PEARLS OF WISDOM Surgical Pearl: Phlebectomy hook Norplant extraction

Norplant is a subdermal implant of six levonorgestrel-containing capsules that provide contraception for up to 5 years. 1 Capsules are 2.4 mm in diameter and 34 mm in length (Fig. 1) and are usually inserted with a trocar in a fanlike configuration on the medial aspect of the upper arm. Because of the long duration of the capsules and variation in the insertion technique, removal may sometimes be difficult. Several extraction methods have been described. In the removal technique originally described by Wyeth-Ayerst Laboratories (distributors of Norplant), 3 ml of local anesthetic is injected under the capsule ends closest to the original incision site, shallow incisions are made at the proximal ends of each of the six capsules, and the capsules are removed by digital manipulation or introduction of forceps into the incision. 1 Subsequently, modifications of the technique have been described. In the "standard" technique, a single transverse incision is made close to and below the distal ends of the capsules and a mosquito forceps is used to extract the capsules. 2 In the Utechnique, a vertical incision is made between capsules 3 and 4 and a modified vas deferensholding forceps grasps and removes the capsules. 2,3 In the hook-traction technique, a horizontal incision is made and with a hypodermic needle fashioned into a hook, the implants are guided toward the incision. 4 We describe a simple technique for isolation and removal of Norplant with a common surgical instrument. The area with the implants is anesthetized with 1% lidocaine with 1:100,000 epinephrine. A 3 to Fig. 1. Set of six successfully extracted Norplant capsules.