example Filshie) or ligation of the fallopian tubes.

c) The procedure should be carried out by a surgeon with appropriate experience. I would ensure correct positioning of the patient in lithotomy. Her BMI is 22 so if she is particularly slim, I would consider Hasaan’s entry as this can be safer in patients who are very slim or very overweight. However, in all other cases there is no safety benefit demonstrated between the different entry techniques. If she has had previous surgery (for example multiple laparoscopies or midline laparotomy) I would consider entry at Palmer’s point which is 3 cm beneath costal margin in the midclavicular line.

I would use a Verres needle umbillically before placing the trochar. There is no test that can be 100% sure of correct placement of the Verres needle, but the most accurate indication of correct placement is low initial insulfation pressures (less than 8 mmHg) and free flow of gas.

Once confirmed I am safely in the abdominal cavity, I would have the patient positioned in head down to help move the bowel out of the operating field. All secondary ports should be placed under direct vision.  Safe sites for secondary ports lie lateral to the inferior epigastric vessels which themselves are lateral to the umbilical ligaments. Good knowledge of pelvic anatomy is required.

I would use an instrument on the cervix (for example Spackman) to mobilise the uterus and therefore lift the fallopian tubes away from the pelvic sidewall or surrounding viscera.

a)I will ask in detail about her obstetric history regarding parity and duration since last childbirth,whether post termination of pregnancy or postpartum at present.I will ask  date of her last menstrual period ,cycle regularity and any menstrual disorders .I will ask her contraceptive history  and whether she is on effective contraception currently to rule out pregnancy.I will assess her mental capacity  for consent as if there is a concern regarding that, I will have to refer to courts.

I will do a per abdomen examination to rule out any abdominal or pelvic masses.

I will do a urine  pregnancy test to rule out any existing pregnancy eventhough a negative test does not exclude luteal phase pregnancy.

b)I will tell her that sterilisation is intended to be permanent and whether she wants that way.If she wants a reversal later,it may not be provided by NHS .Treatment like IVF/ICSI may not be available on NHS.I will discuss with her about advantages,disadvantages and failure rates of  methods  of long acting reversible contraceptives like Cu-T 380A,LNG-IUS and injectables like medroxyprogesterone aceatate.Cumulative pregnancy rates after 10 yrs with Cu-T 380A is around 2% and around 1% with use of LNG –IUS after 5 yrs.

If she is in a stable relation then vasectomy for her partner is also an option.The failure rate of vasectomy is 1 in 2000.

I will discuss with her that the failure rate for tubal ligation is 1 in 200 in lifetime and 2-3 in 1000 after 10 years.If tubal ligation fails there is risk of ectopic pregnancy and she should seek immediate medical advice if she thinks  she is pregnant,has abdominal or pelvic pain and vaginal bleeding.The risk of ectopic pregnancy is around 4-76% depending on method of sterilization.But the risk is lower in sterilised than non-sterilised women of reproductive age.If she is immediate postpartum or post TOP,there is chance that she may later regret the decision,also chance of failure is more.

I will discuss with her methods for tubal ligation either by laproscopy or mini- laparotomy.I will tell her risks associated with laproscopy  like injuries to blood vessels and bowel,risk of converting to laparotomy of around 3/1000 .

I will advice her to take effective contraception till date of procedure and to continue till her next period.

c)After a thorough history and examination,I will rule out any contraindications  and make sure she is fit for laproscopic surgery.The operating table should be horizontal.The patient should be correctly positioned.Bladder should be emptied.The abdomen is palpated to check for any masses and to note the position of aorta before insertion of veres needle.The lower abdominal wall should be stabilised and veres needle inserted at right angles to skin and should be pushed in just enough to penetrate fascia and peritoneum in the closed laproscope method.Excessive lateral movement of needle should be avoided to prevent a small needlepoint injury if any in bowel wall does not become a complex tear.Optimise insertion of primary trocar and cannula.An intraabdominal pressure of 20-25mm Hg to be used for gas insufflation,this results in increased splinting. Insertion of primary trocar should be stopped immediately when it is inside abdominal cavity.Laproscope inserted through canula should then be rotated through 360 degrees to check visually for any adherent bowel.Secondary port must be inserted under direct vision perpendicular to skin maintaining pneumoperitoneum at 20-25 mm Hg.During insertion of secondary port,once the tip has pierced the peritoneum,it should be angled towards the anterior pelvis under careful visual control until sharp tip has been removed.

