What is the proper procedure for performing a salpingectomy?

Salpingectomy Procedure: Technical Guide

A salpingectomy should be performed by completely removing the fallopian tube, including the proximal isthmus but preserving the interstitial portion, with careful attention to avoid damaging the ovarian blood supply. 1

Indications for Salpingectomy

Salpingectomy may be performed for:

• Ectopic pregnancy
• As part of cancer staging/treatment
• Risk-reduction for ovarian cancer
• During hysterectomy
• Female sterilization

Surgical Approaches

1. Open Surgical Approach

• Make appropriate abdominal incision (midline or Pfannenstiel)
• Upon entering the abdomen, perform peritoneal cytologic examination via aspiration of ascites or peritoneal lavage 2
• Visualize all peritoneal surfaces and biopsy any suspicious areas
• Identify the fallopian tube and its blood supply
• Create windows in the mesosalpinx to isolate and ligate the tubal vessels
• Clamp, cut, and ligate the proximal portion of the tube near the uterine cornua
• Clamp, cut, and ligate the distal portion near the fimbrial end
• Remove the entire tube while preserving ovarian vasculature
• Ensure hemostasis

2. Laparoscopic Approach

• Place trocars according to standard laparoscopic technique
• Identify the fallopian tube
• Create windows in the mesosalpinx to isolate the tubal vessels
• Use bipolar diathermy forceps to coagulate the mesosalpinx vessels 3
• Cut the coagulated tissue with laparoscopic scissors
• Proceed from the fimbrial end toward the uterine cornua
• Ensure complete removal of the tube while preserving ovarian blood supply
• Remove the specimen through a trocar or posterior colpotomy
• Ensure hemostasis

3. Vaginal Approach (during vaginal hysterectomy)

• After completing the hysterectomy steps but before removing the uterus
• Identify the fallopian tubes
• Use the "Mesosalpinx Isolation Salpingectomy Technique" (MIST) 4:
  • Create avascular windows within the mesosalpinx close to tubal vessels
  • Skeletonize and isolate the vasculature from adjacent mesosalpinx
  • Suture ligate the individual vessels
  • Remove the entire tube
  • Ensure hemostasis

Specific Technical Considerations

For Cancer Staging/Treatment

• Perform careful examination of all peritoneal surfaces
• Take peritoneal washings for cytologic examination
• Remove the entire tube including the proximal isthmus
• In ovarian cancer cases, perform bilateral salpingo-oophorectomy along with other staging procedures 2

For Ectopic Pregnancy

• Identify the affected tube
• Control bleeding with appropriate clamps or energy devices
• Remove the entire tube if:
  • The tube is ruptured and unsuitable for conservation
  • Patient has no interest in future fertility
  • Previous ectopic pregnancy in the same tube 3

For Risk-Reducing Salpingectomy

• Complete removal of the fallopian tube is essential
• Careful preservation of ovarian blood supply is critical
• Ensure removal of the fimbrial end which is the likely origin of many serous ovarian cancers 2

Potential Complications and Avoidance Strategies

• Bleeding: Ensure proper identification and ligation of mesosalpingeal vessels
• Ovarian damage: Carefully identify and preserve the ovarian blood supply
• Incomplete removal: Ensure complete removal of the tube including the fimbrial end
• Thermal injury: When using energy devices, maintain safe distance from ovary and other structures
• Conversion to laparotomy: May be necessary in cases of difficult anatomy or complications

Postoperative Considerations

• Monitor for bleeding and infection
• Typical recovery time is 1-2 weeks for laparoscopic approach
• Return to normal activities within 2-4 weeks depending on surgical approach

Evidence-Based Outcomes

• Laparoscopic salpingectomy shows comparable reproductive outcomes to open surgery with intra-uterine pregnancy rates of 64% vs 78% respectively 3
• Salpingectomy for sterilization takes approximately 6 minutes longer than tubal occlusion procedures but offers higher efficacy and ovarian cancer protection 5
• Opportunistic salpingectomy during vaginal hysterectomy prevents ovarian cancer in 1 of every 225 women and prevents death from ovarian cancer in 1 of every 450 women 6

By following these technical steps and considerations, a safe and effective salpingectomy can be performed with minimal complications and optimal outcomes.