Laparoscopic Articles from World Laparoscopy Hospital

Dr. Basima Shamkhi Jabar Al. Ghazal
M.B.CH.B, D.G.O, FICOG
Diploma in Minimal Access Surgery

Abstract

Introduction

Tubal sterilization is an operation which blocks the tubes carrying a woman’s egg to her uterus. Worldwide, it is the most commonly used method of birth control. Often the operation is performed through a laparoscope. This instrument is inserted through a small incision in the abdomen. The tubes are visualized so the surgeon can place rings on, or apply clips to, the tubes or burn the tubes .

After a tubal sterilization the egg cannot reach the uterus, and the man’s sperm cannot reach the egg. This operation should be considered permanent. You must be certain you do not want t to deliver more children and will not change your mind .Complete information about this surgical procedure is available from your clinician. In 1994, the WHO in Geneva convened current investigators in sterilization to assess research developments 1 . The following are excerpts from the summary report as concerns laparoscopy:

“The most appropriate method of female sterilization in a particular family planning programme often is determined by local situations and constraints. The ideal female sterilization method would involve a simple, easily learned, one-time procedure that could be accomplished under local anesthesia and involve a tubal occlusion technique that caused minimum damage. The procedure would be safe, have high efficacy, be readily accessible, and be personally and culturally acceptable. The cost for each procedure would be low and there would be minimal costs for the maintenance of equipment. No currently available procedure meets all of these criteria, although minilaparotomy and laparoscopy come close.

Training, to ensure adequate surgical skills, and counseling to ensure that women accepting the method understand fully the possibility of both pregnancy and ectopic pregnancy should the method fail and the highly permanent nature of the procedure, are of major importance in sterilization programmes. The potential reversibility of sterilization was touched on by several speakers. It was agreed that where procedures used in a programme have a high potential for reversibility there should be centers established where the necessary surgical skills are available. It also was agreed that sterilization methods should be presented to potential acceptors as being permanent methods of fertility regulation

The abdominal procedures that have been developed, namely minilaparotomy (postpartum and interval), and laparoscopy, meet the essential requirements of efficacy, safety, and can be carried out under local anesthesia with a minimum use of sedatives. Training in technical skills should put emphasis on the use of local anesthesia and correct site for placement of clips or rings. Accurate placement of clips and rings on the tube is critical to ensure high rates of efficacy World-wide development of laparoscopic sterilization. The following are excerpts pertaining to laparoscopy from a recent WHO overview of the evolution of female sterilization. 2

“Sterilization of women, by surgical occlusion of the Fallopian tubes, is the most widely accepted of all modern family planning measures, being currently used by an estimated 140 million eligible couples worldwide (United Nations 1992), and is the most commonly used modern contraceptive method in many developing countries 3 .

The re-emergence of laparoscopy in the 1960s, made possible by the development of fibre-optics, resulted in a rapid adaptation of this approach to the tubes for sterilization. Initially the technique was employed under general anesthesia, with carbon dioxide being used to provide abdominal distention. Early instrumentation required a two-puncture technique, but refinement of the instruments soon led to procedures being carried out through a single, sub-umbilical puncture. The use of local anesthesia and alternative gases, such as nitrous oxide or operating room air, were further simplifications.

The wider introduction of laparoscopy in the 1970s was a major contributor throughout the world to women’s acceptance of sterilization as a method of family planning. The original unipolar electro coagulation technique by Steptoe in 1967, described in his classic text book of laparoscopy 4 , paved the way for worldwide use of the laparoscope and development of simpler and safer techniques.

The training required the cost of the instruments and the skilled maintenance needed meant that laparoscopy was principally confined to hospital settings where there were established surgical facilities. This was challenged by some. In (the Philippines and) India many saw the potential of laparoscopy for accomplishing large numbers of procedures in a short time. Camp sterilization programs were set up with some spectacular claims being made for the numbers of sterilization that could be done in a day 5 .

Sterilization, other than postpartum, was infrequent before the acceptance of laparoscopy. Many vaginal surgeons were performing a vaginal fimbriectomy as described by Kroener6 in 1969. Other vaginal approaches incorporated the use of tantalum clips. Compared to laparoscopic approaches, however, the vaginal methods have been associated with a higher morbidity from postoperative infection, as well as higher pregnancy rates due to incomplete removal of the fimbriae or incomplete closure of the tantalum clips.

