腹腔镜手术治疗输卵管异位妊娠（图文演示）

10. Exploration

Exploration is performed to:
- determine the precise location of the EP;
- evaluate the extent of the hemoperitoneum;
- determine the condition of the adnexa, especially that of the contralateral tube;
- visualize any active bleeding;
- rule out any other associated abdominal pathology.
A massive hemoperitoneum and clots occasionally prevent the surgeon from establishing a precise workup of the lesions straight away. In these cases, the first operative step consists in evacuating the hemoperitoneum.
If the EP is small in size, both tubes should be explored: there may be a hematosalpinx contralateral to the EP due to retrograde reflux.

11. Conservative treatment
• General principles

The conservative treatment for EP is characterized by the following:
- preservation of the uterine tube;
- incision made on the anti-mesosalpingeal side of the tube;
The surgeon must bear in mind that EP is proximal (towards the uterus) and that hematosalpinx is distal.
The case described here is a left ampullary EP.

• Tubal incision

The surgeon holds the tube on its anti-mesosalpingeal border with an atraumatic grasper.
A 1 to 2 cm longitudinal incision is made on the anti-mesosalpingeal border, over the proximal portion of the EP site. If it is too distal, the risk of leaving the trophoblast in place is high.
The incision is made using a needle point electrocoagulater, until the trophoblast or the hematosalpinx appears. Scissors or a laser may also be used.

• EP extraction

The extraction is performed by aspiration. The suction-irrigation device is introduced into the tube. Saline instillation detaches the trophoblast and the clots in the tube.
The extraction may also be performed using a toothed forceps.
Suture of the tube is unnecessary.
Tubal expression is not recommended, even in case of tuboperitoneal abortion. It increases the risk of failure.
The trophoblast (when it has not been aspirated) should be removed into an extraction bag to avoid it from spreading into the abdominal pelvic cavity and to prevent peritoneal implants from propagating.

• Hemostasis

Hemostasis of the margins of the incision can be useful. A bipolar grasper is used. When there is active bleeding from the bed of the site of implantation, hemostasis is difficult and attempts to achieve hemostasis may result in irreversible tubal damage. A lavage can be useful as it favors hemostasis. In case of failure, it is best to convert to radical treatment.
Ipsilateral or contralateral adhesiolysis as well as fimbrioplasty or contralateral neosalpingostomy may be performed.

12. Specific cases
• Associated measures: injection

A prophylactic injection of ornithine-vasopressin to achieve hemostasis in the mesosalpinx is effective. Its use is forbidden in France, but authorized in the United States.

• Intramural EP

Intramural EP is difficult to treat laparoscopically, although a technique using surgical loops has been reported. It is a good indication for medical treatment. In the case of an unexpected onset and in the absence of rupture or prerupture, a 50 mg local injection of methotrexate is recommended.

• Fimbrial EP

This is the only site where it is not necessary to incise the tube. The trophoblast is aspirated. The infundibulum of the uterine tube is washed; hemostasis using a bipolar grasper is often useful.

13. Lap salpingectomy
• Principle

The main risk of laparoscopic salpingectomy is devascularization of the ovary. It is essential to remain close to the tube, and at a distance from the ovarian vessels and the suspensory ligament of the ovary.

• Proximal tubal division

The surgeon grasps the isthmus of the uterine tube with a toothed grasper and holds it upwards and outwards.
With the other hand, the surgeon cauterizes the isthmus close to the uterus using a bipolar grasper. The grasper should slightly overlap the mesosalpinx to achieve hemostasis, without proceeding too far to avoid cauterizing the internal ovarian artery/ovarian branch of the uterine artery. The tube is then divided with scissors.

• Mesosalpinx division

The bipolar grasper is then used to grasp the mesosalpinx parallel and close to the tube. The mesosalpinx is divided with scissors. As the division proceeds, the grasper holding the tube should be placed back to where the division was interrupted previously.
When the only remaining attachments of the tube are the infundibulo-ovarian ligament and the lateral tubal artery, these are respectively cauterized and divided.


• Extraction of the tube

The uterine tube is removed into an extraction bag through the anterior abdominal wall.
The procedure ends with a verification of the hemostasis and careful lavage.

