| Excerpt from The WHO Reproductive Health Library | Published by Update Software Ltd. |
The primary purpose of this review is to compare operative morbidity and mortality associated with three alternative surgical approaches (minilaparotomy, laparoscopy, and culdoscopy) for entering the abdominal cavity to perform tubal sterilization. As the authors note, the surgical approach to entering the abdominal cavity is but one major determinant of the safety of tubal sterilization – others include the technique of anaesthesia and the method of tubal occlusion. This review concludes that major morbidity seems to be a rare outcome when minilaparotomy and laparoscopy are used as the surgical approach and that there is no difference in risk of major morbidity between the two groups, although the included studies had little power to detect potentially important differences. Culdoscopy was associated with more major complications than minilaparotomy and more minor complications than laparoscopy. The choice between minilaparotomy and laparoscopy can be made on preferences, but culdoscopy is not recommended.
The authors appropriately searched the literature using the search strategy of the Cochrane Collaboration to identify all randomized controlled trials comparing minilaparotomy, laparoscopy, or culdoscopy for tubal sterilization. The inclusion criteria for the studies were appropriate. The studies in the review compared three methods of abdominal entry without regard to the technique of anaesthesia or the method of tubal occlusion, both of which are key determinants of safety of sterilization. The fact that those two determinants were not comparable is one of the major methodological limitations of the studies available to the authors for review. The second limitation is that the trials comparing minilaparotomy with laparoscopy, the single trial comparing minilaparotomy and culdoscopy, and the single trial evaluating minilaparotomy, laparoscopy, and culdoscopy, had far too few subjects to evaluate potentially meaningful differences in risks of mortality and major morbidity. The authors note these limitations in the review. Most of the data for the key comparison between minilaparotomy and laparoscopy are from a single trial conducted by WHO in seven developing country centres.
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