Similarly, the concept of minilaparotomy has been introduced in developing countries as a means of avoiding the expensive equipment necessary for laparoscopy. In trained hands, and under general anesthesia, a minilaparotomy is an effective and comfortable method of accomplishing sterilization with the simple Pomeroy technique. Under local anesthesia, the abdominal invasion is usually sufficiently uncomfortable to make this procedure less acceptable by patients, particularly if laparoscopy is available as an alternative. A large, multi centre study comparing minilaparotomy and laparoscopy has shown few differences between the two approaches, as well as very low short-term complication rates 7 . For these reasons, minilaparotomy has also been abandoned except by a few skilled practitioners.

From the mid 1960s and extending to about 1983, when the last extensive review of the field was undertaken, the period was characterized by the development of new ways of approaching the tubes, such as by laparoscopy and hysteroscopy, and the use of new materials, both plastic and metal, to achieve tubal occlusion. Electro coagulation was refined during this period.” 2

Laparoscopic techniques

1. Unipolar coagulation and division

This technique was the first described by Steptoe and used by gynecologists learning both laparoscopy and electro coagulation techniques. The tube is grasped, and current is passed through the tube (and body) to a base plate. The method produced considerable destruction of tube with electric current but was also associated with hemorrhage from incompletely coagulated vessels severed at the time of tubal division. Deaths were associated with unipolar coagulation8, perhaps as much because of complications of trocar entry as electro coagulation of bowel. This method was abandoned by most laparoscopic in favor of the less destructive techniques described below.

2. Bipolar coagulation

This technique was developed simultaneously and independently in the early 1970s by Rioux in Canada , Kleppinger in the United States , and Hirsch in Germany . The Kleppinger technique emerged as the most popular method of laparoscopic sterilization in the United States . The bipolar technique is the simplest to perform technically and is the most common method of laparoscopic sterilization today. The poles of the forceps conduct the electricity between them, with no current flow beyond the forceps, so the patient is not part of the circuit. Failures after bipolar coagulation have been due to incomplete coagulation, sometimes using inappropriate generators 9 .

The end point of successful coagulation is indicated by a current flow meter on the appropriate or matched generator. When the flow diminishes and ceases, the tubal tissue has been desiccated to the point that it no longer conducts electricity and the forceps can be moved to the next area for coagulation. Kleppinger stresses that three contiguous areas are to be coagulated. This results in at least 3 cm of tube being destroyed and prevents spontaneous recanalisation occurring as a result of the healing process bringing the two stumps closely together 10 . Recent reports of a high incidence of ectopic pregnancy following bipolar coagulation 11 (see Table 1) may be the result of fistula formation between the uterus and peritoneum when the tube is destroyed too close to the uterus 12 . Sperm can travel through these utero-peritoneal fistulas, reach the egg in the distal tube segment, and cause an ectopic pregnancy by this route. This has led to the recommendation that the tube be grasped at least 2 to 3 cm away from the utero-cornual junction at the time of sterilization so that a stump of isthmus remains to absorb the intrauterine fluid under pressure and minimize fistula formation.

3. Silastic band application

The Silastic band for sterilization was developed simultaneously by In Bae Yoon and Coy Lay in the early 1970s. Widely distributed by the U.S. Agency for International Development, the band was offered as a non-electric (and presumably therefore safer) method of tubal occlusion. A loop of the fallopian tube is drawn 1.5 cm into a 0.5 cm diameter metal cylinder, destroying 3 cm of tube. A Silastic ring stretched on the outside of the cylinder is released to form an occlusion at the base of this knuckle. Over time, about 3 cm of constricted tube undergoes necrosis and the tubes separate. Similar to the Pomeroy technique in theory, the laparoscopic application of band is associated with a 2-3% incidence of hemorrhage from stretching the vessels underneath the tube or tearing the tube itself. For this reason, Yoon and associates13 have recommended that bipolar coagulation be available to manage this complication. Post operatively, patients experience pain arising from hypoxic necrosis of the tube in the band. This pain has led to a high incidence of readmission to hospitals (see table 1). This subsides in 48 to 96 hours and can be diminished somewhat by topical application of anesthesia at the time of band application.