• Dangers

Precautions must be taken to avoid a pathology caused by the tubal stump (endometriosis). The stump must be cauterized over a few millimeters to avoid patency from being re-established spontaneously and a utero-peritoneal fistula from forming. This technique limits the risk of subsequent EP from occurring in the intramural portion of the tube or in the remaining stump.
In cases of dense tubo-ovarian adhesions, a part of the tubal wall may sometimes be left on the ovary to avoid its devascularization.

14. Postop period
• Postop period
The urinary catheter and the nasogastric tube are removed at the end of the procedure.
IV may be removed on the evening of the procedure.
Food may be given on the evening of the procedure.
Postoperative analgesia with non-opioid analgesics.
Discharge is possible the day after surgery.
Use of contraceptives should be discussed with the patient.
The patient may try to become pregnant again 2 to 3 months post-op.
The patient is informed of the risk of recurrence.

• Additional follow-up

A: Guaranteed recovery: no further checks
B: Monitoring until hCG is negative if rate >2000 UI/mL
C: Strict monitoring until negative regardless of hCG rate
D: Failure very probable
The beta-hCG level should be checked until negative, every 2 days during the first week, then on a weekly basis. Beta-hCG typically drops to zero by post-op day 20.
The decrease in the beta-hCG level should be exponential. A decrease that is too slow or a secondary rise confirms that the salpingostomy has failed.
A predictive diagram was established for the postoperative monitoring of the decrease in the percentage of hCG following conservative laparoscopic treatment of ectopic pregnancy (Pouly, 1987).

• Failures
To treat failures, either a 50 mg/m2 dosage of Methotrexate is administered, or laparoscopic salpingectomy is performed.
Hysterosalpingography may be performed 3 months after the procedure to assess tubal patency.
If the patient’s blood group is Rh negative, an injection of anti-D gammaglobulins is necessary within 72 hours after an EP is detected to prevent anti-D alloimmunization.

15. Medical treatment
Precautions
Medical treatment can only be considered if the patient is symptom-free and the level of beta-hCG is decreasing.

Medical treatment
- Methotrexate is the most commonly prescribed treatment. The trophoblast is particularly sensitive to this antifolate antimitotic agent. It has been used for many years in the treatment of molar pregnancy.
Methotrexate is generally administered by intramuscular injection, at a dosage of 50 mg/m2 (body surface area) or 1.5 mg/kg. The injection is repeated 7 days afterwards in case of a decrease of <15% between day 4 and day 7.
- Mifepristone: this antiprogesterone may be associated with Methotrexate. Although its theoretical value seems obvious, few studies have confirmed this potential.
In all cases, medical treatment is reserved for:
- EP without sonographic or clinical signs of rupture or prerupture;
- with a stable hemodynamic status;
- presenting with an abnormal rise or stabilization in the level of the b-hCG after 48 hours;
- in motivated and informed patients.

Absolute indications
- multiple surgical procedures/adhesions in the pelvic region;
- contraindications to laparoscopy;
- patients who refuse to undergo surgery.

Good indications
- patients with few or no symptoms;
- beta-hCG <5000 UI/L.

Controversial indications
- increased beta-hCG (>10000 UI/L) with cardiac activity present;
- patients experiencing pain;
- potential poor compliance.

16. Reference
Bruhat MA, Manhes H, Mage G, Pouly JL. Treatment of ectopic pregnancy by means of laparoscopy.
Fertil Steril 1980;33:411-4.
Dubuisson JB, Morice P, Chapron C, De Gayffier A, Mouelhi T. Salpingectomy - the laparoscopic
surgical choice for ectopic pregnancy. Hum Reprod 1996;11:1199-203.
Philippe E, Ritter J, Lefakis P, Laedlein-Greilsammer D, Itten S, Foussereau S. Grossesse tubaire,
ovulation tardive et anomalie de nidation. Gynecol Obstet (Paris) 1970;69:617+.
Pouly JL, Chapron C, Manhes H, Canis M, Wattiez A, Bruhat MA. Multifactorial analysis of fertility after
conservative laparoscopic treatment of ectopic pregnancy in a series of 223 patients. Fertil Steril
1991;56:453-60.
Pouly JL, Mage G, Gachon F, Gaillard G, Bruhat MA. La décroissance du taux d'HCG après
traitement coelioscopique conservateur de la grossesse extra-utérine. J Gynecol Obstet Biol Reprod
1987;16:195-9.