European Journal of Cardiovascular Medicine

India is the most populous country in the world with a growth rate of 0.68% with a population of 1.42 billion (2022 census). Sterilization camps will be an opportunity to control the population growth rate by conducting DPL for women who need permanent sterilization with minimal complications. For women who are satisfied with their family size sterilization is relatively safer way to prevent future pregnancy.

Tubal ligation can be done in the peripartum period during LSCS or 2-3 days in postnatal period or any time remote from abortion or pregnancy (interval sterilization). Interval sterilizations are done by minilaparotomy (Modified pomeroy’s method) or double puncture laparoscopy.

As modified pomeroy’s technique is difficult in case of previous lscs because of complications like adhesions, DPL will be a better alternative. The advantage of DPL over minilaparotomy is that it is highly acceptable to patients as they are discharged on the same day and can resume their daily activities immediately. Patients who had undergone DPL have less pain when compared with people who had minilaparotomy.

MATERIALS & METHODS

Laparoscopic sterilization (DPL) was done in tertiary care centre from February 2023 to July 2023 and a total of 110 cases are done.

All sterilization procedures were performed by gynecologists with DPL training & Anesthetist. A thorough examination was done at the time of admission and only contraindications for laparoscopy are ruled out. Complete blood and urine analysis were done to know hemoglobin, viral status and pregnancy should be ruled out before posting the patient for DPL.

The procedure was performed under general anesthesia after ensuring that the patient had fasted overnight. The patient was positioned in dorsal or lithotomy position if needed with appropriate aseptic precautions. A uterine manipulator was inserted per vaginum to facilitate better visualization and mobilization of the uterus. Pneumoperitoneum was created using a Veress needle at the infraumbilical site and insufflated with carbon dioxide. A 10 mm trocar was then introduced at the umbilicus to insert the laparoscope, followed by the placement of a 5 mm accessory port in the left lower quadrant or suprapubic region under direct vision. Once the abdominal cavity was accessed, a thorough inspection of the uterus, fallopian tubes, and adnexa was carried out. Any adhesions encountered were managed with careful adhesiolysis. The fallopian tubes were then identified and grasped approximately 3–4 cm away from the uterine cornu using atraumatic graspers. Silastic Fallope rings, preloaded on ring applicators, were applied to both fallopian tubes to create a loop or knuckle, ensuring proper occlusion. After confirming hemostasis, the carbon dioxide was released gradually, and both ports were removed under direct vision. The small incisions were closed with absorbable sutures, and sterile dressings were applied. Patients were observed in the recovery room for 4–6 hours postoperatively and discharged the same day if stable, with follow-up advised to monitor for any delayed complications. DPL is a day care surgery. When the surgery is uneventful patient is discharged on the same day. If any operative or post operative complication arises they were treated appropriately and kept under observation till the condition of the patient is stabilized and then discharged. Patients are followed regularly to detect any long term complications and to know failure of sterilization procedure.

A total of 102 cases underwent sterilization by DPL during a period of February 2023 to July 2023. Age wise distribution was as per table-1. Risk factors are as per table-2

The most common technical difficulty faced during DPL is adhesions due to previous lscs followed by PID. The technical difficulties are as per table-3

The Fallope ring sterilization technique was introduced in 1973 and preliminary report appeared in 1974. The procedure began at Michael Rees hospital in 1975. The procedure found to be a relatively simple with less operative time, less complications and easily teachable.

The main reason for technical failure is adhesions. The number of cases of previous LSCS is high 70% compared to studies conducted by Dr. Chandra Prabha^[1] which was around 12.5% cases in urban areas. The reason for increase in the cases of previous LSCS could be due to conducting minilaparotomy sterilization procedures in immediate postnatal period by the PHC doctors leaving the previous LSCS cases. Another important reason was pelvic inflammatory disease. In such cases it is not feasible to apply the rings because of inflammation and edema. If applied it lead to transaction of the tube and bleeding from the site. If the tube is transected, fallope rings were applied to the proximal and distal ends of the tube and the bleeding controlled by coagulation.

Mhatre PN et al,^[2] in their study the average age of patients undergoing sterilization was 30 years and average parity is 3.95% of patients undergoing sterilization at camps were interval cases and the rest were following first trimester abortions. The mean stay in the camp was half a day. About 1% cases required overnight stay. There were 3 failure rates out of 5584(0.05%). 3 patients had pelvic adhesions and 2 had gross obesity making sterilization procedure difficult which was however carried out in all cases.

