Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure, exploration, conservative treatment, specific cases, laparoscopic salpingectomy, Medical treatment.
Consequently, this operating technique is well standardized for the management of this condition.
The management of EP is unique in the history of laparoscopic surgery: it is one of the first laparoscopic procedures (Bruhat et al., 1980) and Manhès, who developed the technique, was the inventor of the Triton, the first laparoscopic multi-function instrument.
The laparoscopic treatment of EP may be either radical or conservative.
At the same time, medical treatment for EP has become increasingly popular.
1. Interstitial or intramural junction
2. Lateral tubal artery
3. Uterine artery
4. Ovarian artery
5. Infratubal arch
The vascular supply of the uterine tube is dependent on two arteries: the medial tubal artery (terminal branch of the uterine artery), and the lateral tubal artery (terminal branch of the ovarian artery). These 2 arteries anastomose at the level of the infratubal arch.
1. the ampulla (64%);
2. the isthmus (25%);
3. the infundibulum (9%);
4. the intramural junction (2%).
The other localizations are less common: ovarian (0.5%); cervical (0.4%); abdominal (0.1%); intraligamental (0.05%).
Absolute contraindications to laparoscopic treatment are as follows:
- ruptured EP with massive hemoperitoneum and hemodynamic instability;
- surgeon’s lack of experience in laparoscopy.
Relative contraindications are as follows:
- multiple previous surgery in the pelvic region;
- unruptured interstitial EP;
- morbid obesity.
The decision as to whether to preserve the tube or not depends on several factors:
- the patient’s choice: in patients who do not wish to become pregnant anymore, the logical treatment for EP is salpingectomy combined or not with a contralateral tubal ligation;
- the patient’s previous history: the risk of EP recurrence is high in cases of prior history ipsilateral tubal plasty or after previous history of EP;
- the condition of the ipsilateral and contralateral tubes. In cases of a highly impaired tube, salpingectomy is the treatment of choice.
In patients with no previous history of tubal or infertility surgery and with a healthy contralateral tube, fertility is similar after conservative treatment and after radical treatment (Dubuisson et al.,1996).
- complete blood count;
- blood group serological typing including Rhesus and Kell phenotypes;
- search for immune system antibodies;
- coagulation workup;
- a quantitative assay of b-hCG.
- fasting, unless emergency;
- bowel preparation by enema, unless emergency;
- shaving of the suprapubic hair;
- premedication: 5 mg midazolam intramuscular injection one hour prior to surgery.
The patient should be informed of:
- laparoscopic modalities;
- its risks and complications;
- the risk of conversion to laparotomy;
- the risk of salpingectomy.
- low lithotomy position;
- 30° Trendelenburg;
- thighs and legs stretched apart, buttocks at the distal edge of the table;
- left arm alongside the body;
- urinary catheter necessary throughout operation;
- nasogastric tube;
- uterine cannulation.
2. The first assistant stands on the patient’s right.
3. The second assistant sits between the patient’s legs.
4. The scrub nurse stands on the surgeon’s left.
2. The second monitor is used by the second assistant and the scrub nurse. It is situated at the level of the patient’s right shoulder.
A: A 12 mm optical trocar is placed at umbilicus level.
B and C: Two 5 mm lateral operative trocars are placed in suprapubic position 3 fingerbreadths above the symphysis pubis within the inferior epigastric pedicles.
Trocar positioning is then as follows:
- one 12 mm optical trocar at umbilicus level;
- two 5 mm trocars at the level of right and left iliac fossae 2 fingerbreadths within the anterior superior iliac spine;
- one 12 mm trocar 3 fingerbreadths above the symphysis pubis.
2. Atraumatic grasper
3. Grasping forceps
4. Toothed forceps
5. Sharp-tipped monopolar device
6. 5 or 10 mm suction-irrigation device, with single hole on tip
Good exposure of the lesser pelvis may be obtained by:
- Trendelenburg position,
- uterine cannulation.
Warning: uterine cannulation should only performed if an intrauterine pregnancy has been ruled out.
1. A Cohen cannula, with which a methylene blue test can be performed. It cannulates only the cervical canal and does not allow for proper mobilization of the uterus;
2. A blunt curette placed in the uterine cavity after dilation, coupled with 2 Pozzi graspers placed on the anterior and posterior labia of the cervix;
3. An asymmetric grasper.
The second assistant anteverts the uterus and pushes it to the side contralateral to the EP.
