腹腔镜绝育术

　　Sterilization is a safe and effective method of permanent contraception used by more than 220 million couples worldwide. For married patients, sterilization remains the most commonly used method in the United States. It is used by 47.3% of married couples (tubal occlusion, 30.2%; vasectomy, 17.1%) (1). Female sterilization can be done either before conception or after pregnancy. Timing may affect which of several methods is selected. Postabortion sterilization may be performed immediately after an uncomplicated spontaneous or induced abortion by laparoscopy or minilaparotomy.

　　绝育术是一种安全有效的永久性避孕方式，全世界有超过2.2亿对夫妇采用这种方式。绝育术仍然是目前美国已婚夫妇最常使用的方法，使用率为47.3%(输卵管阻塞术和输精管切除术使用率分别为30.2%和17.1%)(1)。女性节育术可以在受孕前或怀孕结束后进行。进行手术的时间可能会影响使用的方式。在自然流产或者通过腹腔镜或显微剖腹术进行人工催产且无并发症的情况下，可以立即进行绝育术。

　　Postpartum sterilization can be performed at the time of cesarean delivery or after a vaginal delivery. When performed in conjunction with a cesarean delivery, it can be completed in less than five minutes in most cases when the tubes are easily accessible. When performed after a vaginal delivery, it is usually done through a small (approximately 1.5 cm to 3 cm), infra-umbilical incision. If epidural anesthesia was used for labor, the catheter can be retained and reused for sterilization the following day. This procedure should be planned (and informed consent obtained) during antepartum care. The Pomeroy and Parkland methods are the most commonly used in the United States, both at the time of cesarean section or with the use of a minilaparotomy incision. When an excisional method is used, the tubal segments should be submitted to pathology to confirm complete tubal transaction.

　　产后绝育术可在剖腹产时或顺产后进行。当与剖腹产手术一起安排时，医生可以很容易接触到输卵管，大多数情况下不到五分钟就能完成。如果是在顺产后进行结扎，通常需要在脐下开一个小的切口(大约1.5cm至3cm)。如果分娩时使用硬膜外麻醉，可以保留导管，第二天用于消毒。绝育术需要在产前护理阶段提前规划(且需要患者签署知情同意书)。Pomeroy法和Parkland法输卵管结扎是美国剖腹产和显微剖腹术时最常采用的绝育术。如果使用输卵管切除法，切除的输卵管组织应当送去做病理检查，以确认输卵管处理完整。

　　An interval tubal occlusion is performed via laparoscopy remote from pregnancy. Timing of sterilization in these cases should follow the guidelines to be reasonably certain that the woman is not pregnant. Laparoscopy does require use of general anesthesia, which slightly increases the risk of procedure, but allows the surgeon to inspect the abdominal and pelvic organs.

　　输卵管内部阻塞术是通过腹腔镜完成的，在非妊娠期进行。阻塞术的操作时间要根据指引，并且通过一些合理的方式确认女性患者未在怀孕期。腹腔镜需要全麻，虽然会略微增加手术风险，但是外科医生可以通过腹腔镜检查腹部和盆腔器官。

　　The procedure is usually done using one or two 5 mm-8 mm incisions. The occlusion may be done using bipolar electrocoagulation, mechanical devices, or tubal excision. When bipolar energy is used, at least 3cm of the isthmic portion of the tube must be completely coagulated (1). Available mechanical devices provide compression and destruction of a segment of tube. The Falope Ring utilizes a silicone rubber band placed over a segment of tube using a specialized applicator device. The Filshie Clip applies a titanium clip lined with silicone rubber to the tube. The Hulka Clip uses a spring-loaed silastic clip that is applied to the fallopian tube.

　　腹腔镜绝育术通常需要做一个或两个5mm至8mm的切口，可以用双极电凝法，放置机械设备或切除输卵管来完成。使用双极电凝法时，输卵管峡部至少要有3cm的部位需要完成凝固(1)。机械设备可以给输卵管部分位置施加压力和破坏。其中，Falope环使用特定的涂抹器装置将硅橡胶带放置在输卵管上。Flishie夹使用有硅橡胶内衬的钛夹，而Hulka则使用有加载弹簧的硅橡胶夹。

　　Alternatively, complete or partial salpingectomy may be performed by laparoscopy in order to accomplish sterilization. These techniques may be more technically difficult and require greater surgical skill to perform, but they have advantages in cases of tubal disease such as hydrosalpinx. Advanced surgical devices, such as the harmonic scalpel, or advanced bipolar devices may be used to cut and coagulate the tubes.

　　此外，可以通过腹腔镜进行输卵管部分或完全切除术以完成绝育。此类手术在技术操作上可能更难，需要有更高的手术技能，但是对有输卵管病史例如输卵管积水的患者来说更具有优势。也可以使用先进的手术设备，如谐波手术刀，或先进的双极设备来切除或凝固输卵管。

　　References

　　参考文献

　　1. Basinski CM, A review of clinical data for currently approved hysteroscopic sterilization procedures. Rev Obstet Gynecol 2010;3:101-10. (Level III)