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The Role of Minimal Invasive Surgery in the Therapy of Ectopic Pregnancy

Ferdhy Suryadi Suwandinata1, Hans Rudolf Tinneberg2, Herbert Situmorang1

1. Department of Obstetrics and Gynecology, Cipto Mangunkusumo Hospital, University of Indonesia,


Jakarta, Indonesia
2. Department of Obstetrics and Gynecology, University Hospital of Giessen, Germany

Introduction
Ectopic pregnancy has been recognized for over 400 years, the incidence continues to increase affecting
more than 2% of all pregnancies. The tendency of ectopic pregnancies in the past 25 years has been
correlated to a number of different risk factors. Theoretically, anything that impedes migration of the
conceptus to the uterine cavity can cause ectopic pregnancy. These may be intrinsic anatomic defects in
the tubal epithelium, hormonal factors interfere the transport of the conceptus, or pathologic conditions
as a result from a chronic inflammation that affect normal tubal functioning.

Besides the symptoms commonly associated with early pregnancy, women with ectopic pregnancy
commonly experience pelvic pain and bleeding. The pain is often one sided and the bleeding is often
variable and may be the only sign of a complication. It should be noted, however, up to 20% of women
with first trimester bleeding will go on to have a healthy pregnancy. The differential diagnosis for cases
of suspected ectopic pregnancies are listed in Table 1. In the 1800s, the mortality associated
with ectopic pregnancy was >60%. Until 1970, more than 80% of ectopic pregnancies were diagnosed
after rupture, resulting in significant morbidity and mortality. It still accounts for 9% of pregnancy
related mortality and less than 1% of overall mortality in women. With excellent resolution obtained
from pelvic ultrasound, highly sensitive radio-immunoassays for human chorionic gonadotropin (hCG)
and increased vigilance by clinicians, greater than 80% of ectopic pregnancies are now diagnosed intact
which allows for more conservative management.

Awareness of the possibility of an ectopic pregnancy is most critical for early detection. Measurement
of hCG with a doubling time of 2-3 days should occur if it is a normal gestation. A note of caution is
that approximately 10% of normal pregnancies do not follow this doubling time, and very early in
gestation up to 60% of ectopic pregnancies will follow this doubling time. When hCG levels are
>1000 mIU/mL, transvaginal ultrasound is reliable in diagnosing the location of the gestation
approximately 98% of the time. If using an abdominal ultrasound, then the hCG needs to be above 6000
mIU/mL to make an accurate diagnosis. Progesterone can also be used to help differentiate a
viable from non-viable gestation. A progesterone level of greater than 25 ng/mL is indicative of a
healthy gestation about 97.4% of the time and a level of 5 ng/mL indicates an abnormal pregnancy with
almost 100% sensitivity. Values between 5 and 25 ng/mL are unfortunately more common and these
values are more ambiguous.

The incidence of ectopic pregnancy based on location has been relatively unchanged for many years.
Figure 1 shows the location of various ectopic pregnancies and their incidence in each location. The
ampullary portion of the fallopian tube is the site of the majority of ectopic pregnancies.

Table 1 – Differential diagnosis in cases of suspected ectopic pregnancy


• Spontaneous abortion
• Ruptured ovarian cyst
• Corpus luteum hemorragicum
• Adnexal torsion
• Pelvic inflammatory disease
• Endometriosis
• Urolithiasis
• Urinary tract infection
• Appendicitis
• Other lower gastrointestinal tract disease
Role of laparoscopy
Treatment options for ectopic pregnancy have broadened in the past 10-15 years. Prior to this era,
laparotomy with salpingectomy was the standard. Through a diagnostic procedure and earlier diagnosis,
improved microsurgical laparoscopic techniques and chemotherapeutics, a more conservative approach
has been taken in order to preserve the fertility. Laparoscopic treatment of this condition is growing in
popularity and is currently considered the standard of care. Even hemodynamic instability is not an
absolute contraindication to laparoscopy. The availability of optimal anesthesia, advanced
cardiovascular monitoring, ability to convert quickly to laparotomy, and superior magnification given
by laparoscopy make it a viable option and possibly the best choice. Laparoscopy also has lower
morbidity, shorter hospital stays and decreased costs as well as decreased need for postoperative
analgesia, and some studies have also shown that laparoscopy achieves superior pregnancy
rates to laparotomy.