4. Spring clip application

Devised in the 1970s to offer a mechanical alternative to electrocoagulation, the spring clip (Hulka Clip) occludes the isthmus of the tube by 2 plastic jaws, compressing the tube by a gold-plated stainless steel spring pressing the jaws together 14 . This is the only clip that does not rely on a latch which can potentially tear through a meso-salpingeal vein. Spring clip application by laparoscopy requires careful surgical technique to assure that the clip is completely across the isthmus of the tube. Although the initial pregnancy rates were high as a result of misapplication, the current pregnancy rates for clip, coagulation, and band are comparable. The spring clip is the most reversible of the techniques 15 (see table 1) since less than 5mm of tube is destroyed between the jaws of the clip. For this reason, it should be considered when one is selecting a method for a woman under 30.

5. Cautery techniques

True cautery is the direct application of heat to tissue, in contrast to electro coagulation and desiccation, where electrical energy flows through tissue and heats it. In Germany , the Semm Endotherm forceps is placed across the tube and one prong of the forceps is heated to 100c, cauterizing the tube. The time (30 to 60 seconds) required for each cautery, as well as the high postoperative ectopic pregnancy rate, has limited the popularity of this method.

Techniques under investigation

The laser has been tried for tubal division at laparoscopy but offers no advantage over standard techniques. Burying the fimbriae in a pouch of broad ligament peritoneum, and burying the ovary in an artificial plastic pouch, has been evaluated in animals but have not been used with humans because of the increased morbidity compared to standard techniques. Various other clips have been devised (Bleier and Filshie clips). The Bleier clip has been discontinued because of a high pregnancy rate due to the tube slipping into spaces within the jaws of the clip. The Filshie clip is heavier and more expensive than the Spring clip and is associated with occasional hemorrhage on application due to the latch going through meso-salpingeal vessels. It received approval by the FDA in 1996, but comparative efficacy data are lacking.

A number of hysteroscopic approaches have reached the human trial stage only to prove less cost-effective than the standard laparoscopic techniques. In Europe, plastic tubal plugs developed by Steptoe in England and Hamou in France were abandoned after ectopic pregnancies developed. In the United States , the Silastic plug16 was extensively evaluated17 and found to be efficacious in about 85% to 90% of candidates, but technical failures persisted despite two or three hysteroscopic re-applications. The technique is intended to be reversible, but reversibility has not been demonstrated. Other hysteroscopic approaches have included destroying the endometrium by freezing or coagulation by heat or chemicals, but these approaches have been abandoned or are still in pre-clinical evaluation stages. Similarly, the introduction of methyl cyanoacrylate (crazy glue) into the tube has been clinically tested overseas but is not ready for clinical use. The Chinese have experimented with formalin injection into the tube, but reports of the efficacy and safety of this approach are incomplete. Although there are still active research projects concerning alternative sterilization techniques, the existing laparoscopic approaches of mechanical or electro coagulation tubal occlusion remain the standard against which these alternatives must be measured in terms of cost, efficacy, and safety.

Sterilization failures

A large number of patients (over 1000) must be followed for a 2 to 3 year period with a high rate (over 85%) of follow-up to study the pregnancy rate following sterilization techniques,. This enormously difficult task has been accomplished very few times: by Johns Hopkins University in the early days of electro coagulation and by the University of North Carolina in the development of the spring clip. Currently, the CREST study of the Centers for Disease Control (CDC) is following several thousand patients sterilized by a variety of techniques. This prospective 10 year national study has recently been concluded 18 and is revealing a much higher pregnancy rate than was first appreciated for all methods of sterilization - approaching 1 pregnancy per 100 sterilizations within 3 years, and 2-3 per 100 over 10 years. The latest education pamphlet on sterilization by the American College of Obstetricians and Gynecologists (ACOG 1991) states, “More than 99 out of every 100 women who have this procedure will not become pregnant, but you should be aware that the procedure does not guarantee sterility. Although the risk of failure is low, sometimes the procedure does not work.”

Ectopic pregnancy is a rare but life threatening form of pregnancy failure requiring early intervention for safe management. The CDC study has revealed that the late pregnancies after bipolar coagulation are mostly ectopic in nature. For this reason, we strongly recommend that when this technique is used a segment of isthmic tube next to the uterus be left to minimize the risks of fistula formation. Women with less tissue damage (from Pomeroy, band, and spring clip sterilization) have relatively less risk of ectopic pregnancy.

