1. Tubal Ligation (Female Sterilization) Session IIIF: The Subumbilical Minilaparotomy Procedure

2. Objectives By the end of this session, participants will be able to:
Describe the tasks and steps of the subumbilical minilaparotomy approach
Present the Objectives of this session and allow some time for questions

3. The Subumbilical Minilaparotomy Procedure
The subumbilical surgical procedure is the preferred approach for postpartum clients within one week of delivery.
However, after seven days, the involution of the uterus progresses rapidly, and the uterus is no longer accessible through a subumbilical incision.
In such cases, the client should be scheduled for a suprapubic procedure after 4–6 weeks postpartum.
The uterine elevator is not used in postpartum clients.
Explain:
We shall now go through the steps for subumblical minilaparotomy procedure.
The subumbilical surgical procedure is the preferred approach for postpartum clients within one week of delivery.
However, after 7 days(one week), the involution of the uterus progresses rapidly and the uterus is no longer accessible through a subumbilical incision.
In such cases, the client should be scheduled for a suprapubic procedure after 4–6 weeks postpartum.
The uterine elevator is not used in postpartum clients
Again for subumbilical minilaparotomy, we shall discuss the specific steps under the following Tasks and Steps:
Pre-procedure assessment steps
Preparation of the abdomen
Entering the abdomen
Accessing and delivering the tubes
Occluding the tubes
The last two steps on closing the abdomen and post-procedure tasks have been covered in the previous session on suprapubic minilaparotomy.

4. Preprocedure Assessment Steps
In the preprocedure room:
Greet the client
Review relevant medical information
Verify informed consent
Verify the client’s understanding of the procedure
Check compliance with preoperative instructions
Provide sedative and analgesic
Ask the client to empty her bladder just before entering the operating theater
Explain:
The preprocedure steps are similar to those that have been described for the suprapubic minilaparotomy procedure and include the following:
Greet the client; make her feel welcome and comfortable; ask if she has any questions.
Review the client’s chart for pertinent medical history and physical examination findings; confirm any relevant data, such as the date of delivery and the condition of her baby.
Verify that the client has made an informed decision, that she understands the permanent character of the procedure, and that she has signed the informed consent form.
Verify that the client understands the most important steps of the procedure (e.g., what local anesthesia with sedation and analgesia means, what she might feel at various times, and that she may be asked to “assist” during the procedure by taking a deep breath).
Ensure that the client has complied with the preoperative instructions. 
Give the client medication 45–60 minutes before surgery, as per the selected pain management regimen.
If available, provide surgical attire and privacy for the client to change into it.
Ask the client to empty her bladder just prior to entering the operating theater.
Note: Make sure that there are arrangement to take care of the client’s baby as she undergoes the procedure.

5. Pre-procedure Assessment Steps – In the operating room
Accompany the client into the operating theater.
Help the client onto the operating table,
Continue to maintain constant communication.
Ensure that needed equipment, instruments, and supplies are available in the operating theater.
Monitor the client’s vital signs
The client is then escorted to the operating room or procedure area. The next step is to:
Assist the client onto the operating table, and help her to lie in the dorso-supine position. Just as was with the suprapubic minilaparotomy procedure
Continue to maintain constant communication with the client throughout the procedure.
Ensure that the needed equipment, instruments, and supplies are available in the operating theater. Note: There is no need to set up the uterine elevator insertion tray, since it is not needed for subumbilical minilaparotomy procedures.
All team members are to remain available and attentive throughout the procedure.
Monitor the client’s vital signs (blood pressure, pulse, and respiratory rate) just prior to surgery, and continue to do so at 10–15 minutes intervals during the procedure.

6. Positioning the Client for Subumbilical Minilaparotomy: Assessing the Height of the Uterine Fundus
Explain:
Once the client has been positioned on the operating table, the surgeon assesses the height of the uterine fundus to determine the location of the incision.
Note: For subumbilical minilaparotomy procedure, the incision is in the subumbilical area at least 1 to 2 cm. below the umbilicus.
Source Engenderhealth 2015

7. Preparing the Client’s Abdominal Area before a Subumbilical Minilaparotomy
a) Cleansing the abdomen
b) Postpartum client draped
Explain:
The preparation of the abdominal area, where the incision will be made, follows the same steps given earlier in the description of the suprapubic minilaparotomy procedure. The primary difference is that the area to prepare is the subumbilical area.
In summary, the steps are:
Surgical hand scrub and setting up instruments and related supplies
Cleansing the abdominal wall in the subumbilical area
Draping the abdomen to establish a sterile field
Infiltration of the incision site with local anesthetic

8. Preparing the Abdomen: Infiltration with Local Anesthetic
Explain:
The steps for infiltration with the local anesthetic are similar to those described earlier. However, since the abdominal wall in the subumbilical area is very thin in the midline and there is marked diastasis of the rectus, there is no intervening rectus muscle under the umbilicus following delivery, and the needle should not be inserted too deeply.
The total amount of anesthesia required also will be less, around 6–8 cc of anesthetics solution.
Wait at least two minutes for the anesthetic to take effect.
Continue with communicating with the client.
Confirm that the local anesthetic has taken effect before making the incision.