This laparoscopic procedure was proven in prospective randomized trials to be superior to


laparotomy.[50] Vermesh and associates [46] prospectively randomized patients with unruptured EUP
to either laparoscopy or laparotomy. Those authors analyzed postoperative morbidity, length of hospital
stay, duration of convalescence, hospital cost, postoperative tubal patency by hysterosalpingography,
and pregnancy rates. The two procedures were similarly safe and effective, but the laparoscopic
approach was more cost-effective and required a shorter recovery period. Even more the laparoscopic
approach results in improved fertility rates because of reduced formation of postoperative
adhesions.[51]

Type of surgery
The location, size, and extent of the tubal pregnancy are observed laparoscopically. The management of
each ectopic pregnancy is based upon these factors. Whatever the surgical approach chosen, adequate
hemostasis with minimal trauma is optimal and should be obtained with as little cauterization as
possible. All surgical approaches start by identification and mobilization of the involved fallopian tube
and inspection of the uninvolved side. Since the 1970s, a conservative approach to unruptured ectopic
pregnancy has been advocated by many of the leading authorities in our field. There are several different
types of conservative surgery that can be performed. These include linear salpingotomy, tubal resection
or partial salpingectomy with anastomosis, salpingectomy and ‘milking’ the pregnancy from the distal
ampulla.

Salpingotomy
For unruptured tubal pregnancies, the tube is identified and mobilized. To reduce bleeding, a 5- to 7-mL
diluted solution containing 20 units of vasopressin in 100 mL of normal saline could be injected with a
20-gauge laparoscopic needle in the mesosalpinx just below the EUP and over the antimesenteric
surface of the tubal segment containing the gestational products. The needle must not be within a blood
vessel because intravascular injection of vasopressin solution can cause acute arterial hypertension,
bradycardia, and death.[57] Using a laser, microelectrode, or scissors, a linear incision is made on the
antimesenteric surface extending 1 to 2 cm over the thinnest portion of the tube containing the
pregnancy.
Figure 1. Unruptured ampullary
ectopic pregnancy with
intraabdominal bleeding

Figure 2. Using a monopole


electrode, a linear incision is
made on the antimesenteric
surface extending 1 to 2 cm over
the thinnest portion of the tube.

Figure 3. The conception tissue


is removed by using
laparoscopic forceps.
Figure 4. No suture is needed to
adapt the tubal wall.

The pregnancy usually protrudes through the incision and slowly slips out of the tube; it is removed by
using hydrodissection or laparoscopic forceps (Figure 3). Forceful irrigation in the tube’s opening can
dislodge the gestation from its implantation. As the pregnancy is pulled out or extrudes from the tube,
some products of conception may adhere to the implantation site by a ligamentous structure containing
blood vessels. Using the electrocoagulator, this structure is coagulated before the tissue is removed.
Oozing from the tube is common but usually ceases spontaneously. Occasionally, coagulation is
necessary with a defocused laser beam or an electrocoagulator. Depending on the size, the products of
conception are removed through a 5- or 10-mm trocar sleeve.

Tubal Resection

Resection of the tubal segment that contains the gestation is preferable to salpingotomy for anisthmic
pregnancy or a ruptured tube or if hemostasis is difficult to obtain. Segmental resection is done with
bipolar electrosurgery, fiber lasers, CO2 laser, sutures, or stapling devices. Bloodless segmental
resection is achieved by grasping the proximal and distal boundaries of the tubal segment containing
the gestation with a Kleppinger forceps and coagulating them from the antimesenteric surface to the
mesosalpinx. The segment is cut with laparoscopic scissors or a laser, with little risk of bleeding.
The mesosalpinx under the pregnancy is coagulated, with particular attention given to the arcuate
anastomosing branches of the ovarian and uterine vessels.[64] After coagulation, the mesosalpinx is cut.
The material is then removed through a trocar sleeve.

