|Year : 2019 | Volume
| Issue : 1 | Page : 18-23
Laparoscopic management of ectopic pregnancy: An observational study from North Kashmir
Sieqa Shah1, Samina A Khanday2, Majid Mushtaque3, Ibrahim R Guru4
1 Department of Gynaecology and Obstetrics, SKIMS Medical College, Srinagar, Jammu and Kashmir, India
2 Department of Pathology, Government Medical College, Srinagar, Jammu and Kashmir, India
3 Department of Health and Family Welfare, Sub District Hospital (SDH), Chadoora, Jammu and Kashmir, India
4 Department of Gynecology and Obstetrics, Guru Multi Specialty Hospital, Sopore, Jammu and Kashmir, India
|Date of Submission||24-Jun-2019|
|Date of Acceptance||14-Jul-2019|
|Date of Web Publication||26-Sep-2019|
Dr. Majid Mushtaque
Department of Health and Family Welfare, SDH, Chadoora, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: With advancements in field of minimally invasive surgery, increasing number of patients with ectopic pregnancy (EP) can be managed laparoscopically.
Aims and Objective: To evaluates our experience of laparoscopic management of ectopic pregnancy in terms of its safety and efficacy. This is an observational study conducted over a period of seven years at Guru Multi-specialty Hospital Sopore, Kashmir, India.
Materials and Methods: A total of 84 patients with EP were included in the study. The diagnosis was made by detailed history, clinical examination, βHCG assay, abdominal and transvaginal ultrasonography. All patients underwent laparoscopic salpingectomy or salpingostomy depending on the clinical scenario. The outcome was analysed in terms of details of the procedure, mean operative time, post-operative VAS score (0-10), complications, hospital stay and subsequent fertility. Histopathological examination of the resected fallopian tubes was also evaluated. Statistical analysis was done as a prospective sample survey analyzing percentage and mean values.
Results: Sixty-one patients had chronic ectopic while 23 presented acutely. Seventy-seven (91.66%) patients were diagnosed by clinical, laboratory and sonographic modalities while 7 (14.17%) required diagnostic laparoscopy for confirmation. Ampulla was the site of EP in 75% of cases. Ruptured fallopian tubes were found in 20 (86.95%) and 9 (14.75%) patients who presented with acute and chronic ectopic respectively. The patients with chronic ectopic were managed with laparoscopic salpingectomy and laparoscopic salpingostomy in 45 (73.77%) and 16 (26.22%) patients respectively. Patients with acute ectopic were underwent laparoscopic salpingectomy in 18 (78.26%) and salpingostomy in another 5 (21.73%) cases. The operative time was longer in patients with chronic ectopic ranging between 55-135 minutes. A total of five (5.95%) patients required blood transfusions. One each case of chronic and acute ectopic required conversion to open surgery. Histopathological examination of salpingectomy specimen revealed chronic salpingitis was seen in 39.68% of the cases. On follow-up, a total of 18 (29.5%) and 9 (39.13%) patients conceived within a year and another 5 (8.19%) and 2 (8.69%) did so between 1-2 years who presented with chronic and acute ectopic respectively.
Conclusions: Laparoscopic approach in treatment of EP is safe and feasible irrespective of the type of presentation with all advantages of minimal access surgery and greatly reduced morbidity.
Keywords: Acute ectopic pregnancy, chronic ectopic pregnancy, laparoscopic surgery, salpingostomy, salpingectomy
|How to cite this article:|
Shah S, Khanday SA, Mushtaque M, Guru IR. Laparoscopic management of ectopic pregnancy: An observational study from North Kashmir. Saudi J Laparosc 2019;4:18-23
|How to cite this URL:|
Shah S, Khanday SA, Mushtaque M, Guru IR. Laparoscopic management of ectopic pregnancy: An observational study from North Kashmir. Saudi J Laparosc [serial online] 2019 [cited 2019 Nov 15];4:18-23. Available from: http://www.saudijl.org/text.asp?2019/4/1/18/267856
| Introduction|| |
Eccyesis or ectopic pregnancy (EP) is characterized by implantation of the fertilized ovum in a position other than the uterine cavity. The frequency of EP has gradually increased substantially over the past two and a half decades., It is a common health problem in the women of reproductive age group, particularly in the first trimester of pregnancy and more so with the advent of assisted reproductive technology and in vitro fertilization, especially when performed for women with tubal factor infertility. EP accounts for 2% of first-trimester pregnancies. Ninety-eight percent of EP are located in various parts of the Fallopian tube More Details, and out of these, 70% are in the ampullary region. Other sites of ectopic implantation include isthmic (12%), fimbrial (11%), ovarian (3.2%), and interstitial (2.4%) regions and the abdominal cavity (1.3%).
