Surgical Treatment Operative management is the most widely used treatment for ectopic pregnancy. The surgical approach (laparotomy versus. laparoscopy) and procedure (salpingectomy versus. salpingostomy) used to treat ectopic pregnancies depend on the clinical circumstances, available resources, and provider skill level. Each approach and procedure has associated risks and benefits, and the treatment employed must be individualized to best meet the needs of the patient and provider.
Treatment of an ectopic pregnancy can be accomplished by laparoscopy or laparotomy.
The hemodynamic stability of the patient, size and location of the ectopic mass, and the surgeon’s expertise all contribute to determining the appropriate surgical approach. Laparotomy is indicated when the patient becomes hemodynamically unstable and an expedited abdominal entry is required. A ruptured ectopic pregnancy does not necessarily require laparotomy.
If the hemoperitoneum cannot be evacuated in a timely manner, laparotomy should be considered. Surgeon’s experience with laparoscopy and the availability of laparoscopic equipment will determine the surgical approach. Cornual or interstitial pregnancies traditionally were treated with laparotomy, although laparoscopic management was described and is becoming common among skilled surgeons (174). Laparotomy is chosen for the management of most abdominal pregnancies. In some cases, the patient may have extensive abdominal or pelvic adhesive disease, making laparoscopy difficult and laparotomy more feasible.
Laparoscopy has advantages over laparotomy for management of ectopic pregnancy. In a case-control study of 50 patients comparing the use of laparoscopy and laparotomy for ectopic pregnancy management, hospital stay was significantly shorter (1.3 ± 0.8 versus. 3.0 ± 1.1 days), operative time was shorter (78 ± 26 versus. 104 ± 27 minutes), and convalescence was shorter (9 ± 8 versus. 26 ± 16 days) in the laparoscopy group (175). Laparoscopic management was associated with significant cost savings when compared with laparotomy ($4,368 ± $277 versus 5090 ± 168). Using a prospective analysis, 105 patients with tubal pregnancy were stratified with regard to age and risk factors and randomized to undergo either laparoscopic management or laparotomy (176). Subsequently, 73 patients underwent second-look laparoscopy to assess the degree of adhesion formation. Patients treated by laparotomy had significantly more adhesions at the surgical site than those treated by laparoscopy, but tubal patency rates were similar. A recent Cochrane review confirmed these findings and laparoscopic salpingostomy was associated with decreased cost, operative time, blood loss, and hospital stay when compared to salpingostomy at the time of a laparotomy (177).
An alternative to laparoscopy is the use of a minilaparotomy incision. This approach has the advantage of not requiring laparoscopic equipment and utilizes a smaller incision that should result in decreased postoperative pain and shorter recovery times for patients. A randomized control trial comparing minilaparotomy to laparotomy showed decreased complication rates and reduced costs associated with the minilaparotomy incision with similar success rates in the treatment of the ectopic pregnancy (177,178).