Avoid diathermy as the primary method of sterilisation as there is possibility of bowel injury.

a)    I would enquire about her last menstrual period, as it is recommended to do the procedure during early follicular phase. History of any contraception method that she was on before will be obtained. Any past surgical history will be noted. Her past obstetric history will be explored.  Examination will be performed to check her Blood pressure, pulse rate. Abdominal and pelvic examination will also be done.

b)     The reason why she is keen for sterilization will be obtained. I will explain to her that sterilization (tubal ligation) is a permanent way of contraception. I will ascertain if she is sure to have completed her family. The success of reversibility is undermined by many factors should that be needed, and it won’t be covered under NHS. Failure rate of  tubal ligation is 1:200. If it fails, high likelihood of ectopic pregnancy and need for early medical advice will be explained if misses her period.  Alternatives will be informed to the couple like vasectomy to her male partner as it has lower failure rate(1:2000) and less risk related procedures. Other alternatives of long acting reversible method of contraception like LNG-IUS, subdermal implanon  will be explained with their benefits and risks.  I will assure her that if tubal ligation is done, it has no effect on menstrual regularity. The risk related to the procedure and anesthesia will be explained. Information leaflet will be given and additional counseling session may be arranged if needed.

c)     Adequately trained and experienced operator is needed as part of minimizing the laparoscopic complication.  Well-maintained equipment and theatre staff is also to known  to reduce the risk during laparoscopy. Patient selection is also important. Identification for high risk factors for visceral injury like previous abdominal or pelvic surgery, PID or endometriosis is needed. If patient is at high risk for visceral injury palmer’s point may be used as entry of primary port after excluding splenomegaly  to reduce the risk of visceral injury. The inferior and superior epigastric vessels should be identified prior to secondary trocars in the lower abdomen.  Veress  needle should be checked for sharpness, spring action and patency, to allow free flow of gas. (eg saline aspiration) to confirm the intra peritoneal position of veress should be performed.  The veress needle and trocar should be inserted in thin patient while lying on flat and not in trendelenburg position  to reduce the risk of vessel injury. For adequate distension of abdominal cavity,CO2  should be insufflated to 25mmhg until trocar is inserted and lowerd to 12-15mmhg after insertion. 

(A) 

A menstrual history is taken for frequency, regularity, flow, volume and dysmenorrhoea to assess the possibility of pregnancy as well as considerationg for MIRENA if she has heavy menstrual bleeding. A contraceptive history for current contraceptive use, side effects and compliance to minimise risk of pregnancy after ligation. An obstetric history for previous pregnancy, mode of delivery and outcomes is assessed for completion of family. An abdominal examination is performed for any scars and abdominal massess which may complicate surgery and has implication on mode of delivery.

(B)

Implications of ligations has to be discussed. I will explain that ligation is permanent and its reversal or IVF is not funded by NHS and the success of reversal is not guaranteed. The failure rate is 1/200 and if she gets pregnant there is a higher risk of ectopic pregnancy which is potentially life threatening. There is a potential for regret of the procedure if she has a change in partner and is keen for future fertility. There is a small risk of post-ligation syndrome resulting in a small increased risk of hysterectomy. Alternatives of long acting reversible contraception needs to be offered as they avoid surgical risks. The option of male vasectomy can be discussed as it is safer to perform than sterilisation. Discussion of the procedure includes performing the surgery in day surgery under general anaesthesia. The abdomen is entered via the umbilicus and a pneumoperitoneum is created. A lateral port is created to facilitate insertion of instruments for application of filshie clip or falope rings on the thinnest portion of each tube. Complications include bleeding, infection, injury to visceral structures e.g vessels, bladder and bowel which require further surgery, as well as failure to gain entry into the abdomen resulting in a mini laparotomy or abandonment of the procedure.

(C)
Pre-operatively, I will review the case notes for previous abdominal surgery, PID and STD which may give rise to adhesions. This will prompt tme to consider an alternative entry site for example Palmer's point.  I will anticipate difficulties and inform my consultant for his presence in Operating Theatre prior to starting the case.  I will examine the abdomen prior to surgery, to assess mobility of the uterus, exclude any abdominal massess to assess my entry technique.  I will empty the bladder prior to starting to avoid bladder injury.  

