Laparoscopy vs Laparotomy in Treatment of Ectopic Pregnancies
El-Tabbakh reported the results of a trial in Kuwait from March 1999 to October 2001, involving 207 patients to compare laparoscopy vs. laparotomy for surgical treatment of ectopic pregnancy. One hundred eighty-four were treated by laparoscopy and 23 by laparotomy of the 207 patients with a diagnosis of ectopic pregnancy based on clinical symptoms, history, physical examination, positive serum beta hCG, transvaginal ultrasonography and ectopic pregnancy conformed at laparoscopy. Following surgery, patients were followed with serial quantitative beta hCG on days 4 and 7, then weekly until labels less than 20 IU/L were obtained. Those treated with laparoscopy had an overall success rate of 98.9 percent. Moreover, the patients treated by laparoscopy had significantly lower blood loss. Blood transfusion was required by 13 percent in the laparoscopically treated group compared to 23 percent in the laparotomy group. All patients had the ectopic pregnancy confirmed by laparoscopy and the decision to proceed with operative laparoscopy or laparotomy depended on the minimally invasive surgery experience of the surgeon on call. There were no intraoperative complications and the duration of surgery ranged from 66 minutes to 72 minutes for both groups. The Kuwait study led the author to conclude that laparoscopy treatment offered benefits superior to laparotomy with less blood loss, therefore, a reduced need for transfusion. The patients experienced less need for analgesia and a shortened postoperative hospitalization.
Yuen’s study included 105 patients in Hong Kong, there were no differences in age, parity, gestational age, and pregnancy of the previous laparotomy between the groups had a diagnostic laparoscopy prior to laparotomy. The laparoscopy group had a lower incidence of hemoperitoneum (45.9% vs 75%); Yuen’s study was performed in Hong Kong. Yuen stated that operative laparoscopy has the advantage of combining diagnostic and therapeutic procedures in a single operation in a better approach than laparotomy for the management of tubal pregnancy.
Xiang’s study was conducted in Shanghai. Seventy-two of ectopic pregnancy patients were treated laparoscopically. The author concluded that while it was more expensive than laparotomy the operating time and postoperative hospitalization were shortened. In the laparoscopy studies, the authors stressed reduced blood loss, shortened hospital stay, and reduced need for postoperative analgesia as recurrent positive findings throughout the various studies.
Seeber commented on the laparoscopic treatment of salpingostomy versus salpingectomy. Seeber noted that if salpingostomy has not resulted in improvement of subsequent pregnancy rate over salpingectomy, then she would have recommended salpingostomy for all ectopic pregnancy patients. However, she states that the data to support this contention are not clear cut. The approximate 50 percent subsequent pregnancy rate has been noted with either method. The rate of recurrent ectopic pregnancy appeared higher in the salpingostomy (15–10%). The decision to perform salpingostomy is opposed to salpingectomy is often made intraoperatively. In case of severe damage or tubal rupture, tubal conservation is not indicated. Moreover, if tubal bleeding occurs that requires extensive coagulation, then salpingectomy may be indicated due to tubal damage. The success of in vitro fertilization has been beneficial for those patients who have salpingectomy. The formation of shadisation postoperatively has been more extensive with laparotomy. Seeber noted that ectopic pregnancy occurs most frequently as a result of fallopian tube pathology; therefore, there is a risk of recurrence in both the affected and contralateral tube. Women who undergo a salpingectomy will have a risk of subsequent ectopic pregnancy in the remaining tube.
As the surgeons gain more experience and training with laparoscopic surgery for ectopic pregnancy, it has become the preferred choice when equipment and resources are available.
Discussion
Ectopic pregnancy was first discovered in the 11th century, and until the middle of the 18th century, it was usually fatal. John Bard reported the first successful surgical intervention to treat an ectopic pregnancy in 1759.
