Then what technique do you prefer?

We dont have option of any technique in India. I suggest fimbriectomy should be done after discussing with patient and husband, in these situations.

Pomeroy's technic is best for sterilization, I prefer this over the Fimbriectomy. There is  0.6 percent technical failure for Pomeroy's.

This is my opinion. Presently I am working in a center where 22,000 deliveries are carried out in a year. We do Pomeroy,s technique in post CS cases. Our follow up result is satisfactory. Failure rate depends on the skill of the surgeon and the suture material used to a great extent. We use catgut. You don't have to be worried. It is always better. There is no method with 100% success rate (I am not talking about frimbectomy). 

Failure rate  is depended on skill of operator.However using Plain 2-0 catgut is best.

I think I am discussing something special here, not routine. Please focus o the issue at hand.

This is not a special issue.

In most cases, female sterilisation is more than 99% effective, and only one woman in 200 will become pregnant in her lifetime after having it done. The United States Collaborative Review of Sterilization has examined the failure rate of female sterilization. Rates vary according to the procedure performed. Overall, about 5 women out of 1,000 women who have the procedure become pregnant after one year. This is likely caused by an incomplete closure of the tubes. If pregnancy does occur after the procedure, there is an increased risk for an ectopic pregnancy. 

Tubal occlusion may be performed using the modified Pomeroy method, the Parkland method, or, in limited cases, the Filshie clip device.

Modified Pomeroy method: The fallopian tube is then followed back to the mid-isthmic portion, and a loop of tube is elevated with the Babcock clamp. The base of the loop is ligated with 2 ties of 2-0 plain gut suture, holding one suture long with a hemostat to avoid retraction of the tube back into the abdomen after transection

Parkland method In some circumstances, tubal occlusion by the Parkland method may be appropriate, usually when there is excessive tension on the loop of tube that makes it more likely that the cut ends would slip out of the suture once excised. The fallopian tube is identified and grasped in the mid-isthmic portion as above. An incision is made in an avascular window of the mesosalpinx below the tube with Bovie cautery or Metzenbaum scissors. A 1-2 cm portion of tube is then ligated proximately and distally with chromic suture, and the tubal portion is excised with Metzenbaum scissors. Again, one suture should be held long until hemostasis is assured and the tubal ostia identified.

Filshie clip method. After proper identification of the fallopian tube as above, the tube is followed back to approximately 1-2 cm from the cornua. Using the Filshie applicator designed for laparotomy, the clip is placed in the applicator and the jaws of the clip are opened and advanced around the tube at an angle perpendicular to the tube until the lower jaw of the clip is seen through the mesosalpinx, assuring the entire tube is within the clip. The clip is then slowly applied to the tube using gentle but firm pressure on the finger bar until the stop is reached. Pressure is then slowly released, leaving the clip in place on the fallopian tube. Caution must be taken to avoid lacerating the tube or tearing the mesosalpinx. Next, attention is turned to the remaining side, and the above steps are repeated. Of note, especially edematous tubes are not appropriate for this method..

Uchida Technique. In this method, about 5 cm of the muscular tube towards the uterine end is cut off but the fimbriated end is left untouched. For puerperal ligation, this procedure is  modified by performing a fimbriectomy (removal of the fimbrial end of the tube). In essence, this is a salpingectomy (removal of the fallopian tube) since the fimbria, along with a large portion of the tube, is resected. The low failure rate achieved with this technique is due to such a large segment of the tube being removed.

Irving Technique The tube is lifted and cut. The cut proximal end (uterine end) of the tube is buried in a tunnel in the anterior uterine wall. This technique is designed to be used along with a Cesarean section.

Failure rates should be discussed with any patient considering postpartum tubal sterilization. One third of tubal failures will be ectopic pregnancies. Of all female sterilization procedures, postpartum partial salpingectomy has the lowest cumulative pregnancy rates: 6.3 per 1000 procedures at 5 years and 7.5 per 1000 at 10 years.

The advantages of Pommeroy are that is easy and quick to performe and highly effective. Iys acceptance is quite high. Fimbriectomy does not seem to have advantages due the availability  of easier and moe effective procedures.

Oh dear, Fimbriectomy is not critical.

I am trying to discuss sterilization in following cases

1. Previous 3/4 cesarean section

2. Previous rupture uterus and scar dehiscence this time

3. Scar dehiscence without labour in previous one scar

I am not trying to discuss routine female sterilization

Hi

I am not sure if the attached file will help - it is an evidence based guideline for male and female sterilization. Modified Pommeroy is what we use in Oxford in the vast majority of cases.  I have worked in units which use the longer Filshie clips also.

Of course these guidelines are just guidelines and the clinical situation at the time will need the clinician to make a judgement as to either a) what the best course of action is and b) what possible courses of action are available (e.g. dense adhesions, clinical scenario).

