Fimbrial reconstruction

Fimbrial reconstruction

Although the hysterosalpingogram may indicate that the block in the tubal lumen takes place at the fimbriated end, it is still difficult with the tube in hand to evaluate the extent of the normal tube. It is important to know this before any attempt is made to perform a plastic operation. The necessary knowledge for surgeon can be obtained by employing an insufflation apparatus fixed in place and controlled from outside the operative field. This maneuver, however, is cumbersome. It is possible to get the same information, rather simply, by closing the cervix with a large clamp and injecting air or fluid into the endometrial cavity.

Figure 1. The assistant holds the uterus on tension as the surgeon evaluates the extent of the disease. While the mesosalpinx is free the fimbriated ends of the tube are closed.

Fimbrial reconstruction

Fimbrial reconstruction

 

Figure 2. A large clamp with a broad right-angle base encompasses the entire uterus. When the clamp is closed it will seal off the lower end of the endometrial cavity. The surgeon then injects a solution of indigo carmine or methylene blue into the endometrial cavity. Direct inspection of the tube indicates the point of obstruction.

Figure 3. The surgeon grasps the fimbriated end of the tube, steadying it by the index finger and thumb as he incises the adhesions over the closed ends.

Figure 4. Still steadying the tube with thumb and forefinger the surgeon identifies the lumen. He then introduces the blades of the Kelly clamp into the open end.

Fimbrial reconstruction

Fimbrial reconstruction

 

Figure 5. If the damage is so extensive that simple opening of the tube will be insufficient to keep the ostia open permanently, it is necessary to perform a plastic operation on the fimbria. The assistant holds the tube on tension with a noncrushing clamp. The surgeon steadies the open end while he introduces a nerve hook into the lumen to grasp the interior wall of the tube.

Fimbrial reconstruction

Figure 6. As the hook is withdrawn it is turned to allow firm traction on the endosalpinx.

Fimbrial reconstruction

Fimbrial reconstruction

Figure 7. Continued traction will now cuff back the fibrous end of the fallopian tube.

Figure 8. To facilitate the placing of fine interrupted sutures on the everted tubal cuff it is essential to keep all structures on tension. The operating nurse holds the uterus on tension while the assistant grasps the tube with forceps and applies traction. The surgeon then places the first of the fine interrupted sutures in the leading edge of the everted tubal epithelium and sutures it to the anterior peritoneal surface of the tube at the lateral angle.

Figure 9. A similar suture is placed on the medial angle.

Figure 10. This figure shows the completed operation with the tubal cuff everted and the sutures placed circumferentially.

Fimbrial reconstruction

Fimbrial reconstruction

Fimbrial reconstruction

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