According to Sepilian, the survival rate in the 19th century was dismal, however, at the beginning of the 20th century, improvement in blood transfusion, anesthesia, and antibiotics contributed to the decrease in the maternal mortality. Ectopic pregnancy currently is the leading cause of pregnancy-related deaths in the first trimester. Sepilian stated that ectopic pregnancy is derived from the Greek word “ektopos” meaning out of place, and it refers to the implantation of the fertilized ovum in a location outside of the uterine cavity including the fallopian tubes, cornual or interstitial region of the uterus and fallopian tubes, cervix, ovary, and the abdominal cavity. This abnormally implanted pregnancy grows and draws its blood supply from the site of abnormal implantation, as the gestation enlarges it creates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate fetal development. The arterial blood supply to the mesosalpinx provided by branches of the ovarian artery that derive directly from the aorta as well as the branches from the uterine artery that derive from the internal iliac artery provides the fallopian tubes with a rich arterial supply that can bleed in the event of a perforated tube, to massive catastrophic hemorrhage and maternal death.
Seeber reported in 2006 from a study at the University of Pennsylvania reported that the incidence of ectopic pregnancy has increased six-fold since 1970, and is responsible for approximately nine percent of all pregnancy-related deaths in the United States. The author further reported that a rise in the quantitative beta subunit of human chorionic gonadotropin of a maximum of 53 percent over two days would be required for a viable pregnancy, and a decline of 21 to 35 percent in 48 hours would be mandatory for a diagnosis of spontaneous abortion. Seeber stated that the absence of an intrauterine pregnancy above an established cut point of hCG is consistent with an abnormal pregnancy, but does not distinguish a miscarriage from an ectopic pregnancy. Seeber stated that the symptoms of abdominal pain or pelvic pain and vaginal bleeding are the most common complaints suggestive of ectopic pregnancy. The multiple potential sites of ectopic pregnancies add to the complexity of the diagnosis. Seeber also stated that these symptoms may be erratic and variable, and in some cases, absent. Likewise, such symptoms are non-specific, and also have been associated with spontaneous abortion, cervical irritation, or trauma, and infection.
Sepilian wrote that the classic triad of amenorrhea, pain, and vaginal bleeding has been strongly associated with the clinical presentation of ectopic pregnancy. However, 50 percent of patients with ectopic pregnancy present without this triad. They may have symptoms associated with early pregnancy, including nausea, fatigue, lower abdominal pain, painful uterine cramping, recent dyspareunia, and shoulder pain.
Due to increased technology, most ectopic is diagnosed prior to rupture. Sepilian reported that approximately 20 percent of ectopic patients are hemodynamically unstable at initial presentation suggesting a ruptured ectopic gestation. There is a 10 to 25 percent chance of a recurrent ectopic pregnancy. The risk factor included progesterone intrauterine device. Increasing maternal age plays important roles in ectopic pregnancy and women aged 35 to 44 years have a three to four-fold higher chance compared to women aged 15 to 24 years. Smoking may alter tubal and uterine motility and is associated with a risk of 1.6 to 3.5 times more than non- smokers. Other factors associated with an increased risk of ectopic pregnancies include prior abdominal surgery, a ruptured appendix, exposure to diethylstilbestrol, and uterine developmental abnormalities. Most authors list prior tubal infection. Chlamydia may be asymptomatic and untreated as well as other infectious agents associated with an increased risk of salpingitis and potential tubal damage. Sepilian stated that within the last two decades, there has been a more conservative surgical approach to unruptured ectopic gestation. Utilizing minimally invasive surgery, laparoscopy has become the recommended approach in most cases. Laparotomy has been usually reserved for cases where the patients have been hemodynamically unstable, or when the surgeon is inexperienced in laparoscopy.
Seeber stated that laparoscopic minimally invasive approach has become the preferred surgical approach, and laparotomy is reserved for hemodynamically unstable patients. Other situations in which the open surgical approach may be preferable include extensive pelvic adhesions where adequate visualization of the ectopic is impossible or extratubal, intra-abdominal ectopic gestation, where the risk of injury to other pelvic structures is high. Bruhart reported the first laparoscopic surgery for ectopic pregnancy in 1980.
