The an interprofessional team includes:

• Surgeon
• Surgical assistant (partner, resident, scrub technician, etc.)
• Scrub technician
• Anesthetist/Anesthesiologist (as indicated for local, regional, or general anesthesia)
• Surgical circulator (usually a nurse)

The most critical aspect of preparing for tubal ligation is ensuring adequate patient counseling and informed consent. Appropriate documentation and consent forms should be in place before the procedure. Laws and restrictions regarding timing and the consent process require careful adherence. The technique and approach most appropriate for the individual patient must also be determined, which will allow adequate counseling with regards to any surgical risks, risks of failure, risks of anesthesia, recovery, and follow-up unique to each technique or approach.

The timing of tubal ligation can be [1]:

• Postpartum - at the time of cesarean section or after vaginal delivery before discharge home
• Postabortion - immediately after an uncomplicated spontaneous abortion or induced abortion
• Interval - procedure separate from pregnancy

Appropriate skin preparation preoperatively should be performed. Prophylactic antibiotics are not recommended prior to laparoscopic tubal ligations. Antibiotics are also not routinely administered before mini-laparotomy. The patient should have an empty stomach appropriate for the surgical approach chosen.  

Laparoscopic

This is the most common technique for interval tubal ligations. It allows for inspection of the abdomen and pelvis, is effective immediately, and allows a relatively rapid return to activity.[1] Anesthesia is typically general; however, this can take place with local anesthetic and sedation. Laparoscopic tubal ligation is possible via three methods [1]:

• Electrocoagulation: Bipolar device is used to occlude the tube, at least 3 cm of the isthmic portion. Monopolar electrocoagulation is seldom a choice due to association with thermal bowel injury.
• Mechanical Devices: In the United States, the most commonly used devices are the silicone rubber band, the spring-loaded clip, and the titanium clip lined with silicone rubber. These are deployed using special applicators, and they are most effective if the Fallopian tubes are normal. Misapplication and failure can occur if the tubes are thickened, dilated, or form adhesions.
• Tubal Excision: The surgeon can remove part or all of the Fallopian tubes. This technique is especially useful if the tubes are abnormal, it has high contraceptive efficacy, and it may decrease the risk of ovarian cancer.

Hysteroscopic

In the United States, there are currently no hysteroscopic sterilization devices on the market. Hysteroscopic sterilization cannot be done postpartum or postabortion. It offers a relatively non-invasive method for tubal occlusion that could be beneficial to patients who are weak surgical candidates, and it has the benefit of being able to be performed in the office setting. The hysteroscopic technique involves introducing medicine into the Fallopian tubes via the tubal ostia, which subsequently block or scar the tubes. Some past hysteroscopic techniques required follow-up imaging to ensure occlusion. Either sedation or general anesthesia are options if this procedure occurs in the operating room. In the office setting, a paracervical block or light sedation are options if safely available.

Laparotomy/Minilaparotomy

This technique is generally used for postpartum procedures, though it may merit consideration for patients for whom laparoscopy carries such a high risk that laparotomy is safer.[1] It is also suitable for low-resource settings, because it utilizes basic (and usually reusable) equipment, unlike laparoscopy.[1] A 2 to 3 cm incision is made relative to the fundus (infra-umbilical postpartum or suprapubic postabortion/interval), though a larger incision may be necessary for obese patients.[1] During a cesarean postpartum tubal ligation, the abdomen is already open. The patient's existing regional anesthetic is sufficient for procedures done during a cesarean. After a vaginal delivery, the patient's epidural catheter may remain in place, or a spinal anesthetic can be placed if the patient did not have an epidural or if the epidural catheter required removal.

• Pomeroy: Mid-isthmic portion of the Fallopian tube is elevated and then folded at the midpoint. One or two rapidly absorbable sutures are tied around the double thickness of the tube, and the folded portion excised sharply.
• Parkland: An opening is made in an avascular section of the mesosalpinx. Two absorbable suture ties are passed through the opening and used to ligate the proximal and distal ends of the Fallopian tube. The segment (at least 2 cm) between the ties gets excised.
• Uchida: The midportion of the Fallopian tube is ligated and excised. Then the utero-tubal serosa is hydrodissected, and the proximal tubal stump gets pulled into the mesosalpinx. The peritoneum is closed over the proximal cut end of the tube.
• Irving: The midportion of the Fallopian tube is ligated and excised. Then the proximal tubal stump is inserted into an incision made into the myometrium and securely sutured to bury the proximal stump in the myometrium.
• Distal Fimbriectomy: The fimbriated end of the Fallopian tube is ligated and excised.
• Complete Salpingectomy: The entire Fallopian tube to the (except the interstitial portion) is excised; this can be done with suture ligation, laparoscopic bipolar devices, etc.

Tubal segments require a pathology consultation to confirm transection. A common structure ligated accidentally is the round ligament. Identification of the fimbriated end of the Fallopian tube before excision can help confirm the correct structure. Unless performing a complete salpingectomy, care is necessary to excise a sufficient section of the Fallopian tube. All cut edges require inspection for hemostasis.

