The tubes are usually readily accessible for removal at the time of vaginal hysterectomy. There is evolving evidence that the tube may play a role in malignancy of the female genital tract. Thus, removal may be preventive. In addition, if there are paratubal cysts or hydrosalpinx from prior tubal ligation, it makes sense to remove the tube. There is little evidence to suggest that removal of the tubes accelerates the menopausal transition due to compromise of the blood supply to the ovaries.
You must be very gentle when handling and removing just the tubes. The mesosalpinx is delicate and easily torn or traumatized. A careful and deliberate approach is warranted.
Bilateral salpingectomy: Key take-aways
Locate the tube. The fallopian tube always lies on top of the ovary and should be found there. On occasion, the abdominal packing used to move the bowel out of the pelvis will “hide” the tube; readjusting this packing often solves the problem.
Be gentle with the mesosalpinx as it is very delicate and can easily avulse. It is very important to “flash the clamp” (open the clamp and then close it) as you free-tie the mesosalpinx to avoid cutting through the delicate pedicle.
Remove as much tube as possible. The fimbriae end of the tube usually is free and easy to identify. Try to remove as much of the tube as possible. Often, a bit of the proximal tube is left in the utero-ovarian pedicle tie.
Clean up. You will often find peritubal cysts or “tubal clips” from a sterilization procedure. I recommend that you remove any of these you encounter to avoid problems down the road. Often, these cysts and clip-like devices are removed as part of the specimen.
Dry up. Always confirm hemostasis before concluding the procedure. If there is bleeding, be sure to assess the mesosalpinx. Occasionally, the pedicle can be torn higher up, near the gonadal vessels. Investigate this region if bleeding seems to be an issue.
Transvaginal salpingo-oophorectomy: Key take-aways
Perfect a technique. There are many approaches to transvaginal removal of the adnexae; pick one and perfect it. The better you are, the fewer complications you will have. Recognize that a different approach (use of a stapler or energy sealing device, for example) may prove useful in some settings. Be surgically versatile and recognize situations that might call for something other than your usual approach.
Optimize visualization. The tubes and ovaries are usually very accessible vaginally. Use an abdominal pack to move the bowel out of the pelvis. Adequate retraction and use of a lighted retractor or suction irrigator will facilitate exposure.
Ligate the gonadal vessels. Retraction of the tube and ovary complex medially away from the pelvic sidewall will allow you to place a clamp (or stapler or energy device) lateral to secure the gonadal vessels and ensure complete removal of the adnexae.
Release the round ligament. Although this step is usually not required, it will allow you to isolate the adnexae more precisely, especially when dealing with an adnexal mass transvaginally. It is critical that you “hug” the round ligament and refrain from penetrating deeply into the underlying tissues, or bleeding will occur. Once the round ligament is released, the tube and ovary are isolated on the gonadal pedicle and can be completely excised with this technique.
Manage bleeding. If suturing, I prefer to doubly ligate the gonadal vessels. Once I clamp the pedicle, I “free-tie” the gonadal vessels with an initial suture. This suture secures the vascular pedicle and prevents retraction. The adnexae can then be removed, followed by placement of a “stick-tie” to re-ligate the pedicle. Although this vascular pedicle is more robust than the mesosalpinx, it, too, can be avulsed, so it is important to proceed with caution. I recommend having a long clamp (uterine packing forceps or MD Anderson clamp) available in your instrument pan to facilitate specific isolation of the gonadal vessels along the pelvic sidewall in the event avulsion does occur.
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