Surgical Approach

Overall, laparoscopy as compared with laparotomy has emerged as the preferred surgical approach in the treatment of EP in a hemodynamically stable patient. Laparoscopy has been shown to be associated with less blood loss, reduced postoperative adhesion formation, reduced analgesic requirements, reduced hospital stay and convalescence period, and reduced medical expenditures as compared with laparotomy. In a review of studies examining salpingostomy via a laparoscopic or laparotomy approach, the rates of persistent EP for the laparoscopic approach (3 to 20 percent) versus laparotomy (zero to 11 percent) were reported to be comparable. Reproductive outcomes for patients attempting to conceive after the procedure [intrauterine pregnancy (61 percent) and recurrent EP (15 percent)] also were reported to be similar. Laparotomy is reserved for cases that are too difficult for laparoscopic surgery, for hemodynamically unstable patients, and where the operator is inexperienced with operative laparoscopy. Surgical methods for the treatment of tubal EP include salpingectomy, salpingostomy, salpingotomy, segmental tubal resection and anastomosis, and fimbrial evacuation. Fimbrial evacuation of distal ectopic pregnancies is not recommended because of the higher recurrence rate of EP and high incidence of persistent trophoblastic tissue. Which of the other approaches is used depends on hemodynamic stability, the portion of the fallopian tube involved, and the patient's desire for future pregnancy. Segmental tubal resection and anastomosis is recommended for an unruptured pregnancy in the isthmic portion of the fallopian tube because of associated scarring and narrowing of the tube using other methods (e.g., salpingostomy or salpingotomy). 24

In cases where future fertility is of no concern or the patient is hemodynamically unstable, salpingectomy is the definitive surgical method. Laparoscopic salpingostomy is recognized as the preferred surgical method for the treatment of unruptured EP in patients where future fertility is desired. This more conservative approach has been reported to result in a higher rate of subsequent intrauterine pregnancies (61 versus 38 percent). However, salpingostomy compared to salpingectomy is associated with an increased risk of persistent EP (3 to 20 percent) and recurrent EP (15 versus 10 percent, respectively). Salpingostomy is performed via laparoscopy by making a linear incision (by electrocautery, scissors, or laser) over the antimesenteric side of the fallopian tube overlying the EP. The products of conception are removed (by forceps or suction) and the incision is left open to heal by secondary intention. The tubal incision can also be sutured (salpingotomy).24

Specific indications for laparoscopic salpingostomy include hemodynamic stability, ectopic size £5 cm, unruptured or ruptured fallopian tube with minimal tubal destruction, appropriate location of the conceptus (ampullary, infundibular, isthmic), surgical accessibility of the fallopian tube, and the patient's with to preserve reproductive potential. Laparotomy can also be used to perform a linear salpingostomy and should be utilized for patients who are hemodynamically unstable or for whom the laparoscopic approach is difficult (e.g., secondary to adhesions).

To assess for a persistent EP following laparoscopic salpingostomy, a weekly hCG level is obtained. By the second postoperative week, the hCG level should be undetectable or less than 20 mlU/mL. If hCG values are above 20 mlU/mL 2 weeks postoperatively, then a repeat sample shoud be obtained 2 weeks later to establish absence of hCG concentrations. Persistent trophoblastic tissue can be found in the fallopian tube or peritoneum; it is most commonly found in the proximal portion of the fallopian tube. Persistent ectopic pregnancies have been successfully treated by surgical reoperation, methotrexate treatment, or expectant management.24,2,5,

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