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Simulation

Laparoscopic Salpingectomy for Ectopic Pregnancy

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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

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.

The CREOG Surgical Skills Task Force created this simulation as part of a standardized surgical skills curriculum for use in training residents in obstetrics and gynecology.