#Grand Rounds

Is Opportunistic Salpingectomy an Option for Women Desiring Sterilization at the Time of Cesarean Section?

BACKGROUND AND PURPOSE:

Previous research strongly suggests that most ovarian cancer actually begins in the fallopian tube (see ‘Related ObG Topics’, below)
- To prevent ovarian cancer, ACOG, SGO, and Society of Gynecologic Oncology of Canada recommend a discussion with patients who are undergoing routine gynecologic surgery with ovarian conservation to consider opportunistic salpingectomy
- Salpingectomy during laparoscopic and open hysterectomy adds minimal time with no additional complications
Subramaniam et al. (Obstetrics & Gynecology, 2018) compared the feasibility of salpingectomy vs standard bilateral tubal ligation in women requesting permanent contraception following cesarean delivery

Randomized controlled trial (RCT)
All women delivering at the center were eligible to participate
Exclusion criteria
- Inability to give informed consent | Maternal age <25 years | Fetal death | Fetal anomalies, | Immune-compromising disease | Chronic steroid or immunosuppressive therapy | Anticoagulation therapy | Previous tubal surgery | BRCA mutation carrier
Women were ≥35 weeks desiring permanent sterilization at the time of cesarean delivery (not emergent surgery)
Patients were randomized to the following groups
- Bilateral salpingectomy
- Bilateral tubal ligation
Primary feasibility outcomes
- Total operative time (skin incision to skin closure)
- Bilateral completion of the randomized procedure
Secondary outcomes
- Clinically estimated blood loss
- Surgical complications up to 6 weeks postpartum
Calculations determined 40 patients in each arm would provide >80% power to identify a 10 minute difference for total operative time (baseline of 50 minutes used)

80 women were randomized
- 40 women received salpingectomy | 40 received bilateral tubal ligation
Completion rates
- 27 bilateral salpingectomies and 38 bilateral tubal ligations were completed successfully (68% vs 95%, P= .002)
Total operative time
- On average, 15 minutes longer for salpingectomies (75.4±29.1 vs 60.0±23.3 minutes, P=.004)
Blood loss
- Estimated by surgeon to be greater in the salpingectomy group
- No difference in clinical EBL and change in hematocrit
Safety outcomes were similar for both groups with no significant differences in the following
- Rates of intraoperative complications | Postoperative complications | Blood transfusion | ICU admission | Pain score | Readmissions | Reoperations
Hospital stay was shorter with salpingectomy compared with the bilateral tubal ligation (3.4±0.6 days vs 3.9±1.3 days, P=.018)

Authors state that the results support consideration of opportunistic salpingectomy in women desiring permanent sterilization at the time of cesarean section
- In this study, on average, 15 minutes was added by performing salpingectomy instead of bilateral tubal ligation
- The procedure was completed in approximately 2/3 of women
While this study only included 80 patients, it was powered for primary outcomes, but further research would be required to confirm secondary findings
Note: In the same issue of the Green Journal, Garcia et al., (Obstetrics & Gynecology) undertook an RCT (noninferiority) also comparing salpingectomy to standard tubal ligation at time of cesarean section with the following results
- Salpingectomy vs tubal ligation did not add additional time (mean difference of 30 seconds)
- 95% completion rate
Garcia et al., used the Covidien small jaw LigaSure device unlike the Subramaniam et al. group who used more traditional surgical instruments, which may account for the difference in findings

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