The broad spectrum of clinical manifestations with EP complicates the diagnosis, as they vary from asymptomatic cases to acute abdomen and hemodynamic shock. In our country, majority of (EPs) are diagnosed after rupture. With high-resolution transvaginal sonography, serum beta-human chorionic gonadotropin (β-HCG) assay, and increased vigilance of the clinician, more and more cases are being diagnosed before rupture. Management generally includes medical or surgical methods; both are effective, but the selection depends on clinical situation, localization of EP, and diagnostic tools. The first successful surgery for an EP was performed by Robert Lawson Tait in 1883. Recently, laparoscopy has experienced numerous changes and developments, replacing to a great extent the traditional laparotomy. Laparoscopic approach has many benefits including less postoperative pain, shorter hospital stays, faster recovery, and better esthetic results., Whichever treatment is used, in addition to its effectiveness, it must preserve patients' fertility and limit the risk of recurrence. Not all EPs, however, are suitable for laparoscopic treatment. These include contraindication for laparoscopy, insufficient laparoscopic experience of the surgeon, or severe pelvic adhesion.
The aim of this study was to evaluate safety and feasibility of laparoscopic management of EP.
| Materials and Methods|| |
This retrospective observational study was conducted at Guru Multi Specialty Hospital, Sopore, Kashmir, from January 2010 to February 2017. A total of 119 patients with EP were received in the hospital. Twenty patients were treated medically with methotrexate and another 15 patients by conventional laparotomy. The present study included 84 patients who were managed laparoscopically. The initial diagnosis of EP was made through a combination of detailed history, clinical examination, β-HCG assay, and abdominal and transvaginal ultrasonography. Indications for surgery included hemodynamic instability; suspicion of, or risk factors for, rupture; and contraindications to methotrexate or failed medical treatment. Patients with ruptured ectopic and hemodynamic instability were aggressively resuscitated and operated immediately, while those with unruptured chronic ectopic were operated in the very first elective list.
All patients in the study group underwent a diagnostic laparoscopy with salpingectomy or salpingostomy depending on the clinical scenario. No case of tubal anastomosis was done in our series. All the procedures were performed under general anesthesia with the patient in the semi-lithotomy position. The first port was placed infraumbilically by modified Hasson technique, and after confirming the diagnosis, two 5 mm working ports were placed at the right and left lower quadrants under direct visualization. In the case of hemoperitoneum, aspiration and washing of the pelvis were done with the saline solution under pressure. Salpingectomy was performed by stepwise desiccation of the mesosalpinx with LigaSure and cutting along the mesosalpinx and across the proximal tube using scissors. For salpingostomy, a linear incision was given on the most prominent and distended antimesenteric border of the fallopian tube with a unipolar electrode knife. The suction-irrigation tube (5 mm) was introduced through the salpingotomy incision, and all clots and products of conception were aspirated. Hemostasis was assured, and any bleeding from the salpingostomy edges was managed with bipolar cautery. The tubal incision was left open and allowed to heal by secondary intention. A 5-mm 30 telescope was introduced from one of the working ports for visualization, and the surgical specimens (salpingectomy) placed in an EndoBag were removed through the 10-mm infraumbilical trocar sleeve using a 10-mm grasper. During surgery, tubal patency test with methylene blue was used to check the contralateral tube. The abdominal cavity was copiously irrigated with 4–5 L of warm saline at the end of each procedure, and a 20-Fr soft abdominal drain was kept in the rectouterine pouch in all the patients. The details of procedure, operating time, postoperative complications, conversion rate, visual analog scale (VAS) pain scores, hospital stay, and subsequent fertility were noted. Histopathological study of the resected fallopian tubes was done to look for any predisposing factors for EP. Statistical analysis was done by retrospective sample survey, analyzing percentage and mean values.
