Two procedures-salpingostomy or salpingectomy-are options. Two multicenter, randomized controlled trials have compared laparoscopic outcomes between the two procedures in women with a normal contralateral fallopian tube. he European Surgery in Ectopic Pregnancy (ESEP) study randomized 23i1 women to salpingectomy and 215 to salpingostomy. After surgery, subsequent rates of ongoing pregnancy by natural conception did not difer significantly between groups-56 versus 61 percent, respectively (Mol, 2014). Again, in the DEMETER trial, the subsequent 2-year rate for achieving a uterine pregnancy did not difer between groups-64 versus 70 percent, respectively (Fernandez, 2013). In women with an abnormalappearing contralateral tube, salpingostomy is a conservative option for fertility preservation.
his procedure is typically used to remove a small unruptured pregnancy. A 10-to 15-mm linear incision is made on the anti mesenteric border of the fallopian tube over the pregnancy. The products usually will extrude from the incision. These can be carefully removed or flushed out using high-pressure irrigation that more thoroughly removes the trophoblastic tissue (Al-Sunaidi, 2007). Small bleeding sites are controlled with needlepoint electrocoagulation, and the incision is left unsutured to heal by secondary intention. Serum 3-hCG levels are used to monitor response to both medical and surgical therapy. After linear salpingostomy, serum 3-hCG levels decline rapidly over days and then more gradually, with a mean resolution time of approximately 20 days.
Seldom performed today, salpingotomy is essentially the same procedure except that the incision is closed with delayedabsorbable suture. According to T ulandi and Guralnick (1991), prognosis does not difer with or without suturing, and laparoscopic suturing adds surgical time.
Tubal resection may be used for both ruptured and unruptured ectopic pregnancies. To minimize the rare recurrence of pregnancy in the tubal stump, complete excision of the fallopian tube is advised. With one laparoscopic technique, the afected fallopian tube is lifted and held with atraumatic grasping forceps (Thompson, 2016). One of several suitable bipolar grasping devices is placed across the fallopian tube at the uterotubal junction. Once desiccated, the tube is cut. The bipolar device is then advanced across the most proximal portion of mesosalpinx. Similarly, current is applied, and the desiccated tissue cut. This process moves serially from the proximal mesosalpinx to its distal extent under the tubal ampulla. Alternatively, an endoscopic suture loop can be used to encircle and ligate the knuckle of involved fallopian tube and its underlying vascular supply within the mesosalpinx. Two consecutive suture loops are placed, and the tube distal to these ligatures is then cut free with scissors. Salpingectomy during laparotomy is shown in Chapter 39 (p. 704).
Most tubal ectopic pregnancies are small and pliant. Accord ingly, they can be held firmly by grasping forceps and drawn up into one of the accessory site cannulas. Larger tubal ectopic pregnancies may be placed in an endoscopic sac to prevent frag mentation as they are removed through the laparoscopic port site. Importantly, to remove all trophoblastic tissue, the pelvis and abdomen should be irrigated and suctioned free of blood and tissue debris. Slow and systematic movement of the patient from Trendelenburg to reverse Trendelenburg positioning dur ing irrigation can also assist in dislodging stray tissue and luid.
hese should be suctioned and removed from the peritoneal cavity.