Isthmic and Mid-Tubal Obstruction
Tubal surgery to correct mid-segment occlusions was described in 1910 by Christian and Sanderson. The procedure gained notoriety at mid-century, however, as a method to reverse tubal ligations. Between 1948 and 1968, nine publications on the reversal of sterilizations were described.2 The pregnancy rates ranged from 6% to a remarkable 30%. The techniques were macroscopic and used sutures of catgut and silk. Initial and isolated descriptions of microsurgical techniques can be traced to the early 1950s when Hellman described the role of fine sutures, needles and atraumatic technique and hinted at magnification in tubal surgery as a means to improve outcome.3 Tubal anastomoses became significantly improved in the mid-1960s with the use of magnification instruments, both microscopes and operative loops, and with the evolution of microsurgical techniques. Microsurgery became the standard for repair of any mid-tubal or isthmic obstruction. This technique has yielded significantly higher pregnancy rates whether for the reversal of a tubal ligation or management of salpingitis isthmica nodosa or congenital isthmic absence.4 This chapter describes the circumstances under which tubal anastomosis is most effective, discusses the controversy surrounding the management of salpingitis isthmica nodosa (SIN) and describes the technique of microsurgical anastomosis.