TEALE FENNING

shama · Joined: 17 May 2007 Posts: 44 Location: Malaysia

Why high failure with Filshie Clips? Whats so different about them causing failure? how to minimise it?

Xerxes I · Posted: Tue Jul 29, 2008 10:49 am Post subject:

Hi Shama, I don't think Filshie's failure is particularly high. 2-3 in 1000 over 10 years is not bad. Although the NICE guidelines say that when doing sterillisation postpartum using a mini laparotomy, modified Pomeroy may be preferrable to Filshie. So may I rephrase your question:

Discuss the ways to minimise litigation associated with laparoscopic sterilisation using Filshie clips.

Sterilisation accounts for a significant proportion of litigation in gynaecologic practice.

Patient selection and counselling is of utmost important. The risks associated with sterilisation should be explained in full and clearly documented in the notes. it should be made clea that other methods have been discussed and were not acceptable to the woman and the fact that the woman has been made aware of complications associated with laparoscopy, including bowel injyry, vascular injury and 1 in 12500 mortality. This visit should take place at least one week prior to the procedure and sterilisation as part of an emergency procedure should not be offered. Written information should be provided quoting the failure rates (around 1 in 200) and the fact that the procedure should be considered as irreversible as reversal has low success rates and not availble in NHS.
It is preferrrable to have the partner present during the cocnsultation, however, the partner's consent is not necessary.

On the day of the operation, consent should be checked and confirmed with the patient and a pregnancy test performed to rule out current pregnancy.

Safe laparoscopic entry should be performed and tubes clearly visualised and followed to their fimbrial end. Mistaking the round ligament for the tube is a common reason for failure.

The clips should be applied in the isthmic segment making sure it covers the whole diameter of the tube, it should then be firmly applied by squeezing the applicator for three seconds. Details of the procedure should be documente clearly preferably providing laparoscopic pictures.

The instruments, in specific the filshe applicator shuld be checked regularly. Training is of utmost important here. Junior docctors should recieve appropriate training and the results and complications should be monitored by audits.

etc etc

shama · Joined: 17 May 2007 Posts: 44 Location: Malaysia

Thanks Xerex.The question was like this:

"Discuss the factors contributing to failure of sterilization with the use of filshie clips.What steps can be used to reduce these risks?"

Good to get your answer. Thanks for IOL answer also.

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

OK guys, now attempt this essay, it's a different take on Xerxes' question, it's an easy one and my pass mark for this will be at least a 12.

31 year old woman with 2 children, 5 and 1 years old, is referred by the GP, requesting sterilisation.

A. discuss the salient points in counseling her. -- 6 marks

B. what other options will you offer her? -- 4 marks

C. discuss types of sterilisation -- 5 marks

D. how will you minimize sterilization failure? -- 5 marks

have fun
r
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

Nick Raine-Fenning · Posted: Sun Aug 17, 2008 11:06 am Post subject:

Nice question Raj and quite topical as well.

Maud · Joined: 11 Oct 2007 Posts: 73 Location: Bristol

31 year old woman with 2 children, 5 and 1 years old, is referred by the GP, requesting sterilisation.

A. discuss the salient points in counseling her. -- 6 marks

Sterilisation accounts for high rates of litigation and counselling women about failure rates, irreversibility and alternatives may reduce this.

Sterilisation should be regarded as an irreversible procedure associated with a risk of regret. Reversal can only be attempted privately, is expensive and succes rates are not high.

Surgical risks are related to the laparoscopic procedure and are infection, haemorrhage with need for blood transfusion and damage to the bowel, bladder or blood vessel requiring laparotomy. These risks are higher if there is a history of abdominal surgery. The general anaesthetic required to perform the procedure also carries risks. The patient will have abdominal and shoulder tip pain and though it is performed as a day case procedure, she will need a few days to recover.

Sterilisation fails in 1 out of 200 procedures. This can be early failure due to incorrect clip application or late failure, many years later, due to re-anastomosis. There is an increased risk of ectopic pregancy, which can be life threatening, if pregnancy occurs. There are alternative methods of contraception with lower failure rates that are less invasive and reversible.

If the woman is currently using hormonal contraception, her cycle and periods may change and become heavier as a consequence of stopping this.

B. what other options will you offer her? -- 4 marks

Long-acting reversible contraception has similar or lower failure rates.

An IUCD is reliable, has no hormonal side-effects and does not need a surgical procedure to insert it. It needs to be changed every 5 or 8 years, according to the liscence, but it may be left in situ until after the menopause once the woman is over 40 years of age.