Bhatt RV^[3] in their study in camp laparoscopic sterilization in Gujarat State, India it resulted in 22 deaths among 106,500 women undergoing the operation during 1979 and 1980. Increased risk of death was seen when larger numbers of procedures were performed. The least experienced surgeons had the highest case-fatality rate. Improvised settings (i.e., school buildings) exacerbated the risk of death, as did advanced age, and, to a lesser extent, high parity.

J B Hertz^[4] in their study with an average observation period of 20.8 months, no pregnancies have occurred. Bleeding from the distal site of puncture and tubal transection were the most common peroperative complications, occurring in 4.4 and 3.5% respectively. In 80 patients, hysterosalpingography was performed after 3 months as a control. Unilateral leakage was demonstrated in 6 patients; 5 of these were resterilized via a minilaparotomy.

Gupta SP. Experince in 4500 cases of laparoscopic sterilization,^[5] in their study The difficulties encountered included are omental emphysema and prolapse, bleeding from the mesosalpinx, cervix and abdominal wound, oedematous fallopian tubes and their bisection. In 3 cases, Verres needle penetrated the colon but it was diagnosed before inserting the trocar and cannula. Cardiac and respiratory arrest occurred in one case each but the patients could be revived and there was no mortality. In 3 cases, laparoscopy had to be abandoned because the laparoscope could not be passed into the peritoneal cavity. The failure rate was 0.5 percent.

In the present study the most common complication encountered is adhesions, 12 cases (11.7%) where fallope rings could not be applied where adhesions were dense and medial end of Fallopian tube could not be visualized, in such cases adhesiolysis was done and then fallope rings were applied. In 2 cases where there are dense adhesions where uterus and tubes are adherent to anterior abdominal wall, proceeded for laparotomy. Mean age of patients undergoing the procedure is 27 years with 2 or more children. The most common complication being bleeding from port site which needed simple suturing and infection at port site which responded to simple antibiotic course. There were no deaths recorded.

With cesarean section rates rising in India-currently at 21.5%-DPL has emerged as a preferred sterilization method for women with prior LSCS. Compared to minilaparotomy, DPL provides a minimally invasive, efficient, and patient-friendly approach. The ability to conduct it as a daycare procedure minimizes hospitalization, postoperative morbidity, and economic burden, especially for rural patients.

However, intraoperative challenges like dense adhesions and anatomical distortions from multiple cesarean deliveries are significant. In our study, such adhesions led to difficulty in identifying tubal structures, necessitating laparotomy in two cases. These findings highlight the need for surgical expertise and proper preoperative evaluation to minimize complications.

Laparoscopy also offers lower infection rates due to limited organ exposure. This makes it advantageous in settings with inadequate infection control protocols. Additionally, shorter recovery time supports faster reintegration into daily life-an essential factor for women managing households and children.

A comprehensive preoperative assessment is critical, especially for identifying high-risk cases with prior pelvic surgeries or suspected PID. Such evaluations can guide decisions regarding the feasibility of DPL and help avoid intraoperative surprises.

Postoperative follow-up is crucial for confirming the success of sterilization and identifying rare complications. Though rare, failure can occur due to ring slippage or incorrect application, and patients should be educated on warning signs like missed periods or abnormal bleeding.

Double puncture laparoscopic sterilization by fallope rings is an effective than minilaparotomy as it is simple safe with minimal complications can be done on large numbers by trained gynecologist on a single day and the patient can be discharged on the same day.

Disadvantages of DPL include the need of anesthesia, need of expertise and cost of laparoscopic equipment. Now a days in India most of the primary health centers and area hospitals are upgraded and laparoscopic techniques can be done with minimal complications and failure rates.

1. Chandraprabha N, Usha P, Parnaik S. An experience with double puncture laparoscopy in sterilization camps. Int J Reprod Contracept Obstet Gynecol 2015;4(4):1158-60.
2. Mhatre PN, Parulekar SV, Purandare VN. Laparoscopic sterilization camps and institutional setup. JPGM 1985;31(1):20-3.
3. Bhatt RV. Camp laparoscopic sterilization deaths in Gujarat state, India 1978-1980. Asia Oceani J Obstet Gynecol 1991;17(4):297-301.
4. Hertz JB. Laparoscopic sterilization with falope-ring technique. Acts Obstet Gynecol Scand 1982;61(1):13-5.
5. Gupta SP. Experience in 4500 cases of laparoscopic sterilization. Int Surg 1993;78:76-8.
6. Chatman DL. Laparoscopic Falope Ring sterilization: Two years of experience. American Journal of Obstetrics and Gynecology 1978;131(3):291-4.