Conti filure

Whether a reversible method or sterilization is being considered, the goal of clinician-patient dialogue is to ensure that the woman has enough information and time to determine the best method for her at that point in her life. If sterilization is chosen, the clinician should assess, through two-way dialogue, whether the woman has adequately considered the implications of ending her childbearing potential. Each woman’s knowledge base, cultural context, and experiences are different; each woman has her own unique contraceptive history and contraceptive requirements. As a facilitator, the clinician should strive to convey information that is medically accurate yet understandable, unbiased, and provided at such a time and in such a manner as to permit sufficient time for patient deliberation. Helpful clinician-patient conversations vary in detail and focus as dictated by individual patient circumstances.

Any woman who has completed childbearing is a potential candidate for sterilization. Parity, once considered important in determining eligibility for sterilization, does not correlate with sterilization regret and is not a reason to deny the procedure. 11,12 While regret is associated with having the procedure performed at ages younger than 30, 11,12 age is not a criterion for procedure eligibility. However, younger age should signal the need for a careful, thoughtful dialogue about how desire for sterilization can change with changing life events.

While tubal sterilization is intended to permanently prevent conception, failures do occur. Reasons for failure include undetected luteal pregnancy, occlusion of an incorrect structure (most commonly the round ligament), incomplete or inadequate occlusion, slippage of a mechanical device, development of a tub peritoneal fistula, and spontaneous re-anastomosis or recanalization of the cut ends.11

The U.S. Collaborative Review of Sterilization (CREST) is the landmark prospective, multi center, observational study14 on the use of sterilization in this country. The CREST study was conducted by the Centers for Disease Control and Prevention with support from the National Institute for Child Health and Human Development. CREST recently reported a 10-year (1978 to 1987) cumulative failure rate for sterilization of 1.85 percent in 10,685 women.14 CREST, which reports failure rates that are higher than previously expected, is the largest body of data, thus far, for this length of follow-up.

The CREST study found a higher-than-expected failure rate (i.e., 2.01 per 100 women over 10 years) for interval minilaparotomy sterilization, an office-based procedure14. Most likely, this was a consequence of the low numbers of minilaparotomy cases (i.e., 425 women among a total of 10,685). The higher failure rate also might be caused by the fact that in the United States , interval minilaparotomy often is performed in surgically challenging circumstances, such as when severe pelvic adhesions are present and laparoscopy is deemed inappropriate.14

The risk of sterilization failure persisted throughout the study period14. This finding contradicts the widely held but inaccurate belief that if pregnancies are to occur after sterilization procedures, they will do so within one to two years after the operation. Although the CREST study revealed cumulative 10-year failure rates higher than previously thought, the study confirms that sterilization, when performed with appropriate technique by an experienced clinician, continues to be an extremely effective long-term contraceptive. Contraceptive candidates can be reassured that long-term risk of failure is low and that only the intrauterine device and levonorgestrel (Norplant) implant system (currently unavailable in the United States ) have comparable, long-term failure rates.8-10

The CREST study did not include data on the Filshie clip, which was unavailable in the United States at the time of study enrollment. A 10-year cumulative failure rate of 0.5 percent for 200 women was recently reported for the Filshie clip.11, 15

By preventing pregnancy, female sterilization has an overall protective effect on the risk of ectopic pregnancy. However, when pregnancy does occur it is likely to be ectopic. Of the 143 pregnancies reported in the CREST study, one third were ectopic.16

Regret

The two most common factors associated with regret are young age and unpredictable life events, such as change in marital status or death of a child.11, 17 Regret also has been shown to correlate with external pressure by the clinician, spouse, relatives, or others.11 Interestingly, marital status at the time of the operation, level of education, and the absence of children do not, in many studies, correlate with regret.11, 12, 17

Regret is difficult to measure because it encompasses a complex spectrum of feelings that can change over time. This helps to explain that while some studies have shown “regret” on the part of 26 percent of women, fewer than 20 percent seek reversal and fewer than 10 percent actually undergo the reversal procedure.11, 18, 19.

Depending on such factors as the technique used for sterilization, the resulting length and portion of undamaged fallopian tube remaining, the woman’s age, and the surgeon’s skill, success rates for reversal range from 47 to 90 percent.11 Women who are ambivalent about the permanence of the procedure should be counseled to strongly consider another contraceptive method.