Intraoperatively, I will ensure that the operating table is flat when inserting the trocar.  If I am using the veress entry method, I will insert the needle at 45 degrees and ensure that there are 2 audible clicks and perform a water test prior to insufflation of gas.  If veress entry is difficult, I will consider the Hassan open method to gain entry into the abdomen via direct visualisation to avoid bowel injury. The lateral port is inserted under direct visualisation from the camera to identify and avoid the inferior epigastric vessels to prevent haemorrhage. I will ensure that there is a low entry intra-abdominal pressure when insufflating to avoid subcutaneous emphysema which will increase risk of vessel injury and make further insertion of lateral trocar difficult.  I will ensure that the camera is cleaned prior insertion and intra-abdominal visualisation is clear prior to proceeding.  I will identify relevant anatomy and avoid viseral structures like bladder and bowel. I will engage my consultant if adhesions are seen to avoid bowel injury. 

a-The menstrual history of the patient should be known, asking about her LMP,menarch, kata and the regularity of the cycle, so as to estimate the ovulation day. Her relationship with her partner, and her decision of sterilization should be discussed. Enquire about  her family complete or not, because the operation is permanent. The sexual history and the method of contraceptive  should be known because the possibility of pregnancy. Obstetric history should be known and the method of delivery whether by caesarean section or vaginal because of adhesions. Abdominal examination must be done to look for masses or scars.
b-the issues that must be discussed with the woman is: giving her information about the procedure that it is permanent and irreversible. the relation with her partener should be discussed .is herfamily complete and she dose not want further children this issue must be discussed in details.tell her that reverse of the operation is not in the NHS and the success rate is low. The failure rate is 1:200 and if pregnancy occur the risk of  ectopic is high. Exclusion of pregnancy before the operation should be done but told her it is not guarantee that she is not pregnant if pregnancy test is negative. The contraceptive method should be used untill the procdure done. The alternatve method of contraceptive like LARC and vasectomy should be discussed. Explain the procedure to her that it is a day case procedure under general anaestheseia done laparoscopically by putting a filshe clip on the tubes. The risks and complications is an  issue that must be discussed, like visceral injuries and need for laparotomy , failure to gain entry to abdominal cavity and need for mini laparotomy. Her descision of sterilization should be discussed with her whether final or not. Leaflet information and contact number shoulbe given so to ask about any information. Website address like RCOG patient information.
Procedure should be done by expert gynaecologist or trainee under supervision with good training. The patient should be assessed preoperatively to make sure no cycle and still not change her mind and pregnancy test was done. The team should be familiar with instruments. Put the patient in flat position. Empty the bladder and examine the abdomen. Palpate for the aorta. Use verress niddle, check the string valve and insert it in 45 degrees. observe for the double click . observe the pressure and do palmer test to make sure you are inside peritoneal cavity . inflate pneumo peritoneum  in pressure of 20-25 mmhg. Insert the telescope camera and watch for any injuries. Transluminate the inferior epigastric artery and insert the secondary trocar under direct vision. Identify all the anatomy the tube and avoid bowel and bladder and ureter injury. After you finished putting the clips then look carefully for any bleeding and then remove secondary trocar under direct vision. If incision is large you can made stitches. Give antibiotic and pain relief observe for BP, P  and TEMP so you will know any bleeding or injury rapidly.         

(a)

I will take her past obstetric history, including her parity and mode of deliveries. Her past medical and surgical history is also important, especially if she has previous abdominal operations which predisposes her to adhesions. Contraceptive history should also be obtained, including types of contraception and duration of use and reasons for stopping them. History of smoking, drinking and illicit drug use should be obtained. An abdominal exam should be performed to identify any scars from previous surgeries, or large pelvi-abdominal masses which might make laparoscopic entry difficult. A pelvic examination including speculum and vaginal examinations is needed to characterise any pelvic or adnexal masses

(b)

Other forms of contraception should be discussed with the woman. The use of barrier contraceptions like condoms and diaphragms should be mentioned. Use of hormonal contraceptives like combined hormonal contraception and progesterone-only pills should also be offered as an option. Long-acting reversible contraception like intrauterine device, Mirena, implants, injectables and vaginal rings should also be discussed during the consultation. Lastly, the woman should also be aware of male sterilisation (vasectomy) and this option should be discussed with her husband as well. If the woman is aware of other contraceptive options and wishes to go ahead with sterilisation, she should be informed that the failure rate is 1:200 and although there are procedures to reverse the sterilisation, this is not covered under NHS and reversal may not be possible if the tubes are divided, for e.g. by Pomeroy method. The surgical technique should also be discussed with her, i.e. laparoscopy and type of ligation technique used (Filschie clips or modified Pomeroy method). The complications of laparoscopy, such as bleeding, infection, visceral and vascular injuries, as well as the need to convert to laparotomy if the need to repair viscera or vessels arise. The complication of developing an ectopic pregnancy should be discussed with the woman and she should be advised to take a urine pregnancy test if she misses her period and if positive, to seek medical attention early to exclude an ectopic pregnancy. She should be advised to discuss the options with her partner and arrive at a right decision before being sterilised to avoid feeling regrettable.

