Two Different Laparoscopic Suturing Techniques in a Case of Recurrent Cornual Ectopic Pregnancy 1 Year Apart

Abstract

Although cornual ectopic pregnancy is a rare condition in obstetric practice, it poses a great risk for pregnant women due to bleeding and hysterectomy. In this article, we aimed to minimise bleeding with two different suturing techniques after laparoscopic cornuostomy in a patient with recurrent cornual pregnancy (CP) 1 year apart. In the first operation, the cornuostomy was performed laparoscopically and the bleeding site was sutured one by one in a single layer with 2-0 monofilament absorbable suture. The same patient became spontaneously pregnant 1 year later and was hospitalised again with the diagnosis of CP. Laparoscopically, 3-0 barbed absorbable suture was applied around the gestational sac in the form of purse-string and bleeding was minimised by creating a tourniquet. In conclusion, barbed sutures can be easily applied laparoscopically as a purse-string in cornual pregnancies and surgical success can be increased by minimising the amount of bleeding.

INTRODUCTION

Cornual pregnancy (CP) is a type of ectopic pregnancy (EP) that implants in the interstitial segment of the fallopian tube.[1] It accounts for 2%–2.5% of EP-related deaths due to its difficult diagnosis and high vascular support.[2] Medical (methotrexate [mtx]) and surgical (laparotomic or laparoscopic cornuostomy or cornual resection) treatment options are available. Surgeons are reluctant to perform laparoscopy because of the high risk of bleeding and the difficulty of laparoscopic suturing. In this report, we aimed to minimise bleeding with two different suturing techniques after laparoscopic cornuostomy in a patient with recurrent CP 1 year apart.

CASE REPORT

A 25-year-old patient who first pregnancy was referred to our clinic with a diagnosis of EP. There was no significant gynecological feature in the patient’s medical history. When the patient was met in the emergency department, her general condition was poor, confused, and her blood pressure was 70 / 40 mmHg. The pulse could not be taken clearly because it was filiform. She was 9 weeks’ pregnant according to the last menstrual period and her β-hcg value was 9000 mIU/mL. On transvaginal ultrasound, the uterus was empty and the endometrium was 6-mm thin. A gestational sac with fetal heartbeat was observed 13 mm from the endometrial cavity. Myometrial thickness surrounding the sac was 3 mm (CP?) and there was diffuse free fluid in the douglas. Abdominal ultrasound revealed 5 cm of fluid under the liver and urgent laparoscopy was decided with a prediagnosis of ruptured CP. Laparoscopy revealed a ruptured CP of approximately 3 cm ×4 cm in the right uterine cornu and active haemorrhage. The mean amount of hematoperitenoum was 2000 mL. The gestational material was aspirated and the bleeding areas were coagulated with cautery. The cornual area was then sutured twice in a single layer with 2-0 monofilament absorbable suture (vicryl) to achieve haemostasis [Figure 1]. Approximately 500 mL of bleeding occurred inoperatively. The operation lasted approximately 47 min. Postoperatively, the patient’s hemoglobin value was 7.1/dL and appropriate blood replacement was performed. The patient whose general condition improved was discharged on the 2^nd day. The patient’s b-hcg value became negative on day 8 and follow-up was terminated.

Figure 1.

The first case report, operation images. (a) Active bleeding ruptured cornual pregnancy, (b) aspiration of pregnancy material, (c) achieving hemostasis with 2-0 monoflaman a single suture, (d) Overview of the pelvis

The same patient was admitted to our clinic as soon as she became pregnant 1 year later. The patient had no complaints and β-hcg values were closely follow-up because of her past history. On transvaginal ultrasonography, β-hcg was 4699 mIU/mL and the endometrial cavity was found to be empty. CP was diagnosed because the gestational sac was located in the right cornual region and mtx was administered. On the 5^th day of treatment, the patient developed pain and nausea. Urgent laparoscopy was decided upon the observation of douglas fluid on control ultrasonography. Laparoscopy revealed a ruptured CP measuring approximately 3 cm ×3 cm and active haemorrhage in the right uterine cornea. To facilitate suturing of the haemorrhage area and to isolate the gestational sac, right salpingectomy was first performed with harmonic device. Then a 3-0 barbed absorbable suture (v-loc) was placed in the form of a purse-string to create a tourniquet around the sac and bleeding was controlled with compression. In the next step, the contents were aspirated and normal anatomy was achieved. The cornu was closed continuously in multiple layers from the inside with the remaining barbed suture material [Figure 2]. Inoperative bleeding was approximately <50 mL. The operation lasted approximately 118 min. Postoperatively, the patient’s haemoglobin value was 8.7/dL and intravenous ferric-carboxymaltose was administered. The patient whose general condition improved was discharged on the 1^st day. B-hcg value became negative on day 13 and follow-up was terminated with recommendations.

Figure 2.

