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Laparoscopic Salpingectomy for Ectopic Pregnancy

Module

Ectopic Locations

  • Tubal is most common
    • Ampullary comprises most
    • Interstitial/cornual is most concerning given intersection of uterine and ovarian vessels
  • Non-tubal locations are rare
Ectopic locations diagram.

Indications for Treatment

Medical (Methotrexate)

  • Resources for compliance
  • Hemodynamically stable
  • No fetal cardiac activity
  • Ectopic size ≤ 3.5 cm

Surgical

  • Inability to comply with follow up
  • Hemodynamically unstable
  • Contraindications to MTX
    • Liver or renal disease
    • Breastfeeding
    • Blood dyscrasias
    • Immunocompromise
    • Peptic ulcer disease
    • Active pulmonary disease

Preoperative Preparation

  • Optimal surgical planning involves knowing:
    • Patient’s age, history, and desire for future fertility
    • History of previous ectopic pregnancies or PID
    • Condition of the affected tube (ruptured?)
    • Condition of the contralateral tube
    • Location of the pregnancy
    • Size of the pregnancy
    • Any other surgical or medical confounders

Surgical Options

  • Laparoscopic salpingostomy: Linear incision of fallopian tube with removal of ectopic tissue
  • Laparoscopic salpingectomy: Removal of entire affected fallopian tube
  • Laparotomy with salpingostomy or salpingectomy: Open incision to perform surgical management of ectopic pregnancy

Initial Steps

  • Consent
    • General laparoscopic risks
    • Injury to ipsilateral ovary
  • Labs
    • CBC, bhCG, Rh status, T&C
  • Positioning
    • Dorsal lithotomy
    • Manipulator
  • Abdominal entry
    • Laparoscopic techniques
    • Camera port with 2-3 accessory port sites
    • Inspection of abdomen and pelvis

Instruments

  • Standard laparoscopy set
  • Suction irrigator
  • Retrieval bag (depending on size of ectopic)
  • Electrosurgery device (bipolar, ultrasonic) or laparoscopic suture loop

Laparoscopic Salpingostomy

Indications

  • Unruptured ectopic pregnancy
  • Future fertility desired
  • No previous tubal surgery or ectopic in affected tube

Advantage

  • Higher intrauterine pregnancy rates (73%) than salpingectomy (57%)

Disadvantages

  • Requires follow up
  • Up to 20% will need salpingectomy for bleeding
  • Higher risk of recurrent ectopic (10-15%)

Salpingostomy Steps

  • Inject vasopressin into mesosalpinx below ectopic (A)
  • Monopolar needle tip electrode set to cut is used to make a 1-2 cm longitudinal incision (B)
    • Opposite the mesosalpinx
    • On maximally distended tube
  • Suction irrigator used in between tubal wall and pregnancy ectopic pregnancy to hydrodissect
Steps for a salpingostomy.
With permission from Mann/Stovall Gynecologic Surgery. Churchill Livingston 1996.

Follow Up for Salpingostomy

  • Residual tissue can remain after salpingostomy
  • If Rh negative – RhoGAM
  • Draw weekly bhCG until undetectable
    • If plateaus or rises – consider surgery methotrexate or salpingectomy
  • Reliable contraception is needed until resolved
    • Contraception to prevent confusion of persistent trophoblastic tissue or new pregnancy
    • Ovulation may occur as soon as 2 weeks after the end of an early pregnancy
  • Counsel patient regarding increased risk for future ectopic

Laparoscopic Salpingectomy

Indications

  • Ectopic pregnancy has ruptured
  • Future fertility is not desired
  • Ectopic occurs after sterilization
  • Tube has been previously reconstructed
  • Uncontrolled bleeding after salpingostomy

Advantage

  • Decreases recurrence risk of ectopic

Disadvantage

  • Lower success of subsequent intrauterine pregnancy

Laparoscopic Salpingectomy

  • Tubal excision (A)
    • Lift the affected tube with atraumatic graspers
    • Use an energy source to desiccate tissue and cut starting at the proximal portion of the tube and then advancing to the distal end
  • Ectopic removal (B-C)
    • If small, remove with cannula and grasping forceps all together
    • If larger, use endoscopic sac
  • Irrigation
    • Irrigate and suction all blood and debris to remove all trophoblastic tissue
  • Wound closure
Laparoscopic salpingectomy steps.
With permission from Mann/Stovall Gynecologic Surgery. Churchill Livingston 1996.