(c)

Laparoscopic surgery should be performed by a trained surgeon, who has the experience and has been supervised by a senior surgeon. The theatre and nursing staff should also be trained to assist with laparoscopic surgery. The surgeon should be familiar with the use of laparoscopic instruments. When using the closed technique for entry (Veress entry), the operating table should be horizontal and the abdomen palpated to exclude masses and feel the position of the aorta. The umbilcal incision should be vertical from the base and care taken to avoid incising too deep such as to enter the peritoneal cavity directly. The Veress needle should be checked to make sure it is working. The abdomen should be stabilised before the Veress needle is inserted at right angles to the skin, and insertion should stop once 2 clicks are heard. Care should be taken to avoid excessive lateral movements of the Veress needle to avoid injury to bowel or vessels. After insertion of the Veress, the abdomen should be insufflated with CO2 to 20 to 25 mmHg pressure before inserting the primary trocar. Once good visualisation of the abdominal cavity is obtained and 360 degrees check of the bowel and abdominal cavity for haemorrhage or injuries is performed, the secondary ports should be inserted under direct vision at 20-25 mmHg pressures, visualising and avoiding the inferior epigastric vessels, and the tip of the trocar directed to the pelvis on entry. Once the ports are placed, the intra-abdominal pressure should be reduced to 12-15 mmHg to allow adequate ventilation. If Hasson's technique is used to enter the abdomen, direct vision of the peritoneal cavity should be performed before inserting the blunt-tipped trocar, so as to avoid bowel injuries. If abdominal adhesions are suspected, e.g. midline scar, then an alternative entry point such as Palmer's point should be used to enter. At the end of the procedure, the ports must be removed under direct vision to check for any haemorrhage. The laparoscope should also be used to check that there has not been a through-through bowel injury, caused by adherent bowel under the umbilicus.

a)

History should include her parity and previous obstetric history. History of previous surgeries would predispose her to intraabdominal adhesions that could make the surgery difficult. Ask about her previous contraception, duration of use and reasons behind her decision for sterilisation. History of smoking and illicit drug use should be asked as they could contribute to her surgical morbidity. Her abdomen should be palpated for masses and to note of any existing scars. A pelvic examination to look for abdominal masses and to assess mobility of the uterus. A pelvic ultrasound should be done to look at the pelvic anatomy and to detect any pelvic masses.

b)

She should be asked regarding her certainty of having the procedure, as not to have feeling of regret after the procedure. She should be counselled that the procedure is permenant, however, reversal can be done with a success rate of 45-90%, depending on the type of sterilization. However, she should know that reversal procedures are not funded by the NHS if she intends to have one. Alternative contraception methods, such as long acting reversible contraceptions ( Implanon/ IUCD) or male sterilisation can be offered. Male sterilsation has a lower failure rate of 1:2000, compared the 1:200 failure rate with tubal ligation. Explain to her that tubal ligation is mainly done as a surgical procedure, either laparoscopically or mini-laparotomy. Laparoscopic tubal ligation is done under general anaesthesia, with the tubes ligated with Filshie clips, Fallop rings, diathermy or salphingectomy. Tubal ligation with Filshie clips have a higher rate of success compared to destruction of the tubes via diathermy or salphingectomy. She should also know that although complication rate with laparoscopic tubal ligation is low, there is a risk of bowel, bladder and visceral injury, especially if there are adhesions present. There is also a higher risk of ectopic pregnancy with diathermy. Mini laparotomy tubal ligations are done via a small incision just above the bikini line, and have a higher rate of morbidity compared to laparoscopic surgery, with more pain and longer hospital stay. BIlateral occlusion of the tubes via hysteroscopy is a non surgical option, whereby the ostia of the tubes are occluded with quinarine pellets. It is a safe and inexpensive method, however, she may need repeated insertions to make it more effective. 