The Mirena IUS is reliable and may also treat heavy periods. Long-term it reduces the risk of getting endometrial cancer. It needs to be changed every 5 years, may cause irregular bleeding and systemic side-effects are rare.

Vasectomy is also irreversible, but surgical risks are lower than sterilisation, it does not require a G.A. and the failure rate is much lower at 1 in 2000.

Implanon is the most reliable form of contraception, with only a few cases of failure reported worldwide. It does, however, have a high risk of irregular bleeding, which is unpredictable and may be unacceptable in up to 20 % of women.

The combined pill is safe to take until the menopause, providing there are no contraindications. The progesterone only pill, including Cerazette, is an alternative. They do, however, require daily compliance.

C. discuss types of sterilisation -- 5 marks

Laparoscopy has lower post-operative pain and recovery rates than mini-laparotomy. Filshie clips are attached the the fallopian tubes under direct visualisation.
Alternatively, during a mini-laparotomy or during an elective caesarean section, tuber can be clamped, cut and tied, essentially performing a partial salpingectomy.

D. how will you minimize sterilization failure? -- 5 marks

Adequate patient selection, avoiding patients with morbid obesity or previous laparotomies, ensure laparoscopy can be done with minimal risks.
Operators should be trained, experienced or otherwise adequately supervised.
A pregnancy test should be performed first and the woman instructed to continue any hormonal contraception for at least another week. She should be asked whether she would accept a mini-laparotomy, should laparoscopy fail.
The Fallopian tubes should be identified with fimbrial ends and the clip applied in the isthmic part under direct visualisation, squeezing for 5 seconds or until blanching occurs. Care should be taken not to mistake the round ligament for tube. A picture can be taken and saved in the patient's notes, along with adequate documentation.

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

good first attempt maud

i was thinking of the following in addition -

Stem A

risks --
add PID where you say risk higher with abd surgery
denovo menorrhagia ?? - discuss
chronic pelvic pain
percentage for bowel / bladder damage

info leaflets
second appointment / second opinion
can change mind anytime, consultation or consent form signing not binding
is only 31 yrs old, is it ok to steri??? life situation may change - discuss

need for laparotomy if not possible thru scope

needs few days to recover -- how many?
sick note

Stem B

give mirena failure rate.

Stem C

you need to attempt this again. it's for 5 marks.

Stem D

reconfirm patient identity and consent

use of double clips / diathermy / salpingectomy

confirm entire tube circumference within the jaws of the clip

no evidence in routine intraop dye test -- but if in doubt do one to be safe

schedule op if possible at the end of a period

if any doubts about luteal phase pregnancy offer / consent for combined D&C

ok give stem c a try again, i will post my points for it later.

r
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

Maud · Joined: 11 Oct 2007 Posts: 73 Location: Bristol

C. discuss types of sterilisation -- 5 marks

Sterilisation can be done via laparoscopy or laparotomy. Laparoscopy is quicker and has less minor morbidity. There is no difference in major morbidity.
Filshie clips can be attached to the ithmic part of the Fallopian tube. This is quick, technically easy and reliable.
The Polmeroy technique uses an absorbably suture to tie the base of the loop of tube near the mid-portion and cutting off the top of the loop. It destroys 3-4 cm of the tube, making reversal more difficult.
Diathermy should not be used as a primary method, because it carries an increased risk of ectopic pregnancy. Bipolar is safer and preferable to monopolar.
Culdoscopy should not be used, because it is associated with unacceptably high incidence of technical difficulty and major complications.
Hysteroscopic sterilisation is a new technique, that can be done under local anaesthetic. It is not effective straight away and tubal ligation needs to be checked with a hysterosalpingogram 3 months after the procedure. It is completely irreversible and may be preferable in patients in whom laparoscopic surgery involves higher risks.

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

well done with stem C- the only other points i had was a mention of

intra lscs steri / steri with TOP - higher failure rate

mention the concept of interval sterilisation

where you mention Pomeroy's, also mention Irwine's and Oxford technique ( no details required, only names to show that you know there are other ways to do minilap steri than just Pomeroy's)

r
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

manoj · Joined: 22 Jun 2008 Posts: 7

Is there evidence to suggest higher failure rates for sterilisation with LUSCS and TOP and if so what is the quoted rates?

Maud · Joined: 11 Oct 2007 Posts: 73 Location: Bristol

Yes, there is, but I don't know what the rates are. Also higher rate of regret in both situations.