9. Entering the Abdomen a) Skin incision b) Visualizing the fascia
Explain:
Incise the skin transversely just below the umbilicus, 2–3 cm long, without including the subcutaneous tissue.
With an Allis forceps or a hemostatic forceps, bluntly dissect the subcutaneous tissues gently and precisely, to minimize tissue trauma and bleeding; secure and/or ligate any bleeders.
Expose the fascia and grasp it with two Allis forceps, in the middle of the incision.
Note: Because the peritoneum is sometimes close to and almost adherent to the fascia just below the umbilicus, care must be taken while opening the thin layers, so that the bowel or omentum is not accidentally incised. It is useful before grasping the fascia to ask the client to breathe in; this allows the bowels to move out of the area.

10. Entering the Abdomen (cont.)
c) Opening the fascia
d) Opening the peritoneum
Explain
Make a small transverse incision to open the fascia and grasp the edges with the Allis forceps. Then use the Mayo’s scissors to carefully extend the transverse incision to open the fascia slightly beyond the edges of the skin incision.
Gently position the retractors inside the incision, for better visualization.
Note: Due to diastasis of the rectus, there is no intervening rectus muscle under the umbilicus, and the fascia and the peritoneum usually adhere together, making them one layer. Therefore, a layer-by-layer dissection is usually unnecessary, albeit the process requires careful attention.
If the peritoneum is not adhered to the fascia and, when the retractors are replaced, it is visible and can be opened
Grasp and elevate the peritoneum and look at or feel a fold of tissue to confirm that it is the translucent peritoneum and that the abdominal contents are not adhering to it.
With peritoneum elevated, make a small opening with scissors, checking underlying structures to ensure that the bowel or omentum is not accidentally incised.

11. Entering the Abdomen (cont.)
Explain:
After opening the peritoneum, the next step is to place the retractors inside the peritoneum and gently open the peritoneum further, to maximize the visualization of the abdomen.

12. Accessing the Fallopian Tubes
(a) Pushing the uterus toward the
opposite side of the tube being accessed
b) Moving the incision to be above the tube being accessed
Explain:
As described for the suprapubic minilaparotomy technique, from this point onwards the incision should be kept open by gently maintaining traction on the retractors, while elevating the abdominal wall with the retractors in the horizontal position, using gentle traction and not digging them in.
The steps for accessing the tubes are as follows:
Use the retractors to gently move the abdominal opening over the tube, pulling down and laterally, and/or move the tube to the incision site by gently pressing against the side of the abdomen and pushing the uterus medially.
Move the incision over each tube carefully; avoid trauma to the engorged blood vessels and the edematous and friable tubes common in postpartum clients.

13. Irrigation of the Fallopian Tubes
Explain:
Once one of the tubes have been exposed, drip 2–3 ml of 1% lidocaine on the fallopian tube through the incision. Expose the other tube and drip 2–3 ml of 1% lidocaine. Absorption of the local anesthetic is high, and onset of anesthetic effects is almost immediate.

14. Using the Tubal Hook to Retrieve the Tube
Explain;
If one can visualize the tubes, then use the baby Babcock to grasp the tube, one may use the tubal hook if the tubes are not visible in the same way as we had described earlier under the suprapubic procedure.
The steps are:
With the uterus pushed medially and the incision placed as close to the cornua as possible, gently slide the tubal hook around one side of the uterus toward the anterior, lower part of the uterus and then pull the tubal hook horizontally and out through the incision. This maneuver should hook the tube and sweep it forward to the incision.
Maintain communication with the client throughout these steps.

15. Grasping and Identifying the Tube
Grasping the tube with a
baby Babcock forceps
(b) Moving the tube to the opening
Explain
Use the baby Babcock forceps to gasp and retrieve the tube through the incision.
One may use the nontoothed dissecting forceps or the another baby Babcock to expose the fimbria to confirm that it is the fallopian tube.

16. Grasping and Identifying the Tube (cont)
(c) Pulling the tube out and visualizing the fimbria
Explain:
Surgeon must be gentle when handling the fallopian tubes as the blood vessels are engorged and the tube is edematous and friable.

17. Confirming the Fallopian Tube
Explain
Image shows the fimbrial end of the fallopian tube exposed

18. Occluding the Tubes: Ligation and Excision
Explain:
The technique for inspecting, ligating, and excising the fallopian tube is similar to what was described for the suprapubic minilaparotomy procedure.
The modified Pomeroy technique is also the tubal occlusion technique recommended for subumbilical minilaparotomy procedures.
Confirm hemostasis before dropping the tubal stump back into the peritoneal cavity.
As the tube of the postpartum client may be enlarged and edematous, with engorged vessels, one needs to be very careful in manipulating them.
Occlude the second tube and confirm hemostasis.