She should be advised to continue her current contraception until her first menses after the procedure. She should be informed that tubal ligation has no effect on sexual desires or menses. Written information should be provided so she woulld be more informed on her choices. She can also be referred to the Family Planning Association for more information. 

c)

The rate of complications with laparoscopic surgery is about 1:1000. There is a higher risk of complication if the patient is obese, significantly underweight, or if there is previous abdominal surgeries, peritonitis or inflammatory bowel disease. The surgeons undertaking the surgery should be well trained in the procedure, equipment, instrumentation and power source used to reduce risk of complication. The nursing staff and assistants should also be trained for their roles during the procedure, and to ensure good communication and teamwork.The equipment should be regularly maintained and working in optimal condition. The surgical bed should be flat, instead of the Tradenlenburg 45 degree position. Abdomen should be palpated for any abdominal masses to determine site of primary trocar. If adhesions or mass suspected, the primary trocar can be inserted at the Palmer's point, which is 3cm below the costal margin, at the midclavicular line. The Veress needle should be sharp, with a good and tested spring action. A vertical incision is usually made at the base of the umbilicus which is the thinnest part of the abdomen. The lower abdominal wall should be stabilized so that the Veress needle can be inserted at right angles to the skin. Two audible clicks should be heard to ensure that the needle is in abdominal cavity. Excessive lateral movement of the Veress needle should be avoided to avoid enlargement of any small tears that may have happened. If the patient is obese, the open or Hasson method is preferable. The abdomen is opened until the peritoneum layer, and a blunt tipped cannula inserted. This avoids the use of sharp instruments and reduce risk of bowel injury. 

Gas is insufflated to an intraabdominal pressure of 20-25mmHg before insertion of primary trocar, to reduce the risk of injury to the major vessels. The prssure is then reduced to 12-15mmHg once the trocar is inserted for safe and effective ventilation of the patient by the anaesthetist. 

Upon insertion of the trocar, the laparoscope has to be rotated to 360 degree view to check for any adherent bowel. If adherent bowel is present, check for any haemorrhages or retroperitoneal hematoma. The epigastric vessels should be visualised before insertion of the second trocar to avoid injury to the vessels. The second trocar should be inserted under direct vision. Removal of the ports should be done slowly and by direct vision to ensure no bowel has herniated. Any port entry 7mm - 10mm should be closed to reduce risk of hernia. For the obese and very thin patients, insertion at the Palmer's point or the Hasson method is recommended to reduce risk of bowel and major vessel injury. 

a) I will take a menstrual history including last menstrual period to ascertain if she has a chance of being pregnant currently. I will take a past obstetrics history including parity, mode of delivery and whether she has completed her family. I will take a contraceptive history to see if she is using effective contraception, any side effects of contraception and if she is tolerating well. I will perform an abdominal exam to look for any abdominal scars which can increase risk of adhesions and also masses. I will also do a vaginal exam to palpate for pelvic masses. I will perform a urine pregnancy test to ascertain if she is pregnany if she missed her menses.

b) I would explain the different methods of sterilisation using laparoscopic, mini-laparotomy or hysteroscopic method, their advantages, disadvantages and failure rates. I will offer laparoscopic sterilisation with filshie clips for this patient. I will explain alternative contraceptions like long acting reversible contracetives including copper IUCD, mirena, depo provera and subdermal implants and explain their increased effectiveness and reversibility. I will also explore vasectomy and explain that it is associated with lower risk of failure (1 in 2000) and lower morbidity and mortality compared with tubal sterilisation. Failure rate of laparoscopic sterilisation is 1 in 200 lifetime an 2-3 per 1000 after 10 years. Laparscopic tubal ligation is permanent and irreversible. Success rate of reversal is between 30-70% dependent on method of sterilisation. Intrauterine pregnancy rate is about 30 to 90% after reversal. Reversal is not covered under NHS. Alternative to reversal is IVF which is also not covered under NHS. If performed after 30 years old, not associated with increased risk of menstrual irregularity. Alternative contraception needs to be used after sterilisation till the next menses. Effective contraception is advised till the day of operation. There is an increased risk of ectopic pregnancy (4-76%) if patient becomes pregnant after sterilisation. Patient should ideally be seen together with her partner. Verbal information should be given together with patient information leaflet. Properly documented in case notes.

c) Laparoscopic sterilisation should be performed by a doctor that has been trained and has experience in performing this procedure. Patient should be catheterized before inserting of trocars. Primary incision is made at the base of the umbilicus, vertically downwards. Care must be taken not to enter the peritoneal cavity. Veress needle that is sharp with good and tested spring action should be used. Abdomen should be palpated for masses and position of aorta before insertion. Patient should be horizontal with no tilt. Veress needle should be inserted at 90 degress to the abdominal wall at the incision. Insertion should be stopped once the needle penetrate the fascia and peritoneum. 2 audible clicks will be heard as it passes through these 2 layers. Avoid lateral movement of the needle as it can convert a needle size injury of bowel into a complex tear. Needle placement is confirmed with a low insufflation pressure of less than 8mmHg. Abdomen should be insufflated with CO2 to 20-25mmHg before insertion of primary trocar. Primary trocar should be inserted through the incision, at the base of the umbilicus, at 90 degrees vertically downwards. Stop insertion once the sharp edge of the trocar is past the peritoneal layer. Laparoscope should be inserted and rotated 360 degrees to loof for any bowel adhesions or trauma to the bowel. Secondary ports are inserted under direct laparoscopic guidance. Once the sharp edge of the trocar is past the peritoneum, it should be directed to the anterior pelvis. Avoid use of diathermy. 