Complications

Overall, major complications of tubal ligation are rare, occurring in fewer than 0.5 percent of cases.11, 20-22 Complications are influenced by factors such as choice of anesthetic, patient characteristics, positioning, technique, and operator experience.11 Short-term complications (e.g., anesthetic difficulties and hemorrhage) occur in the operating room and manifest immediately or in the first several weeks after surgery. Trauma to organs such as the bowel, bladder, ureter, uterus, and cervix can result from cautery, occlusion, and sharp and blunt traumas. Death, a rare outcome of tubal ligation, occurs in only one or two of every 100,000 cases in the United States.23 Currently, the U.S. death rate secondary to complications of pregnancy is seven per 100,000 live births.24 The 29 sterilization-associated deaths reported in the United States between 1977 and 1981 were associated with complications of anesthesia (11 women), sepsis (seven women), hemorrhage (four women), myocardial infarction (three women), and “other causes” (four women).25

Potential risk of tubal ligation. As with any surgical procedure, tubal ligations pose certain risks. These include:

There are disadvantages to both minilaparotomy and laparoscopic sterilization that must be weighed by the patient. Disadvantages of minilaparotomy include:

Disadvantages of laparoscopic sterilization chiefly revolve around certain medical conditions that may prohibit use of the procedure. Women who have heart or lung disease or a history of bleeding may not be candidates for tubal ligation. In addition, women who are obese or have intra-abdominal scarring may be prohibited from the procedure. According to the Food and Drug Administration (FDA), less than 1 percent of women who have had a tubal ligation become pregnant each year. However, failure rates increase over time, as the fallopian tubes can fuse back together. This is especially true of women who had the procedure early in their reproductive years. Some medical centers have reported a failure rate in young women of 5 percent during the first decade after the surgery. Women who get pregnant after a tubal ligation are at higher risk for an ectopic pregnancy. Recently published results from a 14-year study that was supported by the National Institutes of Health (NIH) found that the likelihood of ectopic pregnancy varied according to the method of sterilization used and the age at which the patient underwent the tubal ligation. Generally, women who are younger than age 30 at the time of sterilization are at greater risk of experiencing a subsequent ectopic pregnancy than older women. The researchers also found that ectopic pregnancy may occur as many as 10 years after tubal ligation.

Patients who experience symptoms of an ectopic pregnancy should seek immediate medical care. These symptoms include:

Feelings of faintness or dizziness

While major complications are uncommon after tubal ligation, there are risks with any surgical procedure. Possible side effects include infection and bleeding. After laparoscopy, the patient may experience pain in the shoulder area from the carbon dioxide used during surgery, but the technique is associated with less pain than mini-laparotomy, as well as a faster recovery period. Mini-laparotomy results in a higher incidence of pain, bleeding, bladder injury, and infection compared with laparoscopy. Patients normally feel better after three to four days of rest, and are able to resume sexual activity at that time.

The possibility for treatment failure is very low—fewer than one in 200 women (0.4%) will become pregnant during the first year after sterilization. Failure can happen if the cut ends of the tubes grow back together; if the tube was not completely cut or blocked off; if a plastic clip or rubber band has loosened or come off; or if the woman was already pregnant at the time of surgery

About 1–4% of patients experience complications following tubal ligation. There is a low risk (less than 1% or seven per 1,000 procedures) of a later ectopic pregnancy. Ectopic pregnancy is a condition in which the fertilized egg implants in a place other than the uterus, usually in one of the fallopian tubes. Ectopic pregnancies are more likely to happen in younger women, and in women whose tubes were closed off by electro coagulation.

Rarely, death may occur as a complication of general anesthesia if a major blood vessel is cut. The mortality rate of tubal ligation is about four in 100,000 sterilizations.

Tubal ligation reversal

More than 650,000 women undergo tubal ligation in the United States annually, thus ending their ability to have children. What happens when circumstances change and a woman decides that she really does want to become pregnant? Approximately six percent of women who originally decided that tubal ligation was the way to end their childbearing years will, within five years, decide that she does indeed want to experience pregnancy and the birth of a new baby.

Post Tubal Ligation Syndrome

Sometimes, tubal ligation reversal is desired not for the purpose of having children, but to reverse the effects experienced by many women of post tubal ligation syndrome. The symptoms of post tubal ligaiton syndrome may include:

Rates of Tubal Ligation Reversal?