El-Tabbakh reported the results of a trial in Kuwait from March 1999 to October 2001, involving 207 patients to compare laparoscopy vs. laparotomy for surgical treatment of ectopic pregnancy. One hundred eighty-four were treated by laparoscopy and 23 by laparotomy of the 207 patients with a diagnosis of ectopic pregnancy based on clinical symptoms, history, physical examination, positive serum beta hCG, transvaginal ultrasonography and ectopic pregnancy conformed at laparoscopy. Following surgery, patients were followed with serial quantitative beta hCG on days 4 and 7, then weekly until labels less than 20 IU/L were obtained. Those treated with laparoscopy had an overall success rate of 98.9 percent. Moreover, the patients treated by laparoscopy had significantly lower blood loss. Blood transfusion was required by 13 percent in the laparoscopically treated group compared to 23 percent in the laparotomy group. All patients had the ectopic pregnancy confirmed by laparoscopy and the decision to proceed with operative laparoscopy or laparotomy depended on the minimally invasive surgery experience of the surgeon on call. There were no intraoperative complications and the duration of surgery ranged from 66 minutes to 72 minutes for both groups. The Kuwait study led the author to conclude that laparoscopy treatment offered benefits superior to laparotomy with less blood loss, therefore, a reduced need for transfusion. The patients experienced less need for analgesia and a shortened postoperative hospitalization.
Yuen’s study included 105 patients in Hong Kong, there were no differences in age, parity, gestational age, and pregnancy of the previous laparotomy between the groups had a diagnostic laparoscopy prior to laparotomy. The laparoscopy group had a lower incidence of hemoperitoneum (45.9% vs 75%); Yuen’s study was performed in Hong Kong. Yuen stated that operative laparoscopy has the advantage of combining diagnostic and therapeutic procedures in a single operation in a better approach than laparotomy for the management of tubal pregnancy.
Xiang’s study was conducted in Shanghai. Seventy-two of ectopic pregnancy patients were treated laparoscopically. The author concluded that while it was more expensive than laparotomy the operating time and postoperative hospitalization were shortened. In the laparoscopy studies, the authors stressed reduced blood loss, shortened hospital stay, and reduced need for postoperative analgesia as recurrent positive findings throughout the various studies.
Seeber commented on the laparoscopic treatment of salpingostomy versus salpingectomy. Seeber noted that if salpingostomy has not resulted in improvement of subsequent pregnancy rate over salpingectomy, then she would have recommended salpingostomy for all ectopic pregnancy patients. However, she states that the data to support this contention are not clear cut. The approximate 50 percent subsequent pregnancy rate has been noted with either method. The rate of recurrent ectopic pregnancy appeared higher in the salpingostomy (15–10%). The decision to perform salpingostomy is opposed to salpingectomy is often made intraoperatively. In case of severe damage or tubal rupture, tubal conservation is not indicated. Moreover, if tubal bleeding occurs that requires extensive coagulation, then salpingectomy may be indicated due to tubal damage. The success of in vitro fertilization has been beneficial for those patients who have salpingectomy. The formation of shadisation postoperatively has been more extensive with laparotomy. Seeber noted that ectopic pregnancy occurs most frequently as a result of fallopian tube pathology; therefore, there is a risk of recurrence in both the affected and contralateral tube. Women who undergo a salpingectomy will have a risk of subsequent ectopic pregnancy in the remaining tube.
As the surgeons gain more experience and training with laparoscopic surgery for ectopic pregnancy, it has become the preferred choice when equipment and resources are available.
Discussion
Ectopic pregnancy was first discovered in the 11th century, and until the middle of the 18th century, it was usually fatal. John Bard reported the first successful surgical intervention to treat an ectopic pregnancy in 1759.