a) clinical asessment includes history , examination and investigations. Menstrual history for date of last menstrual period and regularity of cycles. Obstetric history for the number of children, mode of delievry.Contraception history to make sure that she is not pregnant at the time of sterilisation. Any history of previous abdominal surgeries, PID and peritonitis.Abdominal examination for any masses and pelvic examination for any adenexal masses.Investigations include a pregnancy test to make sure that she is not pregnant.

b) Patient needs to be given a detailed verbal information supported by written information. It is ideal to involve both the partners in discussion although it is not a legal reuirement.She should be informed that sterilisation is a permanent method of contraception. Although reversal is possible but with low success rates and procedures like reversal and IVF may not be available with NHS. Failure of sterilisation may happen in 1:200 patients ( life time risk). If coceived chances of ectopic pregnancy are more although overall risk is less than non sterilised woman. Method of surgey  - laparoscopy or laparotomy. Day care procedure under general anaesthaesia. Faster recovery with laparoscopic procedure. Even while doing laparoscopy, risk of conversion to laparotomy is there ( 1.5-3/1000 patients). There is a minimal risk of visceral and vascular injury. Sterilisation is not associated with any long term effects on rate of menstrual blood loss although hysterectomy rate may be slightly increased. Alternative options like long acting reversible contraception and vasectomy should also be explained. Risk of failure is less with vasectomy ( 1/2000 ), chances of ectopic are not increased. Vasectomy is not associated with increased risk of testicular cancer or heart disease although chronic testicular pain is more.

c) Proper assessment for any abdominal masses, palpation of aorta and make sure bladder is empty.Adequate training and supervision of the operator is a must.Veeres needle shoul have a tested spring action. Confirm the proper placement of veres needle by low pressure ( less than 8 mmHg) and free flow of gas. Pneumoperitoneum of 20-25 mm Hg shold be created before trocar insertion and reduced later on. Closed veeres needle technique should be used unless there is previous midline abdominal surgery.Alternative entry points like palmers point should be used if previous midline surgery and infraumbilical trocar inserted under vision. Secondary ports should be inserted unser vision after visualisation of  inferior epigastric artery and pneumoperitoneum of 20-25 mm Hg. Removal of secondary ports instruments under vision. Abdominal cavity should be examined for any evidence of bowel damage. Removal of laparoscope under vision and laparoscope should be checked for any through and through bowel injury

A. Starting from history of parity is vital if she had completeted her family as reversal of sterilization will be difficult and would never acheive the normal anatomy. If her deliveries were NVD if any complication in terms of CSor any surgical scar as this could alter management choice and subject her to more surgical complication. History of her Mensural cycle and what kind of contraception she currently using if COC may need to alert anasthetist for DVT complication. Any history of medical or allergic condition which needed to be addressed and stabilised prior to surgery. History of last smear and if was normal or needed further evaluation. Abdominal assessment is vital to check for any mass or pathology prior to local inspection of the vulva then speculum to check  and inspection of the vagina and cervix as vaginal route for sterilization may be an option to discuss. Bimanual examination to check for any adhesion or fixation in the uterine mobilty for high risk assessmentand to exclude ovarian mass.

B. The sterilization can be done under general anasthesia or local depending on the choice, it could be done in the NHS however if she change her mind and decide to have further children then to re-open the block would not be covered by NHS. Failure rate is 1/200, Then explain the procedure depending on woman choce laparoscopic clips of the tube and when to to stop her current contraception which should be after her next period. If it was tras-vaginal Histroscopic approach then she may need to continue her contraception for further couple of months and could have higher failure rate and need special expertise to be done. In case of laparoscopic sterilisation then think of the minore complication  which are bruses to the abdomen where the port of entry , shoulder tip pain due to CO2 trapped gas , GIT symptoms mild nausea may be a comp[alint, failure to gain entry during the lapraoscopic entry . If she had previous scar that will increase her risk to organ truama which usually 0.4/1000 and major vessels injuries 0.6/1000. She should have some next ken be with her on the day of surgery and she will be discharge the next day to home and can resume her activity in few days later if all went right.