Several factors play a key role in the success rate of tubal ligation reversal. These include:

Women who make the best candidates for tubal ligation reversal are those whose tubal ligations included either the removal of a small section of the fallopian tubes, or those whose tubal ligation was achieved by clips or rings placed around the tubes to prevent eggs released during ovulation from traveling through the fallopian tubes. Overall, success rates for tubal ligation reversal can vary from 20 percent to 70 percent.

Tubal Reversal Procedures

Before your health care provider can advise you about the potentialfor successful tubal ligation reversal, you will need to provide him with all the facts and records from your tubal ligation procedure. The type of tubal ligation procedure used will determine the best procedure for tubal reversal, and have a major impact on your chance of success.

The tubal ligation reversal procedure uses microsurgery to rejoin the two remaining sections of the fallopian tubes. Certain factors have a direct effect on the potential for a successful tubal reversal procedure. Because the fallopian tube’s diameter varies from one end to the other, the best chance for success occurs when the diameters of the two remaining sections of fallopian tube are almost identical. In cases where the two remaining ends of the tubes are of different diameter (for example, a narrow end of tube close to the uterus is being connected to a wider end near the end of the fallopian tube), success rates for pregnancy are lower.

The ideal candidate for tubal ligation reversal is a woman who has nearly equal diameter of the remaining ends of the tubal sections, and whose tubes are at least three to four inches long following reversal of the tubal ligation. (Before tubal ligation the fallopian tubes are approximately eight inches long.) The decision to undergo tubal ligation reversal should be carefully weighed against the potential for successful in vitro fertilization. Women who have little chance of successful tubal reversal should be advised to consider in vitro fertilization. You should discuss your personal situation with your health care provider to determine your best option for achieving successful pregnancy either by tubal ligation reversal

Counselling issues

Counseling for reversible contraceptive methods generally involves clinician and patient dialogue regarding safety, efficacy, potential side effects, and integration of the method into the woman’s lifestyle. All health care professionals who counsel women about contraception should recognize the advantages and disadvantages of female sterilization compared with nonpermanent, long-acting methods (Table 1).3, 7-10 Sterilization counseling should include discussing permanence of the method, possibility of future regret, and information about the surgical procedure. Assessment of whether the woman’s partner might consider undergoing sterilization rather than the woman also is appropriate (Table 1).3, 7-10.

Whether a reversible method or sterilization is being considered, the goal of clinician-patient dialogue is to ensure that the woman has enough information and time to determine the best method for her at that point in her life. If sterilization is chosen, the clinician should assess, through two-way dialogue, whether the woman has adequately considered the implications of ending her childbearing potential. Each woman’s knowledge base, cultural context, and experiences are different; each woman has her own unique contraceptive history and contraceptive requirements. As a facilitator, the clinician should strive to convey information that is medically accurate yet understandable, unbiased, and provided at such a time and in such a manner as to permit sufficient time for patient deliberation. Helpful clinician-patient conversations vary in detail and focus as dictated by individual patient circumstances.

Any woman who has completed childbearing is a potential candidate for sterilization. Parity, once considered important in determining eligibility for sterilization, does not correlate with sterilization regret and is not a reason to deny the procedure.11,12 While regret is associated with having the procedure performed at ages younger than 30,11,12 age is not a criterion for procedure eligibility. However, younger age should signal the need for a careful, thoughtful dialogue about how desire for sterilization can change with changing life events

Final Comment

Permanent sterilization is the contraceptive choice of many women. Whether performed in the interval time period or immediately postpartum, tubal sterilization is a safe and effective procedure. While safety and efficacy should be discussed with each prospective candidate, a more important issue for deliberation is whether the woman is making an informed decision. Is she choosing the best possible option for her current and future life circumstances? While ultimately the decision must be hers, clinicians can facilitate informed decision-making through the counseling content and approach. Counseling dialogue should include the permanence of the procedure, the lack of protection against STDs, the need for continued gynecologic preventive care (e.g., Papanicolaou smears, bimanual examination, mammography), and the context surrounding who may or may not be influencing the woman’s decision.

Minilaparotomy under local anesthesia is a safe alternative to conventional interval sterilization by laparoscopy and belongs in any general discussion of provision of this service.

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