Literature Review
FERTILITY AND STERILITY
Sterilization Failures with Bipolar Tubal Cautery
Reference is made to the article by Ayers1 "Sterilization failures with bipolar tubal cautery," and the letters from Soderstrom,2 Seller," Barnes,4 Kleppinger,5 and Ayers.6
Since none of the authors critically reviewed the coagulation to be accomplished, I feel obligated to point this out.
It is a misconception to use bipolar coagulation to destroy the cellular life of the fallopian tube and let the course of postsurgical developments seal the tube. Bipolar coagulation accomplishen immediate and total sealing of the fallopian tube. If this is not done, the method was inappropriately applied.
Many laparoscopists who utilize the unipolar technique find it difficult to change over to the bipolar approach correctly, because the subjective and objective observations significantly differ, as do voltage and temperature. Since the bipolar method operates at a relatively low voltage and temperature, the duration of the application must be extended significantly. If Ayers'1 technique, as he describes it, is utilized, the outer surface of the fallopian tube may be destroyed and even the cellular life beneath. But the duration of the current application must be too short, and thus the lumen is not closed at the moment of coagulation. Soderstrom2 and Kleppinger5 insist on using the complete system as produced by the Richard Wolf Medical Instrument Company, Rosemont, IL, which includes the Kleppinger forceps. An objective analysis will tell you that practically all bipolar forceps on the market, when used with a proper bipolar generator, employed correctly, will give equal results. Having been involved in laparoscopic sterilization technology from its inception and having introduced many innovations, including the bipolar generator for laparoscopy, we can speak with authority. An analogy between bipolar tubular sterilization and bipolar hemostasis can be made. Even though the size of the vessel differs--as does the size of the forceps and current requirements-there is a similarity. An artery, when sealed with bipolar forceps, must not only be sealed immediately, but must withstand the blood pressure until permanent sealing through the healing process is accomplished. Although the fallopian tube is bigger, it can be firmly sealed at the time of application.
This clarification will help to prevent undesired complications during bipolar tubular sterilization.
Karl Hausner President, ELMED Incorporated 60 West Fay Avenue Addison, Illinois 60101 March 24, 1986
REFERENCES
1. Ayers JWT. Johnson RS. Ansbacher R. Menon M. LaFerla JJ. Roberts JA: Sterilization failures with bipolar tubal cautery. Fertil Steril 42:526, 1984
2. Soderstrom RM: Bipolar tubal cautery failures. (Letter) Fertil Steril 43:943, 1985
3. Seiler JS: Bipolar tubal cautery failures. (Letter) Fertil Steril 43:943, 1985
4. Barnes AD: Bipolar tubal cautery failures. (Letter) Fertil Steril 43:945, 1985
5. Kleppinger RK: Bipolar tubal cautery failures. (Letter) Fertil Steril 43:946, 1985
6. Ayers JWT: Bipolar Tubal cautery failures. (Letter) 43:944, 1985
Mr. Hausner's remarks are the last in a series of comments regarding the article by Ayers et al.1on "Sterilization failures with bipolar tubal cautery," or, alternatively, "Bipolar tubal coagulation (BTC)." Individual experiences are, by definition, limited, but readers should benefit from the aggregate letters of Drs. Soderstrom, Seller, Barnes, Kleppinger, and Mr. Hausner.
Paul G. McDonough, M.D.
REFERENCE
1. Ayers JWT. Johnson RS. Ansbacher R. Menon M, LaFerla JJ, Roberts JA: Sterilization failures with bipolar tubal cautery. Fertil Steril 42:526, 1984
Ferlilily and Sterility July, 1986
Mr. Hausner, a prominent electrical engineer, is correct. After our study was accepted for publication, new information provided by several manufacturers prompted a new study, which is close to completion. We have "dissected" the Kleppinger system and found there is no output compensation system--a claim inferred from past conversations with the Richard R. Wolf Company. In simple terms, the Kleppinger system supplies an unmodulated (cutting) waveform at a peak voltage of 100 volts and has a power output of 20 watts against 100 ohms. Because we were unaware of these characteristics unique to the Kleppinger bipolar generator, our original study compared the other systems in either the "blend" or "coagulation" mode. The power output of electrogenerators in the coagulation mode may be as low as 25% of the power output in the cutting mode, assuming the physician uses the same dial setting. To complicate matters further, the capacitance phenomenon, described by Mr. Hausner, decreases the available power delivered to the tissue as the capacitance measurement in pico Farads (pF) increases. Tn our current study, when the Kleppinger bipolar forceps are connected to a Valley Lab SSE2-L generator and the output power is set at 20 watts in the cutting mode, the fallopian tube is completely coagulated!
Mr. Hausner asked why we could not connect the Wolf generator to other bipolar forceps. The Richard Wolf Company does not supply adapters for that purpose. I am sure, if one were available, that the other forceps would perform well. The use of a current flow indicator reassures the surgeon that the maximum amount of available power has been delivered to the tissue. But it does not guarantee complete coagulation. A musical current flow indicator as suggested by Jaraslav Hulka, MD, is a creative idea and one of merit.
As this story has unfolded, our confusion has become apparent. Though the answers are more clear, the wisdom of our original conclusion rings true "... each system should be analyzed in test situations as described (coagulate human tubes in patients undergoing hysterectomy for benign reasons, and examine the coagulated specimen in a serial histologic fashion) before they are used freely on patients."
Richard M. Soderstrom, MD Reproductive Health Specialists, PS, 726 Broadway, Suite 305 Seattle, WA 98122
My sincere apologies for not writing earlier concerning your beautiful bipolar current generator [LBC 50] . With the holiday season I have not had enough patients until recently to evaluate the instrument.
The "automatic setting" which you have provided is quite satisfactory. It is not too long a duration to expect the clinician to wait. In contrast, I set the manual on 3, 4, and 5. Setting on 3 resulted in a very long duration, setting on 5 resulted in a very short and alarmingly rapid coagulation. I believe the automatic setting is at 25 watts, which is a nice combination.
The audible signals are extremely helpful in knowing when the endpont for coagulation has been reached. For bipolar of the fallopian tube (for use with the bipolar forceps you supplied)I would even suggest eliminating the options the physician has of dial setting, and offer only the automatic (although this may not be an attractive option from the marketing viewpoint). This would eliminate the error which creeps into operating rooms where dials are often mis-set.
I would prefer to use your forceps design with the generator because of the ease of knowing when the endpoint for coagulation has been reached, thanks to the clear audible signal. The configuration of the forceps also allows a firm grasp of the tube, and thorough coagulation without the risk of contact between the jaws stopping the electric flow through tissue. In these two areas, it is a clear improvement over the original Kleppinger concept.
I hope my comments have been helpful and not too late in the development process. I would very much like to continue using the equipment you provided.
Sincerely,
J.E Hulka, M.D. Professor Obstetrics and Gynecology
Obstetrics & Gynecology VOL. 70, NO. 5. NOVEMBER 1987