With the knowledge that most ovarian cancers originate from the fallopian tube (mostly the fimbria), I suspect that the standard for sterilisation may indeed change from segmental resection of the isthmus to fimbriectomy or salpingectomy in the future.

        I think in future we the daily workers in obstetric unit will be in problem due the policy made by you. It is just like the technique that involving TAH which will delete all the risk factors women have in their lifetime. There is a great difference between the policy makers and the practicing doctors. We have to believe the evidence if not conflicted. We should not be puzzled until strong evidences are available. Personnel opinion could be helpful or dangerous.   

           If there is dense adhesion or difficulty in successful surgery, then in Indian society, vasectomy could be an option. The main purpose in a case of repeat CS or rupture uterus is to decrease maternal morbidity.

           No one is satisfied in this topic. We are  escaping from the topic and forgetting the basic clinical protocol. Now, I think, I must be questioned that if vasectomy, then what would be the female if she would have second marriage. It is funny. We are thinking very deeply. My opinion may be wrong as I am working in a busy place and we do not think deeply. We are not afraid, if any body, then search the follow up reports of the similar cases so that we could get some evidence at least which already I have. 

Salpingectomy or fimbriectomy should be considered instead of interruption of the fallopian tube for sterilization in light of the strong evidence that serous cancer of ovary originates in the fimbrial portion of the fallopian tube. Ref 

Kamran MW, Vaughan D, Crosby D, Wahab NA, Saadeh FA, Gleeson N. Opportunistic and interventional salpingectomy in women at risk – a strategy for preventing pelvic serous cancer (PSC). European Journal of Obstetrics, Gynecology & Reproductive Biology 2013; 170:251-4.  doi:10.1016/j.ejogrb.2013.06.030

This is not true. This is misinterpretation. I read the article. Topic is during a CS with some critical factors, whether tubectomy could be done or not. Women having high risk for serous carcinoma could not be fully immune to it. There is no evidence that TAH with tubectomy  could decrease the incidence of carcinoma among those women. Do not bend the topic. Above reference is not a RCT. Its simply the personal preference of gynaecologists and obstetricians. 

Salphingectomy as a method of sterilization in select cases, which can prevent ovarian cancer also. Excellent thought. In India because of population, sterilization is priority health programme. TL related complications are intensively scrutinized and mostly by specialist from other field of medicine or by non medics. Supreme Court of India has directed all health professionals not to deviate from the guidelines set and it says only modyfied pomeroys. There is no mention of special clinical setting or situations where in we can decide the mode of sterilization.

Vasectomy is not the option here, as it not guaranteed that male will go and perform it. Why we should ask any other person to undergo surgery when we have open abdomen in front of us and patient wants sterilization.So there is no point in discussing vasectomy.

As far as salphingectomy is concerned in such cases, WHY NOT. It is the most viable option. Even if there is minimal evidence in support of this procedure preventing any major illness, why not perform it when u r not doing any extra special surgery for this (abdomen is already opened).

The evidence is in favour of  salpingectomy for female sterilization at abdominal hysterectomy for benign disease (ABH), vaginal benign hysterectomy (VBH) and electively for women with BRCA mutations. You and me not the authority to change the the protocol with limited evidence. Salpingectomy should not be done during CS in selected cases. 

Pomeroy's method is justified in all cases. You don't have any evidence against it.

In these cases you proposed

1. Previous 3/4 cesarean section

2. Previous rupture uterus and scar dehiscence this time

3. Scar dehiscence without labour in previous one scar

I would rather use Salpingectomy. IIs easier and safer.

If your laws reinforce you for only to do pomeroy type tubal ligation, you can add cauterization to it. you can cauterize cut edges of tubes after pomeroy procedure. This combination might decrease risk of failure after tubal ligation.

Cauterization or crushing the tubes is not allowed

Consider excising fallopian tubes or at least the fimbrial end to prevent serous cancers of ovary and peritoneum

I think Dr. you are making it a game. 

You said, "We dont have option of any technique in India. I suggest fimbriectomy should be done after discussing with patient and husband, in these situations."

Later you said,"Cauterization or crushing the tubes is not allowed."

Indian Govt rule does not allow fimbriectomy, or cauterisation or crushing tube. But my opinion is that fimbriectomy should be done in select cases or situations like I mentioned in the question. We r not discussing female sterilization in routine or normal situations here.

Dear Dr.

 Your said, "As far as salphingectomy is concerned in such cases, WHY NOT. It is the most viable option. Even if there is minimal evidence in support of this procedure preventing any major illness, why not perform it when u r not doing any extra special surgery for this (abdomen is already opened)."

 Now, Why don't you include this in your opinion. Now, you are agreed to the followings

Enough discussion, this is the time to know which option has come out for Indian women in the following situations.

 The review committee appointed by the honorable Supreme Court is flexible. They reviewed the technique exclusively done in India, and made a guideline for practicing doctors. This does not restrict to make a new study proposal in a medical college, rather it would be welcomed. If you argue on this topic, you might get the permission.