Page 34 - WJOLS - World Journal of Laparoscopic Surgery

Laparoscopic Conservative Treatment and Laparoscopic Salpingotomy
are recommended to achieve lower failure rates and reduce the severe bleeding, removal of the tube must be considered but only
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probability of persistent ectopic pregnancy. Faulty equipment after mechanical compression of the mesosalpinx for at least 5
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and use of inappropriate instrumentation have been cited as minutes (Fig. 6). A preventive injection of vasoconstrictive drugs
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reasons for conversion or change in surgical techniques. (Pitressin) is an efficient alternative when permitted (Fig. 7). The
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The linear salpingotomy must be as nontraumatic as possible. salpingotomy incision is left open to heal by secondary intention
The most common technique is monopolar electrosection, because to decrease the risk of obstruction and allow better healing of
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it is the easiest and cheapest method. mucosal folds (Fig. 8). It was proved that suturing the tube
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As previously described, linear salpingotomy must be increases the risk of obstruction and decreases postoperative
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performed along the antimesenteric border to preserve tubal fertility. In addition, laparoscopic suturing is time-consuming and
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vascularization. The salpingotomy must be carried out at the it does not have additional benefits. Fertility performance after
internal part of the hematosalpinx. The trophoblast is located there, surgery appears to be related to reproductive performance before
and the distal part contains generally only clots. The incision should the ectopic pregnancy (Fig. 9).
be done over the ectopic pregnancy, reaching the proximal (medial)
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portion of the hematosalpinx. lApAroscopIc rAdIcAl treAtment
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This is very important because one study noted the (sAlpIngectomy) for tubAl ectopIc
trophoblastic tissue to be implanted medial to the salpingotomy
site in tubes that had been excised after the diagnosis of persistent pregnAncy
ectopic pregnancy. These findings suggest that surgeons may not Salpingectomy is the standard procedure if the condition of the
remove adequately the tissue medial to the site of the “bulge” tube is compromised (ruptured or otherwise disrupted), bleeding
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within the tube. is uncontrolled, or the gestation appears too large to remove with
Salpingostomy must be large enough (10–15 mm) to allow the salpingostomy. Salpingectomy is required in women who have
introduction of a 10 mm cannula and extraction of trophoblast contraindications to methotrexate therapy.
without difficulty through it. With a narrower device, the risk of
partial removal of the trophoblast increases. The high rate of
failure in some series is largely explained by the use of inefficient
suction devices.
The products of conception are released from the tube using
a combination of hydrodissection with irrigating solution under
high pressure and gentle blunt dissection with a suction irrigator.
The specimen can then be placed into a laparoscopic pouch and
removed from the abdominal cavity; it is also useful for removal
of large fragments of placental tissue. Using fluid to remove the
gestation is preferable to removing it bluntly. Extracting the
products of conception in pieces with forceps may lead to retained
trophoblastic tissue, particularly in the area of the tube proximal
to the ectopic gestation. The tubal expression (“tubal milking”)
without associated salpingotomy procedure is associated with
a higher rate of persistent ectopic pregnancy and should be
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avoided.
The use of a fine monopolar needle, as a result of its minimal Fig. 4: Exposure of an unruptured ampullar ectopic pregnancy (Donnez
surface, allows clean and the most precise cutting of the three tubal J, et al. Atlas of Operative Laparoscopy and Hysteroscopy. Informa; 2007)
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layers, avoiding further tissue damage.
The use of monopolar scissors or other devices with greater
surfaces leads to a less precise cutting limit and unnecessary
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thermal damage to the surrounding tissue.
The crucial point is to avoid large coagulation of the tubal wall,
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which can lead to a tuboperitoneal fistula. Therefore, it must be
achieved with a fine electrode and a cutting current. The electrode
must not be pressed on the tube but rather should just touch it
slightly to increase the power density. The speed of movement
along the incision must be sufficiently fast to maximize the cutting
effect and limit the collateral coagulation. Bipolar coagulation is
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forbidden for this step.
The tube is carefully irrigated, inspected for complete removal
of the trophoblast, and explored to ensure hemostasis.
Complete hemostasis of the tube is unnecessary or even
deleterious. If no vasoconstrictive drugs are used, the bleeding
generally comes from the trophoblast implantation area (Fig. 4).
Bipolar electrocoagulation, used to achieve hemostasis, leads to Fig. 5: A forceps, a monopolar electrode, and a suction device are
large destruction of the tube and is not efficient. Generally, the introduced into the abdomen (Donnez J, et al. Atlas of Operative
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bleeding stops by itself after 5–10 minutes (Fig. 5). In the case of Laparoscopy and Hysteroscopy. Informa; 2007)
142 World Journal of Laparoscopic Surgery, Volume 11 Issue 3 (September–December 2018)