Surgical Treatment Calls For Minimally Invasive Techniques
Most ectopic pregnancies—even interstitial pregnancy, heterotopic pregnancy, and ectopic pregnancy in the presence of hemoperitoneum—can be treated through a laparoscopic procedure. Your approach, or course, should depend upon your experience and the judgment of the anesthesiologist.
To Spare the Tube or Not
When it comes to choosing salpingostomy or salpingectomy, there are some uncertainties, and we face an absence of data from randomized studies. In some—but not all—of the nonrandomized studies that have been done, the intrauterine pregnancy rate has been higher after the tube-sparing surgery than after salpingectomy. However, the risk of recurrent ectopic pregnancy has been shown to be slightly higher after the more conservative treatment.
These differences most likely reflect tubal status and not the choice of surgical procedure. In other words, contralateral tubal abnormalities predispose patients to recurrent ectopic pregnancy regardless of the type of surgery. In one study of women who underwent laparoscopic salpingectomy, rates of intrauterine pregnancy and recurrent ectopic pregnancy were better among women who had normal contralateral tubal anatomy and no history of infertility (approximately 75% and 10%, respectively), compared with women who had abnormal tube anatomy or infertility (37% and 18%, respectively).
In the absence of data from a randomized study, though, salpingostomy should be the treatment of choice, particularly for women who want another pregnancy. I do not remove the tube in patients who wish to conceive again, provided the tube is relatively normal by gross inspection. If the patient has completed her family, I will remove the tube.
Some other ectopic pregnancies are often best treated by salpingectomy. These include cases of uncontrolled bleeding, a severely damaged tube, most cases of recurrent ectopic pregnancy within the same tube, and a tubal gestational sac larger than 3 cm in diameter. In these cases, the probability of normal tubal function in the future is low, and the likelihood of recurrent tubal problems is high.
Salpingostomy Technique
Laparoscopic salpingostomy is fairly straightforward. First, inject a dilute solution of vasopressin (0.2 IU/mL of physiologic saline) into the tubal wall at the area of maximal distention. This will minimize bleeding. Using a unipolar needle electrocautery (laser and scissors can also be used), make a 10− to 15-mm linear incision along the antimesenteric border overlying the ectopic site.
Do not use forceps and do not pull the products of conception out piece by piece, or you could cause more bleeding and mistakenly leave tissue behind. Instead, use a combination of hydrodissection with irrigating solution under high pressure and gentle blunt dissection with a suction irrigator. Remove the specimen from the abdominal cavity. A laparoscopic pouch can be useful for removing large pieces of gestational tissue.
Carefully irrigate the tube and make sure there is no bleeding. Control any bleeding points with pressure or with a light application of bipolar coagulation. If bleeding persists, ligate the vessels in the mesosalpinx with a 6–0 polyglactin suture. The suturing is technically demanding, but this is one condition in which suturing skill is extremely helpful, and all laparoscopists should acquire it.
Do not keep coagulating the inside of the tube to stop the bleeding. The thermal damage will affect the integrity of the tube, and that integrity is important for future pregnancies.
Leave the incision open to heal by secondary intention. A randomized study I led several years ago showed no difference in the rates of adhesion formation and subsequent fertility between patients who had suturing after laparotomy and those who did not. If there is no difference after laparotomy, then the outcomes associated with secondary intention and primary closure after laparoscopy will also be similar.
Some physicians have proposed giving women MTX right after surgery. Although I do not recommend administering MTX prophylactically, it might be worthwhile to administer one dose of MTX in those rare cases in which you suspect that you might have left behind some gestational tissue.
Salpingectomy Technique
There are several methods for laparoscopic salpingectomy. For one, you may ligate the part of the tube that contains the ectopic pregnancy, then resect and remove the tube.
Alternatively, use electrosurgery to coagulate the tube and mesosalpinx and then resect the specimen with scissors. The cornual portion of the tube should be desiccated close to the uterus. Elevate the tube when using the electrocautery, or you may inadvertently damage the ovarian vessels. You may perform either partial or segmental salpingectomy using a laparoscopic approach.
Regardless of the method of treatment, always check the patient's blood group. If she is Rh negative and the male partner's Rh factor is positive or unknown, the patient should be given RhoGAM.