- determine the precise location of the EP;
- evaluate the extent of the hemoperitoneum;
- determine the condition of the adnexa, especially that of the contralateral tube;
- visualize any active bleeding;
- rule out any other associated abdominal pathology.
A massive hemoperitoneum and clots occasionally prevent the surgeon from establishing a precise workup of the lesions straight away. In these cases, the first operative step consists in evacuating the hemoperitoneum.
If the EP is small in size, both tubes should be explored: there may be a hematosalpinx contralateral to the EP due to retrograde reflux.
- preservation of the uterine tube;
- incision made on the anti-mesosalpingeal side of the tube;
The surgeon must bear in mind that EP is proximal (towards the uterus) and that hematosalpinx is distal.
The case described here is a left ampullary EP.
A 1 to 2 cm longitudinal incision is made on the anti-mesosalpingeal border, over the proximal portion of the EP site. If it is too distal, the risk of leaving the trophoblast in place is high.
The incision is made using a needle point electrocoagulater, until the trophoblast or the hematosalpinx appears. Scissors or a laser may also be used.
The extraction may also be performed using a toothed forceps.
Suture of the tube is unnecessary.
Tubal expression is not recommended, even in case of tuboperitoneal abortion. It increases the risk of failure.
The trophoblast (when it has not been aspirated) should be removed into an extraction bag to avoid it from spreading into the abdominal pelvic cavity and to prevent peritoneal implants from propagating.
Ipsilateral or contralateral adhesiolysis as well as fimbrioplasty or contralateral neosalpingostomy may be performed.
With the other hand, the surgeon cauterizes the isthmus close to the uterus using a bipolar grasper. The grasper should slightly overlap the mesosalpinx to achieve hemostasis, without proceeding too far to avoid cauterizing the internal ovarian artery/ovarian branch of the uterine artery. The tube is then divided with scissors.
When the only remaining attachments of the tube are the infundibulo-ovarian ligament and the lateral tubal artery, these are respectively cauterized and divided.
The procedure ends with a verification of the hemostasis and careful lavage.
In cases of dense tubo-ovarian adhesions, a part of the tubal wall may sometimes be left on the ovary to avoid its devascularization.
IV may be removed on the evening of the procedure.
Food may be given on the evening of the procedure.
Postoperative analgesia with non-opioid analgesics.
Discharge is possible the day after surgery.
Use of contraceptives should be discussed with the patient.
The patient may try to become pregnant again 2 to 3 months post-op.
The patient is informed of the risk of recurrence.
B: Monitoring until hCG is negative if rate >2000 UI/mL
C: Strict monitoring until negative regardless of hCG rate
D: Failure very probable
The beta-hCG level should be checked until negative, every 2 days during the first week, then on a weekly basis. Beta-hCG typically drops to zero by post-op day 20.
The decrease in the beta-hCG level should be exponential. A decrease that is too slow or a secondary rise confirms that the salpingostomy has failed.
A predictive diagram was established for the postoperative monitoring of the decrease in the percentage of hCG following conservative laparoscopic treatment of ectopic pregnancy (Pouly, 1987).
Hysterosalpingography may be performed 3 months after the procedure to assess tubal patency.
If the patient’s blood group is Rh negative, an injection of anti-D gammaglobulins is necessary within 72 hours after an EP is detected to prevent anti-D alloimmunization.
Medical treatment can only be considered if the patient is symptom-free and the level of beta-hCG is decreasing.
- Methotrexate is the most commonly prescribed treatment. The trophoblast is particularly sensitive to this antifolate antimitotic agent. It has been used for many years in the treatment of molar pregnancy.
Methotrexate is generally administered by intramuscular injection, at a dosage of 50 mg/m2 (body surface area) or 1.5 mg/kg. The injection is repeated 7 days afterwards in case of a decrease of <15% between day 4 and day 7.
- Mifepristone: this antiprogesterone may be associated with Methotrexate. Although its theoretical value seems obvious, few studies have confirmed this potential.
In all cases, medical treatment is reserved for:
- EP without sonographic or clinical signs of rupture or prerupture;
- with a stable hemodynamic status;
- presenting with an abnormal rise or stabilization in the level of the b-hCG after 48 hours;
- in motivated and informed patients.
- multiple surgical procedures/adhesions in the pelvic region;
- contraindications to laparoscopy;
- patients who refuse to undergo surgery.
- patients with few or no symptoms;
- beta-hCG <5000 UI/L.
- increased beta-hCG (>10000 UI/L) with cardiac activity present;
- patients experiencing pain;
- potential poor compliance.
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