What are the surgical steps for a bilateral salpingectomy in a patient with a history of pelvic surgeries or significant adhesions, considering their overall health and reproductive desires?

Surgical Steps for Bilateral Salpingectomy

Bilateral salpingectomy involves systematic removal of both fallopian tubes through identification and ligation of the mesosalpinx, division of tubo-ovarian ligaments, and complete excision from the cornual insertion to the fimbrial end, typically adding 11 minutes to operative time with minimal additional blood loss.

Preoperative Planning and Patient Positioning

• Assess for risk factors that may complicate the procedure, including prior adnexal surgery (odds ratio 2.9 for unsuccessful completion) and uterine fibroids (odds ratio 5.8), which significantly increase difficulty of tube removal 1
• Evaluate pelvic anatomy preoperatively with imaging to identify adhesions, tube position, and accessibility, particularly in patients with history of pelvic surgeries 1
• Choose surgical approach based on concurrent procedures: laparoscopic approach provides superior visualization and is recommended when ovarian assessment is needed, while vaginal approach is feasible in 81% of cases during vaginal hysterectomy 2, 1

Abdominal Entry and Exploration

• Perform systematic inspection of the entire abdominal cavity, including peritoneal surfaces, diaphragm, liver, omentum, and pelvic organs to identify any suspicious lesions or adhesions 2, 3
• Obtain peritoneal washings for cytology if malignancy is suspected, as this provides critical staging information 2, 3
• Lyse adhesions carefully if present, taking care to identify and protect the ureters, bowel, and major blood vessels throughout the procedure 4

Identification of Anatomical Structures

• Identify the round ligament bilaterally as the initial landmark for accessing the adnexa 2
• Trace the fallopian tube from the cornual insertion at the uterus to the fimbrial end, noting its relationship to the ovary 5
• Identify the mesosalpinx, which contains the tubal blood supply running parallel to the fallopian tube 5, 6
• Locate the tubo-ovarian ligament connecting the fimbrial end to the ovary, ensuring the ovarian blood supply remains intact if ovarian preservation is planned 5, 6

Salpingectomy Technique

Right Fallopian Tube Removal

• Coagulate and divide the mesosalpinx systematically from the cornual end toward the fimbrial end using electrosurgical energy or laser, staying close to the tube to preserve ovarian vasculature 5, 6
• Ligate the proximal isthmus at the cornual insertion, ensuring complete removal of the tube including the isthmic portion but avoiding the interstitial segment to prevent uterine perforation 5
• Divide the tubo-ovarian ligament at the fimbrial end, separating the tube from the ovary while preserving ovarian blood supply 5, 6
• Remove the entire tube ensuring no remnant tissue remains, as incomplete removal may leave potential sites for pathology 5

Left Fallopian Tube Removal

• Repeat identical steps on the contralateral side with the same systematic approach 6
• Maintain hemostasis throughout by careful coagulation of vessels before division 6

Special Considerations for Difficult Cases

• If tubes are positioned high in the pelvis (occurs in approximately 47% of unsuccessful cases), consider gentle traction on the ovary or round ligament to bring structures into view 1
• In presence of bowel or sidewall adhesions (18% of unsuccessful cases), complete adhesiolysis first before attempting tube removal 1
• For ovarian adhesions obscuring the fimbrial end, carefully dissect the ovary free before dividing the tubo-ovarian ligament 1
• If bilateral removal is not feasible, perform unilateral salpingectomy on the accessible side rather than abandoning the procedure entirely 1

Specimen Removal and Documentation

• Extract tubes through a suprapubic port site in laparoscopic cases or through the vaginal cuff in vaginal hysterectomy 6, 1
• Avoid morcellation outside of endoscopic bags, as this carries high risk of worsening prognosis if occult malignancy is present 2
• Send specimens for pathologic examination to exclude malignancy, particularly examining the fimbrial ends where serous carcinomas often originate 7
• Document operative findings precisely, including tube appearance, ease of removal, any adhesions encountered, and completeness of excision 2, 4

Expected Operative Metrics

• Mean additional operative time: 11 minutes for bilateral salpingectomy (up to 15 minutes with suture ligation technique) 1, 8
• Mean additional blood loss: 6 mL, which is clinically insignificant 1
• Success rate: 81% completion via vaginal approach, higher via laparoscopic approach 1

Critical Pitfalls to Avoid

• Do not damage ovarian blood supply by dissecting too far from the tube or injuring the infundibulopelvic ligament if ovarian preservation is intended 5
• Do not remove the interstitial portion of the tube, as this requires cornual resection and increases risk of uterine perforation and bleeding 5
• Do not proceed blindly in cases with dense adhesions; convert to laparotomy if visualization is inadequate to prevent bowel or ureteral injury 1
• Do not assume tubes are absent without thorough exploration, as congenital absence is rare (6% of unsuccessful cases) 1