What is the step-by-step surgical technique for a salpingectomy?

Step-by-Step Surgical Technique for Salpingectomy

Surgical Approach Selection

Laparoscopic surgery is the preferred approach for salpingectomy, offering reduced morbidity, shorter hospitalization, faster recovery, and superior visualization of pelvic anatomy compared to laparotomy. 1

• The laparoscopic approach is particularly advantageous in obese patients where conventional techniques may be limited 2
• Robotic-assisted laparoscopy can be considered as an enhancement to standard laparoscopy, especially in obese women 3
• Laparotomy should be reserved for cases where laparoscopic access is not feasible or when complications occur that cannot be managed laparoscopically 4

Patient Positioning and Port Placement

• Position the patient in dorsal lithotomy with Trendelenburg positioning to optimize visualization of the pelvis 4
• Use a triple-puncture technique for standard laparoscopic salpingectomy: one umbilical port for the camera and two lateral ports for instruments 5
• Alternative reduced-port techniques using 3mm ports can be employed for improved cosmetic outcomes in appropriate cases 6

Surgical Steps

Step 1: Initial Assessment

• Perform comprehensive visualization of the entire pelvic cavity, examining both adnexa, peritoneal surfaces, and identifying any pathology 1
• Assess the condition of both fallopian tubes and ovaries before proceeding 7

Step 2: Mobilization of the Fallopian Tube

• Grasp the fallopian tube at the fimbrial end using atraumatic grasping forceps 4
• Elevate the tube to identify the mesosalpinx and its vascular supply 7
• Carefully identify the ovarian blood supply to avoid damaging the vascular supply to the ovary during the procedure 7

Step 3: Vascular Control and Tube Removal

• Coagulate the mesosalpinx using bipolar electrocautery, working from the fimbrial end toward the uterine cornu in sequential steps 8
• Ensure complete hemostasis at each coagulation site before transecting the tissue 4
• Divide the mesosalpinx after adequate coagulation using scissors or electrocautery 8
• Continue this process along the entire length of the tube, maintaining careful attention to hemostasis 4

Step 4: Proximal Transection

• Coagulate and transect the tube at the uterotubal junction, including the proximal isthmus but not the interstitial portion 7
• The interstitial portion should remain intact to avoid creating a defect in the uterine wall 7
• Ensure the cornual area is adequately coagulated to prevent bleeding 8

Step 5: Specimen Removal

• Remove the fallopian tube through one of the laparoscopic ports, using an endoscopic bag if necessary to prevent spillage 4
• For bilateral salpingectomy, repeat the procedure on the contralateral side 1

Step 6: Final Inspection and Closure

• Irrigate the pelvis and inspect all coagulation sites for hemostasis 4
• Verify that the ovarian blood supply remains intact and the ovary appears well-perfused 7
• If bleeding occurs and fails to respond to cauterization, convert to laparotomy immediately 4
• Close port sites according to standard technique 8

Special Considerations for Specific Contexts

For Risk-Reducing Surgery in BRCA Carriers

• Process the specimen using the SEE-FIM (Sectioning and Extensively Examining the FIMbriated End) protocol to detect occult malignancy 1

For Endometrial Cancer Staging

• Perform bilateral salpingo-oophorectomy as part of standard surgery with hysterectomy 3, 1
• The minimally invasive approach is recommended for low- and intermediate-risk disease and can be considered for high-risk endometrial cancer 3, 1

For Non-Epithelial Ovarian Tumors

• In young patients with germ cell tumors, unilateral salpingo-oophorectomy with preservation of the contralateral ovary and uterus is standard 3
• Systematic ovarian biopsy is not necessary when the contralateral ovary is macroscopically normal 3

Critical Pitfalls to Avoid

• Do not damage the ovarian blood supply during mesosalpinx coagulation, as this can compromise ovarian function 7
• Do not remove the interstitial portion of the tube, as this creates an unnecessary uterine defect 7
• Do not proceed if hemostasis cannot be achieved laparoscopically—convert to laparotomy promptly 4
• Ensure adequate coagulation before transecting tissue to prevent postoperative bleeding 8
• In patients undergoing bilateral salpingo-oophorectomy before natural menopause, ensure appropriate counseling about hormone replacement therapy to mitigate cardiovascular, bone, and cognitive risks 9