The second case report, operation images. (a) Recurrent ruptured cornual pregnancy at the same anatomical site, (b) Salfenjectomy to facilitate suturing, (c) Curved arrow indicates application of 3-0 barb suture in the form of a purse string, (d) Arrowhead and curved arrow together indicate the creation of a tourniquet to ensure hemostasis, (e) Multilayer closure of the defect

The patient was recommended not to get pregnant for 1 year and the endometrial cavity before pregnancy evaluate with operative hysteroscopy. Informed signed consent was obtained from the patient for both operations and publication.

DISCUSSIONS

CP is a rare subtype of EP with a 7-fold higher mortality rate due to high vascularization.[3] Although medical (methotrexat) and surgical treatment options are available, treatment should be individualized. The success rate of medical treatment in the early diagnosis of this pathology is 66.7%.[4] In this special case, cornuostomy or cornual resection can be performed laparotomically or laparoscopically. Although previous studies have reported no difference between these two techniques in terms of blood loss, postoperative complications and changes in fertility,[5] caution should be exercised as the possibility of uterine rupture may increase in pregnancies after resection. Therefore, we performed laparoscopic cornuostomy in our patient who had never given birth and had CP twice.

Different techniques have been used in the literature to ensure hemostasis in CP surgery. Sherer et al.[6] applied the stapling device (Endo GIA) for this procedure. Considering the cost, it is certain that both sutures we applied in our case are more advantageous than the stapling technique.

In a previous study, endoloop was applied to CP. Although blood loss is reduced with this technique, because the method is not fixed to the uterus, it may slip from the cornual area and bleed again. In another study, in a heterotopic pregnancy with CP, a modified purse-type suture was applied around the sac with 3-0 PDS and the suture tip was extracorporeally embedded in the uterine serosa to prevent slippage.[7] In this special case of active bleeding, where suturing is difficult in laparoscopic surgery, the application of intracorporeal PDS requires considerable experience and a high level of expertise.[8] With the developing technology, many innovations were offered to the service of medicine. Barb technology suture material (V-Loc) is one of them and is an important material for surgeons who do not have experience in intracorporeal knot tying. In our case, more sutures were applied in the second operation and the amount of bleeding was minimised. This can be said to be an advantage compared to the first operation. Although the duration of the second case was longer, we believe that the use of tourniquet-shaped purse-string barbed sutures fixed to the uterine serosa with experience will provide less bleeding in a shorter time.

Mallick and Ajala[9] laparoscopically applied carboprost to the myometrium and resected the EP without using sutures. Although this may control bleeding, given the bronchospasm and utero-tonic effects of carboprost, it should not be administered to women with active lung disease or heterotopic pregnancy because of its side effects and the safety of the intrauterine foetus.

In a recently published series of 17 cases, 15 patients underwent laparoscopic injection of vasopressin and cornual resection (VIPER) combined with purse-type suture. This integration reportedly minimises blood loss and reduces the risk of return to laparotomy.[10] Potential adverse effects of vasopressin such as bradycardia, cardiovascular collapse and death are also known in the literature. In our recurrence case, contrary to other studies, we did not administer vasopressin or any other uterotonic agent due to safety concerns, but only created a tourniquet by placing a barbed suture around the sac in a purse-string manner. By keeping the knot tight, we reduced the blood supply to this area as much as possible and easily achieved haemostasis. We also repaired the defect area with the remaining suture material in a multilayered continuous manner. Considering the problems experienced by OECD countries in supply vasopressin or carboprost and the undesirable side effects of these drugs, we completed our operation without the use of uterotonic agents. In this way, we believe that we reduced bleeding at least as much as other techniques and the possibility of transition to laparotomy. In our recurrence case, bleeding was completely stopped with the purse-string technique which we applied by creating a tourniquet on the uterine serosa with the help of barbed suture and then the cornual area was closed in multiple layers without coagulation. We believe that this is an advantage in terms of less bleeding and coagulation compared to our first case. In addition, in a previous study, adequate coagulation is recommended in cornual pregnancies. However, excessive coagulation may weaken the muscular layer of the uterus and cause a spectrum of placenta acreata in subsequent pregnancies.[11] We think that we can prevent the potential for placental invasion defect by minimizing bleeding with the purse-string technique we applied and without the need for coagulation.

CP accounts for a large percentage of maternal deaths due to EP because of its difficult diagnosis and high vascular support. Although laparotomy is initially considered in patients with impaired haemodynamics, with improved laparoscopic technique and experience, the amount of bleeding in the operation can be minimised by easily applying a barbed suture as a tourniquet around the cornual gestational sac. As a result, operative success can be increased by decreasing the rate of conversion to laparotomy without systemic side effects at low cost.

Ethics statement

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its amendments. The author certify that he has obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Author contributions

Conceptualisation, Methodology, Software, Validation, Formal Analysis, Research, Resources, Data Curation, Writing - Original Draft, Writing - Review and Editing, Visualisation, Supervision, Project Management by Gumusburun Neset. Gumusburun Neset has read and agreed to the final version of the manuscript.

Data availability statement

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.