Laparoscopic tubal ligation is overall safe and effective. Mortality rates in the United States are estimated at 1 to 2 per 100000 procedures, with most deaths attributable to hypoventilation and cardiopulmonary arrest while administering general anesthesia.[1] Several studies have shown no deaths at all.[1] Major laparoscopic complications include unplanned major surgery, transfusion, damage to surrounding structures, fever, infection, bleeding, transfusion, and readmission. These reports show approximately 0.9 to 1.6 per 100 procedures.[1] The reported risk of conversion to open laparotomy is 0.9 per 100 cases.[1] The risks of complications increase with the use of general anesthesia, previous pelvic or abdominal surgery, obesity, and diabetes.[1]

Complications following mini-laparotomy are also very low. In one Swiss study, the overall rate of major morbidity after postpartum tubal ligation was 0.39%.[10] This statistic included cases of blood loss greater than 500cc, febrile morbidity, pulmonary embolism, and stomach injury.[10] The rate of minor morbidity was 0.8%, including urinary tract infections, wound dehiscence, abdominal wall hematomas, uterine injury, and ileus.[10]

The 10-year risk of failure varies by technique [1][11]:  

• Postpartum partial salpingectomy = 7.5 per 1000 procedures
• Bipolar coagulation = 24.8 per 1,000 procedures (19.5 per 1000 1978 to 1982 and 6.3 per 1000 1985 to 1987)
• Silicone band = 17.7 per 1000 procedures
• Spring clip = 36.5 per 1000 procedures

Since the original CREST study was published, additional data regarding method efficacy have emerged, and follow-up analyses have taken place on the CREST data. Bipolar coagulation has specifically received attention. During the follow-up period, as techniques evolved, the failure rates fell significantly.[12]

Care should be taken to identify luteal phase pregnancies before performing interval tubal ligations. A pregnancy test is necessary, but also a careful history should be taken to identify patients at risk of being pregnant despite a negative pregnancy test. On average, women ovulate on day 14 of their cycle, where day 1 of the cycle is day 1 of the last menstrual period. The fertile period extends from several days before ovulation to shortly after, and many urine pregnancy tests do not have the sensitivity to detect very early pregnancy. Patients who have had unprotected intercourse within the last week could be at risk of luteal phase pregnancy. Patients at risk should be counseled preoperatively regarding the risks of surgery and anesthesia during early pregnancy, and the risks merit strong consideration against the benefits of proceeding with the procedure.

If pregnancy does occur after tubal ligation, there is a risk of ectopic pregnancy that varies by technique as well [1][11]:

• Postpartum partial salpingectomy = 1.5 per 1000 procedures
• Bipolar coagulation = 17.1 per 1000 procedures
• Silicone band = 7.3  per 1000 procedures
• Spring clip = 8.5 per 1000 procedures

Post-tubal ligation syndrome is a potential complication that is well-documented in the lay media. Its actual existence, however, controversial. Symptoms may include dyspareunia, low back pain, premenstrual tension syndrome, menstrual abnormalities (missed periods, heavy menstrual bleeding), or menopausal symptoms.[13] The etiology of post-tubal ligation syndrome may be related to adnexal vascular disruption.[13] Treatment may be symptomatic if patient bother is mild. However, some patients may require/request surgical management, such as reversal of the tubal ligation.[13]

Female sterilization is the most common method of contraception used worldwide. It can be done immediately after delivery or between pregnancies, and the number of techniques available is many. It is crucial to understand the complexities surrounding tubal ligation, including the various surgical risks/benefits/alternatives, alternative contraceptive options, and the challenging ethics involved. An adequate understanding of all these is necessary to counsel patients adequately and obtain valid informed consent.

Approximately half of all pregnancies in the United States are unintended. Tubal ligation offers patients a safe and effective contraceptive option that has a low failure rate, has no risk of user-related failure, and does not require replacement. Barriers do exist concerning access to postpartum sterilization. Unfortunately, only 50% of patients who request postpartum tubal ligation ultimately undergo the procedure. A patient must be 21 years old to be eligible for Medicaid coverage of a sterilization procedure, and consent documents must be signed at least 30 days before the procedure. Operating rooms or anesthesia may not be available, or the institution may be religiously affiliated. Physicians, nurses, anesthesiologists, office staff, and other patient advocates can work together to ensure proper patient education and access to services such as postpartum tubal ligation. Hospital systems and medical providers can develop policies and procedures to ensure consent forms are obtained in the antenatal period and are available at the time of delivery. Providers, including nurses, can emphasize that postpartum tubal ligations are urgent and advocate for these procedures to be scheduled and done. Women receiving care at religiously-affiliated institutions should still be counseled regarding all their options and be offered referrals to other institutions if they desire.[14] [Level V]

Ethically, providers who counsel patients regarding tubal ligation or who participate in these patients’ care may be better able to ensure patient satisfaction and outcomes if they also understand the CREST study and potential pitfalls such as regret and failure. [Level II]

One study looking at written informed consent for tubal ligation found wide variations in the complications discussed, both among providers with the same level of training and between levels of training. This data leaves providers at risk legally. The authors concluded by recommending standardized patient education that can aid in obtaining consistently valid informed consent. This standardized education could be helpful for all members of each patient's healthcare team.[15] [Level V]

• Ensure the patient understands the procedure
• Educates the patient on the procedure and that it is a permanent form of sterilization
• Ensures a valid consent has been obtained
• Preps the patient
• Prepares the instrument tray for sterilization
• May assist the surgeon
• Labels the specimen for the pathologist

• Monitors the patient during surgery
• Monitors the patient after surgery
• Ensures instrument and sponge counts are correct
• Ensure wound hemostasis after surgery