Page 33 - WJOLS - World Journal of Laparoscopic Surgery

Laparoscopic Conservative Treatment and Laparoscopic Salpingotomy
ectopIc pregnAncy: mAnAgement of of clinical symptoms, potential need for further treatment,
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treAtment optIons bAsed on locAtIon and postoperative serum hCG monitoring. Laparoscopic
salpingotomy should be considered as the primary treatment when
The management of ectopic pregnancy can be expectant, medical, managing tubal pregnancy in the presence of contralateral tubal
or surgical. The choice depends on the clinical circumstances, site disease and the desire for future fertility. The possibility of further
of ectopic pregnancy, and serum hCG levels. ectopic pregnancies in the conserved tube should be discussed
The laparoscopic approach is emerging as the gold standard for if salpingotomy is being considered by the surgeon or requested
the management of ectopic pregnancy by salpingostomy (incising by the patient.
the tube to remove the tubal gestation but leaving the remainder The European Surgery in Ectopic Pregnancy (ESEP) study
of the tube intact) or salpingectomy (removal of the fallopian tube), group suggests that salpingectomy should generally be preferred
depending upon the clinical scenario. to salpingotomy in women with tubal pregnancy and a healthy
In 1973, Shapiro and Adler described treatment of ectopic contralateral tube as salpingotomy does not significantly improve
pregnancy and reported laparoscopic salpingectomy using fertility prospects compared with salpingectomy.
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electrocoagulation. Results from another recent randomised controlled trial
Salpingotomy by laparoscopy was first reported using multiple (DEMETER) found that salpingostomy and salpingectomy resulted
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punctures in 1980. Linear salpingotomy with a cutting current was in similar rates of spontaneous conception of an intrauterine
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described by DeCherney et al. pregnancy at two years (70% vs 64%).
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Laparoscopy is the surgical procedure of choice to both confirm In a large prospective cohort study in France, the cumulative
and facilitate removal of an ectopic pregnancy. However, not all intrauterine pregnancy rate within 24 months was higher after
ectopic pregnancies are suitable for laparoscopic treatment, these salpingotomy than after salpingectomy (76% vs 67%). This
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include contraindication for laparoscopy, insufficient laparoscopic difference became significant, after multivariate analysis, in women
experience of the surgeon, or severe pelvic adhesion. older than 35 years and in those with a history of infertility or tubal
Laparotomy may be indicated if the patient is hemodynamically disease, in line with other data.
57–59
unstable or the size of the ectopic indicates an open surgery. The persistent trophoblast was more common in the
Patients should always be counseled on the risk of conversion to salpingotomy group than in the salpingectomy group, with the
laparotomy when laparoscopy is performed (Fig. 3). reported frequency similar to the 6% reported elsewhere.
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In reviews of controlled and uncontrolled studies, rates of
conservAtIve lApAroscopIc treAtment vs persistent trophoblast have been 8.1–8.3% after laparoscopic
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salpingotomy and 3.9–4.1% after open salpingotomy. Factors
rAdIcAl treAtment for ectopIc pregnAncy that have been suggested as increasing the risk of developing
The laparoscopic conservative treatment of ectopic pregnancy was persistent trophoblast include higher preoperative serum hCG
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reported by Manhes et al. Pouly investigated the fertility of cases levels (>3,000 IU/L), a rapid preoperative rise in serum hCG and

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that preserved tubes after surgical treatment for ectopic pregnancy. the presence of active tubal bleeding.
The ratios of intrauterine pregnancy and ectopic pregnancy after Two randomized trials found that the rates of recurrent ectopic
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salpingostomy were 67% and 12%, respectively. pregnancy after salpingostomy or salpingectomy are similar.
Laparoscopic procedures were associated with shorter Results of a cohort study reported in 2012 suggest that
operation times, less intraoperative blood loss, shorter hospital the 2-year cumulative rate of recurrence of ectopic was 19%
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stays, and lower analgesic requirements. whatever the treatment received. There was 18.5% recurrence
The use of conservative surgical techniques exposes women after salpingostomy or salpingectomy and 25.5% after medical
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to the risk of persistent trophoblast which may lead to recurrence treatment. After adjustment to confounders, the rate of
recurrence was significantly higher among women who had a
history of voluntary termination of pregnancy.
Conversely, fewer recurrences occurred among women having
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a history of infertility or previous live birth.
Ectopic implantation usually occurs because clinical or
subclinical salpingitis causes anatomic and functional changes
in the fallopian tubes. These changes are typically bilateral and
permanent; thus, it is not surprising that ectopic pregnancy is often
followed by recurrent ectopic pregnancy and infertility.
technIcAl Aspects of lApAroscopIc
conservAtIve treAtment
In the late 1970s, Bruhat et al. described principles and techniques
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for laparoscopic salpingostomy, and some improvements
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to the initial technique were made in the 1980s. Since then, the
technique has not been substantially modified.
There is some evidence that favors the conservative approach
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in terms of fertility prognosis.
Fig. 3: Sites of implantation of ectopic pregnancies (Nezhat C, Siegler A, In the absence of clinically relevant predictive factors of failure
et al. Operative Gynecologic Laparoscopy: Principles and Techniques. for a conservative surgical technique by laparoscopy, a standardized
2nd ed. McGraw-Hill; 2000) 45 surgical technique and the use of appropriate instrumentation
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