| Results|| |
A total 84 patients with EP were managed laparoscopically, of which 61 (72.61%) presented with chronic ectopic, while 23 (27.38%) presented acutely with symptoms and signs, suggestive of acute/ongoing blood loss. The detailed demographic features and presentations are shown in [Table 1]. Mean gravidity and gestational age at presentation was higher in patients who presented with chronic ectopic. Seventy-seven (91.66%) patients were diagnosed by clinical, laboratory, and sonographic [Figure 1] modalities. Confirmation of diagnosis by laparoscopy was required by 6 (9.83%) and one (4.34%) patients presenting with chronic [Figure 2] and acute [Figure 3] ectopic, respectively.
|Table 1: Demographic and clinical characteristics of women with an ectopic pregnancy according to presentation|
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|Figure 1: Transvaginal scan showing live extra-ovarian tubal pregnancy with minimal free fluid in pouch of Douglas|
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The most common site of tubal EP was the ampullary region in 63 (75%) of cases, followed by the isthmic and fimbrial regions. Two patients had heterotopic pregnancy. Operative findings and postoperative outcomes are depicted in [Table 2]. Ruptured fallopian tubes were found in 20 (86.95%) patients who presented acutely, while only 9 (14.75%) patients with chronic ectopic had tubal rupture which was contained by omental and adnexal adhesions. The patients with chronic ectopic were managed with laparoscopic salpingectomy in 45 (73.77%) and laparoscopic salpingostomy in 16 (26.22%) patients, while those with acute presentation were subjected to laparoscopic salpingectomy in 18 (78.26%) and laparoscopic salpingostomy in another 5 (21.73%) cases. The operative time was longer in patients with chronic ectopic ranging between 55 and 135 min. A total of 5 (5.95%) patients required blood transfusions [Table 2]. One each case of chronic and acute ectopic required conversion to open surgery because of uncontrolled bleeding. Mean VAS score, mean hospital stays, and complication rates were comparable between acute and chronic presentations. Histopathological examination of salpingectomy specimen (n = 63) revealed chorionic villi in the wall of the tube, confirming the ectopic gestation. Chronic salpingitis was seen in 39.68%, salpingitis isthmica nodosa in 6.34%, and tuberculosis in another 3.17% of the cases. On follow-up, a total of 18 (29.5%) and 9 (39.13%) patients conceived within a year and another 5 (8.19%) and 2 (8.69%) did so between 1 and 2 years who presented with chronic and acute ectopic, respectively.
| Discussion|| |
Robert Lawson Tait in 1883 introduced salpingectomy for the management of ruptured EP. It was much later, in 1973, that Shapiro and Adler described the treatment of EP by laparoscopy. Since then, there has been tremendous progress in the field of laparoscopy, which is now preferable to laparotomy in the management of the unruptured EP. Laparoscopic approach is also safe in acute ectopic provided the patient is hemodynamically stable and the surgical team is well experienced.
In the present study, the mean age was 28.3 and 27.1 years for patients presenting with chronic and acute ectopic, respectively, which was comparable to that of the other studies., Mean gravidity and gestational age at presentation was higher in patients who presented with chronic ectopic. The clinical presentation, risk factors, preoperative mean serum HCG, and hemoglobin values were also comparable to a historical cohort of patients with EP.,,,, Only 17 (20.2%) women in our series presented with shock at admission. Clinical signs of blood loss (tachycardia and hypotension), peritoneal signs, and adnexal tenderness were more frequent in patients with acute ruptured ectopic. Some series showed fewer women presenting with shock, while another showed a slightly higher proportion of patients presenting with shock compared to this study. Majority of patients (91.66%) in our study were diagnosed on the basis of combined clinical examination, urinary β-HCG levels, and transabdominal and/or transvaginal ultrasonography. The final diagnosis of EP was made at diagnostic laparoscopy in the rest of 7 (8.33%) patients. Similar results were reported in other studies.,,,,,
Ninety-eight percent of EP are located in various parts of the fallopian tube, of which about 70% are in the ampullary region. In our study, the patients who presented with chronic ectopic (n = 61) had tubal abortion, unruptured tubes, and ruptured tubes in 11.47%, 73.77%, and 14.75% of the cases, respectively, while those who presented acutely (n = 23) had tubal abortion in 13.04% and ruptured tubes in 86.95% of the patients. All the patients in this study were operated laparoscopically including those with shock who were adequately resuscitated before the procedure.