C.Familarise my self to the patient and check no scar in the abdomen check all the instruments are working in good condition, whenthere is midline scar then chose either palmer approach or hassan  open lapraoscopy approach. Patient on stright level once inserting the veres needle  right angle with care not with aggression precussion to be used to ensure right lane using saline test.  allow pressure to flow and check that the abdomen has extended and then change the postion of pateint by lowering the head down. after insertion of the laparoscope check for bleeding and any further instrument should only inserted under direct vission . Good view should be optimised and apply the clip carefully each time for each tube make sure that it cliped the tubes not other tissues with it ensure to have agood look around for any pathology or bleeding and remove the instrument under direct vision ensure that the CO2gas was deflated from the port prior to clusure document all the steps in a neet writting with video for future learning or audit. prescribe an appropriate analgesia for the patient with information after discharge.

A)Menstrual history is taken about LMP,regularity of cycle and amount of blood loss.This is important to plan the procedure during the follicular phase.If she has menorrhagia,she may be advised to use alternatives such as IUS.Contraception history is taken and she  should be advised to continue her present method of contracetion.

Obstetric history is taken about the parity,mode of deliveries,and age of youngest child.She should be sure that she has completed her family.Sterilization done in the postoartum period is associated with high rate of regret and failure.Medical history of inflammatory bowel disease and peritonitis is taken.These are associated with high risk of adhesions.Previous h/o abdominal surgery with mid line incisions is also associated with intraabdominal adhesions and there is risk of failed entry into abdomen.

On examination  BMI and BP is noted.Abdominal examination done and presense and site  of  any incisions noted.

B) Woman should be informed that sterilization is usually done by laparoscpe  under general anesthesia.It is a day case procedure.Clips are applied to block the fallopian tubes.She would be advised that sterilization is permanent and irreversible method  of contraception .Failure rate is 1:200.If she concieves due to failed sterilization,there is high risk of ectopic pregnancy.She should continue taking contraception till the next periods afrer sterilization.

Should she wish to have children and reversal of sterilization it is successful in only 50-60% of cases. and it may not be available on NHS.After reversal there is high risk of ectopic pregnancy. IVF and ICSI is also not available on NHS.

Alternate methods of long acting contracetion such as IUS,IUCD or DMPA injections would be offered according to her suitabilitiy.Vasectomy  is another option if she and her husband  both have children and do not want any more children.This is associted with lower failure rate, 1:2000,  and less complications .

Laparoscopy is associated with.frequently occring risks include bleeding ,infection ,shoulder tip pain and hernia formation at later stage.Serious risks include bowel injury in 0.4 in 1000, and vessel injury in 0.2 in 1000 cases.Risk of death is very rare in 3-8per 100,000 cases.Additional procedures such as laparatomy may be required if any complication are encountered.Verbal information is supported by written information and carefully documented.

C) Risk of visceral injury is minimised by following measures.If she is found to be at high risk of having intraabdominal adhesions,she should be advised against laparoscopic procedure,There is high risk of failure to gain  abdominal entry and visceral or vessel injury.rShe may have mini-laparotomy .

I would ensure that equipments , instruments and power source is in optimum condition and the staff assissting are adequately trained.

Veress needle  should be sharp and tested for spring action.Patient should be positioned flat.Abdominal examination is done to look for any masses,position of aorta is noted and bladder is emptied.

A vertical incision is given in the base of umbilicus.Abdominal wall is elevated and Veress needle is passed at right angle to skin.It should be sufficiently pushed to penetrate fascia and peritoneum.Two audible clicks are heard as it traverses these two structures.  Excessive lateral movement  of needle is avoided as it may worsen any bowel or vessel injury. CO2 is insufflated. Position of veress needle  inside the abdominal cavity is confirmed by low pressure (8mmHg) and high  flow of gas.Peressure should be 20-25mmHg before the primary trocar is inserted. Secondary trocar is inserted under direct vision .Excessive use of diathermy should be avoided.

a)         Clinical assessment would include history to ensure family is complete (parity and mode of delivery).  What her current contraception is and why she would like to change and ensure she cannot conceive prior to sterilisation. Previous contraception tries.  Previous abdominal surgery as increases complications of laparoscopic. PMH is condition that may cause increased adhesions in the pelvis such as endometriosis, inflammatory bowel disease.

