Essure removal: comparison of two minimally invasive approaches

Abstract

Objective: To study differences between robotic and laparoscopic approach in Essure device removal.

Design: Demonstration video of two different surgical approaches.

Setting: Clinico San Carlos University Hospital in Madrid, Spain.

Patient(s): A total of 737 Essure devices were implanted until June 2017 in Clinico San Carlos Hospital. Nineteen of them were removed. Fourteen (73.7%) were removed using the laparoscopic approach, 4 (21%) using the robotic approach, and 1 (5.3%) using hysteroscopy. We show two cases, one performed using the robotic approach and one using the laparoscopic approach. The first patient was 49 years old and the indication for Essure removal was nickel allergy. The second patient was 52 years old and she had chronic pelvic pain.

Intervention(s): We performed two cases of Essure device removal and bilateral salpingectomy operated using the laparoscopic and robotic approaches to compare both procedures. The first step was coagulation of the antimesenteric edge of the fallopian tube with bipolar forceps 2 cm from the uterine horn. The second step was cutting of the coagulated tissue and dissection to visualize the metallic spiral. The third step was pulling gently to extract one of the spirals of the device. The fourth step was salpingectomy and extraction of the proximal part of the Essure. After Essure removal and bilateral salpingectomy, we performed X-ray of the pelvis to ensure complete removal of the device in both patients.

Main outcome measure(s): We recorded intraoperative and postoperative complications, total operative time and blood loss.

Result(s): We did not have intraoperative or postoperative complications in any of the surgical approaches. Total operative time was 30 minutes in the robotic surgery (total time in the operating room, 60 minutes) and 45 minutes in the laparoscopic approach (total time in the operating room, 65 minutes). Estimated blood loss was 10 mL in the robotic surgery and 25 mL in the laparoscopic surgery. Both patients were asymptomatic after 3 months of follow-up. The same results could be extrapolated to our series; we observed a median of total operating time of 45 minutes, no complications, length of stay of 2 days, and total resolution of symptoms after 3 months of follow-up. Our results are similar to the results reported by other authors who consider laparoscopic salpingectomy for removal of Essure inserts to be safe and feasible.

Conclusion(s): Robotic and laparoscopic approaches allow complete removal of Essure devices in symptomatic patients without major complications. On the other hand, robotic surgery provides advantages to the surgeon, such as greater precision, elimination of tremor, three-dimensional visualization of surgical field, and ease of minimally invasive suturing. But robotic surgery has the disadvantages of increased cost and increased case time in some circumstances.

Keywords: Essure; minimally invasive surgery; removal; robotic approach.