Laparoscopic surgical treatment of tubal ectopic pregnancy

The description of the laparoscopic surgical treatment of tubal ectopic pregnancy covers all aspects of the surgical procedure used for the management of tubal ectopic pregnancy. 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.

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Laparoscopic   surgical   treatment   of   tubal   ectopic   pregnancy

Authors
Abstract
The description of the laparoscopic surgical treatment of tubal ectopic pregnancy covers all aspects of the surgical procedure used for the management of tubal ectopic pregnancy.
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.
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2001-11
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E-publication
WeBSurg.com, Nov 2001;1(11).
URL: http://www.websurg.com/doi-ot02en154.htm

Laparoscopic   surgical   treatment   of   tubal   ectopic   pregnancy

1. Introduction
The developments in ultrasonography, as well as accurate and rapidly available measurements of beta-human chorionic gonadotropin (b-hCG) levels, have modified the diagnosis and management of ectopic pregnancy (EP). Until recently considered a potentially life-threatening surgical emergency, it is now detected earlier and can usually be treated laparoscopically.
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.
2. Anatomy
• Topographical anatomy
The uterine tube is made up of 4 segments:
1. Interstitial or intramural junction
2. Isthmus
3. Ampulla
4. Infundibulum
• Vascular supply
1. Medial tubal artery
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.
• Ectopic pregnancy
Ectopic pregnancy (EP) usually occurs (99% of cases) in the uterine tube (Philippe, 1970). It can be found in:
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%).
3. Indications
At the present time, most cases of EP may be treated surgically via laparoscopy.

Absolute contraindications
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
Relative contraindications are as follows:
- multiple previous surgery in the pelvic region;
- unruptured interstitial EP;
- morbid obesity.
4. Radical treatment/other
• Conservative surgery
Conservative surgery for EP (salpingostomy) maximizes the preservation of the affected tube for subsequent fertility. However, it is associated with a risk of EP persistence (5%, Pouly, 1991) and of recurrence.
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.
• Scoring system
Pouly et al. (1991) proposed a therapeutic scoring system of EP mainly based on information provided by the patients.

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).
5. Preop period
The preoperative workup includes:
- 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.

Patient preparation
- 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.

Patient information
The patient should be informed of:
- laparoscopic modalities;
- its risks and complications;
- the risk of conversion to laparotomy;
- the risk of salpingectomy.
6. Operating room set-up
• Patient
- general anesthesia;
- 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.
• Team
1. The surgeon stands on the patient’s left.
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.
• Equipment
1. The first monitor is placed opposite the right foot of the patient. It is used by the surgeon and the first assistant.
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.
7. Trocar placement
• Trocar placement
Three trocars are generally sufficient.
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.
• Fourth trocar
The additional use of a fourth 10 to 12 mm trocar is recommended in cases of: EP of large diameter, active bleeding, massive hemoperitoneum, difficult operative conditions (obesity).
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.
• Pneumoperitoneum
The Veress needle may be introduced either at umbilicus level or at Palmer’s point (3 cm below the costal margin on the left midclavicular line). The peritoneal cavity is inflated with CO2 to a pressure which does not exceed 14 mm Hg.
8. Instruments
• Optical
The procedure may be performed using a 0° or 30° laparoscope.
• Operating
1. Bipolar grasper
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
7. Scissors
• Retractors
Uterine cannulation with an asymmetric grasper
9. Exposure
• Principles
Laparoscopic procedures in gynecology are performed in the pelvic cavity. In supine position, the cavity is naturally filled with part of the small intestinal loops and with the sigmoid colon.
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.
• Trendelenburg position
It causes the small intestinal loops and the sigmoid loop to move cephalad, thereby exposing the pelvis. Its angle should not exceed 30°.
• Uterine manipulation
• Principle
The uterus is anteverted in order to expose the rectouterine pouch. It is also displaced towards the side contralateral to the ectopic pregnancy, freeing the adnexa requiring treatment.
• Instruments
The cannulation may be performed using diverse instruments.
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.
• Exposure
The first assistant holds the laparoscope, pushes the small intestinal loops cephalad and maintains the sigmoid loop cephalad using a flat fenestrated grasping forceps.
The second assistant anteverts the uterus and pushes it to the side contralateral to the EP.
10. Exploration
Exploration is performed to:
- 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.
11. Conservative treatment
• General principles
The conservative treatment for EP is characterized by the following:
- 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.
• Tubal incision
The surgeon holds the tube on its anti-mesosalpingeal border with an atraumatic grasper.
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.
• EP extraction
The extraction is performed by aspiration. The suction-irrigation device is introduced into the tube. Saline instillation detaches the trophoblast and the clots in the tube.
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.
• Hemostasis
Hemostasis of the margins of the incision can be useful. A bipolar grasper is used. When there is active bleeding from the bed of the site of implantation, hemostasis is difficult and attempts to achieve hemostasis may result in irreversible tubal damage. A lavage can be useful as it favors hemostasis. In case of failure, it is best to convert to radical treatment.
Ipsilateral or contralateral adhesiolysis as well as fimbrioplasty or contralateral neosalpingostomy may be performed.
12. Specific cases
• Associated measures: injection
A prophylactic injection of ornithine-vasopressin to achieve hemostasis in the mesosalpinx is effective. Its use is forbidden in France, but authorized in the United States.
• Intramural EP
Intramural EP is difficult to treat laparoscopically, although a technique using surgical loops has been reported. It is a good indication for medical treatment. In the case of an unexpected onset and in the absence of rupture or prerupture, a 50 mg local injection of methotrexate is recommended.
• Fimbrial EP
This is the only site where it is not necessary to incise the tube. The trophoblast is aspirated. The infundibulum of the uterine tube is washed; hemostasis using a bipolar grasper is often useful.
13. Lap salpingectomy
• Principle
The main risk of laparoscopic salpingectomy is devascularization of the ovary. It is essential to remain close to the tube, and at a distance from the ovarian vessels and the suspensory ligament of the ovary.
• Proximal tubal division
The surgeon grasps the isthmus of the uterine tube with a toothed grasper and holds it upwards and outwards.
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.