Abdominal examination for scars from previous surgery and palpable masses.  A Vaginal examination may be indicated by the history to assess size of uterus and if fixed.

b)         Key issues to discuss would be that she is certain of her decision as sterilisation should be viewed as irreversible. It can be reversed but rarely on nhs mainly privately with no guarantee of success.

Long acting reversal contraception is more effective than female sterilisation.  There should be a discussion of Nexplanon, mirena and progesterone injection.  Consider male sterilisation which has a failure rate of 1 in 2000.  The failure rate is 1 in 200 (lifetime risk) for laparoscopic sterilisation and if she conceived it is more likely to be an ectopic pregnancy.

Risks of laparoscopic surgery; Bleeding infection, damage to bowel, bladder, ureter, post site hernia. If these occur she may require laparotomy. 

Minimise visceral injury;

c)         Laparoscopy should be performed by doctors who are trained in laparoscopy or with adequate supervision. They should be familiar with the equipment.

            Primary port; The base of umbilicus is the thinnest part of the abdominal wall and should be used in women of normal BMI with no previous abdominal surgery.  Palpate for abdominal mass and aorta prior to insertion of primary port.  If low or high BMI or previous midline laparotomy palmars point can be used with a 5mm scope for primary port as this is the area least likely to be associated with adhesions.  Suprapubic primary port can be associated with bladder injury and should be avoided as a primary port.

            Open Hassan technique and verress needle have a similar complication of vessel injury but Hassan had a slightly higher bowel injury rate.  The surgeon should use the technique that they are most confident in.

            The table should be level as trendenlenberg position is associated with higher visceral injury rate.   If a veress needle is used it should be inserted at 90 degrees to the skin with stablisation of the abdominal wall.  2 clicks should be heard to enter the abdomen.  A low (<8mmHg) pressure and free flow of gas suggest entry into the abdomen.  The gas should be infused until the pressure is 20-25mmHg prior to insertion of the primary and secondary ports this means that when pressure is applied there is approx 5cm before the viscera.  If there are 2 failed attempt with the verress needle an open Hassan method should be used and confirmation of entry into the abdomen but visualisation of the bowel or omentum.

When the camera is inserted a 360 degree check for injury should be performed and on removal of the port a check made for a through and through injury. Secondary port should be inserted under direct vision with a pressure of 20-25mmHg to minimise injury to the viscera. Secondary port should be removed under direct vision to ensure no active bleeding. 

  I will ask about last menstrual period  and if  any irregularity and if she  completed her family ,current contraceptive history which method she uses . Pervious history of pelvic inflammatory disease  or abdominal surgery because it increase risk of abdominal and pelvic adhesions .Cervical smear history   .                     

Examination  abdominal  examination for abdominal masses . pelvic examination for pelvic  tenderness  uterine tenderness  and mobility also cervical motion tenderness.                                                                   

Urine pregnancy test to exclude pregnancy.                                                                                                        

              B                                                                                                                                                                         

Women  should be competent to give consent for sterilization  ,explanation to her procedure and use of alternative method  for contraception  including   long term reversible methods , vasectomy which has failure rate 1/2000 but tubal ligation failure rate 1/200 . tubal ligation should be done  during follicular phase of period to exclude  luteal phase pregnancy . Sterilization can be done through minilaparotomy ,  laparoscopy or hysteroscopy.  Laparoscopic  tubal ligation carries risk of vascular and bowel injury  and incisional hernia  but laparoscopic surgery faster than minilapartomy and less postoperative pain and will be done in day care clinic. Reversal of sterilization or Ivf are not funded by NHS. There is increase risk of ectopic pregnancy0—7%  but risk less than that in women non sterilized  . There no increase risk of menorrhagia  after tubal ligation . supply the women  with written informations.                                                                                                             

                                                                                                                                         c                                    

Patient selection  decrease risk of procedure . surgeon must be competent familiar with the equipment , instrument and energy source . staff also must be trained well. Choice of entry method  suitable for patient  in case of obese or pervious abdominal surgery  open method decrease risk of vascular injury. Incision should be subumblical . verres needle should be tested to its spring action . operating table should be horizontal . palpation  to feel any  abdominal   masses and abdominal aorta . stabilization of abdominal wall and insertion of verres  needle at 45 degree  , keep intra abdominal  pressure from 20---25 mmhg during insertion of primary trocar . After introduction of laparscopy   360 degree  view af abdominal cavity to make sure that no vascular or bowel injury . insertion of secondary trocar under vision to avoid injury of inferior  hypogatric vessel

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