Figure 5. Tubal resection.


Salpingectomy
Salpingectomy is chosen by the presence of uncontrolled bleeding, tubal destruction by the EUP, and a
recurrent pregnancy in the same tube. This operation is done by progressively coagulating and cutting
the mesosalpinx, beginning with the proximal isthmic portion and progressing to the fimbriated end of
the tube. It is separated from the uterus by using bipolar coagulation and scissors or a laser. The isolated
segment containing the EUP is removed intact or in sectioned parts through the 10-mm trocar sleeve.
Products of conception can be placed in an “Endo-bag” and removed (Figure 9.4.8). Occasionally, a
patient is admitted overnight to be observed for postoperative bleeding and to receive emotional support
from the infertility team.

Salpingectomy or Salpingotomy
There has been considerable debate about whether salpingectomy or salpingostomy should be done. The
possible advantages of removing the tube completely include almost entirely eliminating the risk of
persistent trophoblast and that of a subsequent ectopic pregnancy, whereas the possible advantage of
conserving the fallopian tube is that future fertility is preserved.[40] There are no randomized controlled
trials published that specifically compare laparoscopic or open salpingectomy and salpingotomy.
There are four cohort studies that specifically compare laparoscopic tube-sparing and radical treatments
of ectopic pregnancy.[67–70] Silva et al. [67] examined reproductive outcomes prospectively in 143
women undergoing laparoscopic salpingectomy or laparoscopic salpingotomy. The intrauterine
pregnancy rates were similar when comparing the two groups (intrauterine pregnancy in 60% of
subjects after salpingotomy versus 54% after salpingectomy; relative risk 1.11). In a study of
155 women, Job-Spira et al. [68] reported subsequent intrauterine pregnancy rates with salpingotomy
that were comparable to those following salpingectomy (hazard ratio, 1.22). The cumulative pregnancy
rates at 1 year were 72.4% after salpingotomy and 56.3% after salpingectomy. In a study byMol et al.
[69] of a cohort of 135 women, the fecundity rate ratio when comparing laparoscopic salpingotomy with
salpingectomy during the 18-month follow-up period was 1.4 for women with a healthy contralateral
tube and 3.1 for women with contralateral tubal disease.
The 3-year cumulative pregnancy rate was 62% after salpingotomy and 38% after salpingectomy. In a
study by Bangsgaard et al. [70] reviewing a cohort of 276 women undergoing salpingotomy or
salpingectomy, the subsequent cumulative pregnancy rate at 7 years was 89% following salpingotomy
and 66% following salpingectomy. The hazard ratio for intrauterine pregnancy following salpingectomy
was 0.63 when comparedwith salpingotomy. Regardless of the type of surgery, contralateral tubal
abnormalities predispose the patient to recurrent ectopic pregnancy.
There was no significant difference in the risk of repeat ectopic pregnancy (17% after conservative
surgery and 16% after radical surgery).[70]
Salpingotomy remains the definitive and universal treatment for EUP in women who are
hemodynamically stable and who wish to preserve their fertility.[1,2] The reproductive performance
after salpingotomy appears to be equivalent to or better than that after salpingectomy, but the recurrent
EUP rate may be slightly greater. Salpingectomy may be necessary for women with uncontrolled
bleeding, recurrent ectopic pregnancy in the same tube, a severely damaged tube, or a tubal gestational
sac greater than 5 cm in diameter.[1]

Conclusion
Ectopic pregnancy remains an increasing health problem. Its incidence continues to rise, paralleling
increase in the incidence of the risk factors, such as sexually transmitted diseases. With improved
minimally invasive techniques, the surgical management of this worrisome condition can be
accomplished with minimal trauma and maximal preservation of fertility. Minimally invasive surgery
has lower morbidity, shorter hospital stays and decreased costs as well as decreased need for
postoperative analgesia, and achieves superior pregnancy rates to laparotomy.