• Mesosalpinx division
The bipolar grasper is then used to grasp the mesosalpinx parallel and close to the tube. The mesosalpinx is divided with scissors. As the division proceeds, the grasper holding the tube should be placed back to where the division was interrupted previously.
When the only remaining attachments of the tube are the infundibulo-ovarian ligament and the lateral tubal artery, these are respectively cauterized and divided.

• Extraction of the tube
The uterine tube is removed into an extraction bag through the anterior abdominal wall.
The procedure ends with a verification of the hemostasis and careful lavage.
• Dangers
Precautions must be taken to avoid a pathology caused by the tubal stump (endometriosis). The stump must be cauterized over a few millimeters to avoid patency from being re-established spontaneously and a utero-peritoneal fistula from forming. This technique limits the risk of subsequent EP from occurring in the intramural portion of the tube or in the remaining stump.
In cases of dense tubo-ovarian adhesions, a part of the tubal wall may sometimes be left on the ovary to avoid its devascularization.
14. Postop period
• Postop period
The urinary catheter and the nasogastric tube are removed at the end of the procedure.
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.
• Additional follow-up
A: Guaranteed recovery: no further checks
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).
• Failures
To treat failures, either a 50 mg/m2 dosage of Methotrexate is administered, or laparoscopic salpingectomy is performed.
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.
15. Medical treatment
Precautions
Medical treatment can only be considered if the patient is symptom-free and the level of beta-hCG is decreasing.

Medical treatment
- 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.

Absolute indications
- multiple surgical procedures/adhesions in the pelvic region;
- contraindications to laparoscopy;
- patients who refuse to undergo surgery.

Good indications
- patients with few or no symptoms;
- beta-hCG <5000 UI/L.

Controversial indications
- increased beta-hCG (>10000 UI/L) with cardiac activity present;
- patients experiencing pain;
- potential poor compliance.
16. Reference
Bruhat MA, Manhes H, Mage G, Pouly JL. Treatment of ectopic pregnancy by means of laparoscopy.
Fertil Steril 1980;33:411-4.
Dubuisson JB, Morice P, Chapron C, De Gayffier A, Mouelhi T. Salpingectomy - the laparoscopic
surgical choice for ectopic pregnancy. Hum Reprod 1996;11:1199-203.
Philippe E, Ritter J, Lefakis P, Laedlein-Greilsammer D, Itten S, Foussereau S. Grossesse tubaire,
ovulation tardive et anomalie de nidation. Gynecol Obstet (Paris) 1970;69:617+.
Pouly JL, Chapron C, Manhes H, Canis M, Wattiez A, Bruhat MA. Multifactorial analysis of fertility after
conservative laparoscopic treatment of ectopic pregnancy in a series of 223 patients. Fertil Steril
1991;56:453-60.
Pouly JL, Mage G, Gachon F, Gaillard G, Bruhat MA. La décroissance du taux d'HCG après
traitement coelioscopique conservateur de la grossesse extra-utérine. J Gynecol Obstet Biol Reprod
1987;16:195-9.