Salpingectomy with Endoloop

  • Alternative excision method uses endoscopic suture loops to ligate the vascular supply to the fallopian tube
  • Two or three suture loops are sequentially placed and the tube distal to the ligature is excised with scissors
  • Associated with shorter operating times and lower postoperative pain scores than other methods
Salpingectomy with endoloop.
With permission from Mann/Stovall Gynecologic Surgery. Churchill Livingston 1996.

Laparotomy

  • Reserved for:
    • Unstable patients
    • Cornual ectopic location
    • Surgeons with inexperience in laparoscopy
    • Difficult laparoscopic approach due to adhesions or massive hemoperitoneum
Technique of salpingectomy at laparotomy. 
Technique of salpingectomy at laparotomy. With permission from Mann/Stovall Gynecologic Surgery. Churchill Livingston 1996.

Interstitial Ectopic

  • Often diagnosed later due to distensibility of uterine myometrium
  • Rupture may cause significant hemorrhage due to anastomoses of uterine and ovarian vessels
  • Usually managed surgically by cornuostomy or cornual wedge resection
  • Many cases now managed laparoscopically
  • When deciding on route and procedure consider:
    • Gestational age
    • Presence of rupture
    • Hemodynamic stability
    • Desire for future fertility
    • Surgeon preference and skill
    Cornual resection and removal of interstitial pregnancy. 
    Cornual resection and removal of interstitial pregnancy. With permission from Mann/Stovall Gynecologic Surgery. Churchill Livingston 1996.
  • Exposure
  • Inspect pelvis
  • Inject dilute vasopressin into surrounding myometrium (vasopressin 20 u mixed in 50-100cc of saline - use 2-5 cc)

Cornuostomy

  • Linear incision through serosa and myometrium overlying the pregnancy
  • Remove products with blunt or sharp dissection, suction, hydrodissection
  • Control bleeding with electrosurgical coagulation or figure of 8 stitches using 2-0 delayed absorbable suture
  • Close myometrium with interrupted or continuous running fashion with delayed absorbable suture, typically 2-0 or 0-gague. May require multiple layers

Cornual Wedge Resection

  • Excise pregnancy, surrounding myometrium and ipsilateral tube en bloc
  • Serially ligate mesosalpinx
  • Incise cornual serosa surrounding the pregnancy with an electrosurgical blade, incision is angled inward as it is deepened
  • Achieve hemostasis with electrosurgical blade or figure of-8 stitches
  • Close myometrium with 2 or 3 layers of delayed absorbable suture with interrupted stitches or continuous running stitches
  • Consider final subserosal layer closure to prevent adhesions after either cornuostomy or wedge resection

Surgical Complications

Salpingostomy

  • Systemic vasoconstriction from intravascular vasopressin injection
  • Conversion to salpingectomy
  • Persistent trophoblastic tissu

Salpingectomy

  • Injury to ipsilateral ovary

General

  • Injury to surrounding structures: bowel, bladder, ovaries, uterus
  • Injury to nerves, vessels
  • Need to convert to open procedure

References

  • Chapter 33. Diagnosis and surgery for ectopic pregnancy. In: Mann/Stovall Gynecologic Surgery. Churchill Livingston; 1996.
  • Chapter 34. Ectopic pregnancy. In: Rock JA, Jones HW. Eds. Te Linde’s Operative Gynecology, 10e. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
  • Medical Management of Ectopic Pregnancy. ACOG Practice Bulletin; No 94, June, 2008.

Contributing Authors

  • Sarah M. Appleton, MD Assistant Professor Dept, of Obstetrics and Gynecology University of Colorado
  • Helen Dunnington, MD Assistant Professor Dept, of Obstetrics and Gynecology Baylor College of Medicine

Developed in association with The Society for Academic Specialists in General Obstetrics and Gynecology.