According to Sepilian, the survival rate in the 19th century was dismal, however, at the beginning of the 20th century, improvement in blood transfusion, anesthesia, and antibiotics contributed to the decrease in the maternal mortality. Ectopic pregnancy currently is the leading cause of pregnancy-related deaths in the first trimester. Sepilian stated that ectopic pregnancy is derived from the Greek word “ektopos” meaning out of place, and it refers to the implantation of the fertilized ovum in a location outside of the uterine cavity including the fallopian tubes, cornual or interstitial region of the uterus and fallopian tubes, cervix, ovary, and the abdominal cavity. This abnormally implanted pregnancy grows and draws its blood supply from the site of abnormal implantation, as the gestation enlarges it creates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate fetal development. The arterial blood supply to the mesosalpinx provided by branches of the ovarian artery that derive directly from the aorta as well as the branches from the uterine artery that derive from the internal iliac artery provides the fallopian tubes with a rich arterial supply that can bleed in the event of a perforated tube, to massive catastrophic hemorrhage and maternal death.
Seeber reported in 2006 from a study at the University of Pennsylvania reported that the incidence of ectopic pregnancy has increased six-fold since 1970, and is responsible for approximately nine percent of all pregnancy-related deaths in the United States. The author further reported that a rise in the quantitative beta subunit of human chorionic gonadotropin of a maximum of 53 percent over two days would be required for a viable pregnancy, and a decline of 21 to 35 percent in 48 hours would be mandatory for a diagnosis of spontaneous abortion. Seeber stated that the absence of an intrauterine pregnancy above an established cut point of hCG is consistent with an abnormal pregnancy, but does not distinguish a miscarriage from an ectopic pregnancy. Seeber stated that the symptoms of abdominal pain or pelvic pain and vaginal bleeding are the most common complaints suggestive of ectopic pregnancy. The multiple potential sites of ectopic pregnancies add to the complexity of the diagnosis. Seeber also stated that these symptoms may be erratic and variable, and in some cases, absent. Likewise, such symptoms are non-specific, and also have been associated with spontaneous abortion, cervical irritation, or trauma, and infection.
Sepilian wrote that the classic triad of amenorrhea, pain, and vaginal bleeding has been strongly associated with the clinical presentation of ectopic pregnancy. However, 50 percent of patients with ectopic pregnancy present without this triad. They may have symptoms associated with early pregnancy, including nausea, fatigue, lower abdominal pain, painful uterine cramping, recent dyspareunia, and shoulder pain.
Due to increased technology, most ectopic is diagnosed prior to rupture. Sepilian reported that approximately 20 percent of ectopic patients are hemodynamically unstable at initial presentation suggesting a ruptured ectopic gestation. There is a 10 to 25 percent chance of a recurrent ectopic pregnancy. The risk factor included progesterone intrauterine device. Increasing maternal age plays important roles in ectopic pregnancy and women aged 35 to 44 years have a three to four-fold higher chance compared to women aged 15 to 24 years. Smoking may alter tubal and uterine motility and is associated with a risk of 1.6 to 3.5 times more than non- smokers. Other factors associated with an increased risk of ectopic pregnancies include prior abdominal surgery, a ruptured appendix, exposure to diethylstilbestrol, and uterine developmental abnormalities. Most authors list prior tubal infection. Chlamydia may be asymptomatic and untreated as well as other infectious agents associated with an increased risk of salpingitis and potential tubal damage. Sepilian stated that within the last two decades, there has been a more conservative surgical approach to unruptured ectopic gestation. Utilizing minimally invasive surgery, laparoscopy has become the recommended approach in most cases. Laparotomy has been usually reserved for cases where the patients have been hemodynamically unstable, or when the surgeon is inexperienced in laparoscopy.
Seeber stated that laparoscopic minimally invasive approach has become the preferred surgical approach, and laparotomy is reserved for hemodynamically unstable patients. Other situations in which the open surgical approach may be preferable include extensive pelvic adhesions where adequate visualization of the ectopic is impossible or extratubal, intra-abdominal ectopic gestation, where the risk of injury to other pelvic structures is high. Bruhart reported the first laparoscopic surgery for ectopic pregnancy in 1980.