One of the greatest advantages of laparoscopy includes possibility of therapeutic intervention in the same sitting apart from providing a definitive diagnosis. Patients managed laparoscopically have lesser blood loss, lesser postoperative pain with less need for analgesics, less postoperative adhesions, and early recovery apart from other advantages of minimal access surgery when compared to laparotomy.,,,, With trained surgeons, skilled anesthetist, and supportive staff, along with availability of blood and blood components, volume expanders, and immediate conversion if necessary, laparoscopy is still possible even with massive hemoperitoneum after resuscitation of patients.
In all our cases of ruptured ectopic cases, the hemoperitoneum ranged from 1000 to 1800 ml which was managed by suction with a 5-mm suction cannula. Hemoperitoneum did not appear to be a deterrent in laparoscopic surgery, and patients can be managed successfully. We performed laparoscopic salpingectomy in 73.77% and salpingostomy in another 26.22% of the patients with chronic ectopic, while those who presented with acutely underwent salpingectomy in 78.26% and salpingostomy in 21.73% of the cases [Table 2]. The decision to perform salpingectomy was taken intraoperatively taking into consideration the severity of tubal damage or rupture, recurrent EP in the same tube, a large tubal pregnancy of >5 cm, and women who have completed their family. The tubal incision was left open and allowed to heal by secondary intention in patients who underwent salpingostomy in our study. Tulandi and Guralnick and Fujishita et al. in their studies emphasized that suturing of fallopian tubes has no additional benefit over the nonsuturing technique during salpingotomy in terms of number of subsequent intrauterine pregnancies and repeat EPs.
The mean operative time was longer with chronic ectopic (90 min) as compared to cases of acute ectopic (42 min). Two patients required conversion to open surgery because of uncontrolled hemorrhage, which is a key factor requiring conversion as per other studies. Blood transfusion was required by 5.95% of the patients in our study, of which majority had ruptured tubal pregnancy. Minor postoperative complications were noted in a total of 11 patients which did not affect the overall outcome.
Apart from other advantages of minimal access surgery in EP, laparoscopic approach provides an excellent view of the entire peritoneal cavity which helps in thorough lavage and more effective clearance of clots, dead tissues, and membranes from every quadrant of the abdomen which is difficult when done via laparotomy wound. This helps to reduce postoperative ileus and adhesions and can have a positive effect on long-term fertility rates. Furthermore, avoiding a laparotomy incision, laparoscopic approach leaves a virgin area for possible future lower segment cesarean section if there has not been one before.
Histopathological examination of the resected fallopian tubal ectopic can provide an insight into the etiopathogenesis of EP, and in some cases, it can also aid in the treatment modality to prevent a recurrent ectopic. In our study, histopathology of salpingectomy specimen (n = 63) revealed chronic salpingitis with villi in 39.68%, salpingitis isthmica nodosa in 6.34%, and tubercular salpingitis in another 3.17% of the patients which was in accordance with other earlier studies.
Fertility after salpingectomy has been compared with salpingostomy in many retrospective studies or reviews. The crude intrauterine pregnancy rates up to 24 months after surgery were 55.5% for salpingectomy and 50.9% for salpingostomy as reported by Li et al. We did not compare the fertility rates after different types of procedures. On follow-up, a total of 40.47% of our patients treated with laparoscopic technique conceived within a period of 2 years. Whether the combination of surgical approach (laparoscopic/open) with the type of surgery (salpingectomy/salpingostomy/tubal anastomosis) have a direct impact on subsequent fertility needs further evaluation.
The laparoscopy should be a primary approach for the treatment of EP in suitable patients. We believe that conventional laparotomy will eventually be replaced by laparoscopic approach for almost all cases of EPs.
| Conclusion|| |
Laparoscopic surgery for EP in skillful hands can be considered a safe and feasible management technique carrying all the advantages of a minimally invasive procedure apart from having a great role in diagnosis of clinically suspicious cases.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]