Laparoscopic Management of Cornual Ectopic Pregnancy: A Step-by-step Approach

ABSTRACT

Interstitial and cornual pregnancies are dangerous, yet rare, forms of ectopic pregnancy, accounting for 2%–4% of all ectopic pregnancies. A 38-year-old female, para 1, gravida 3 had undergone another in vitro fertilisation (IVF) cycle (a salpingectomy performed elsewhere for treating a hydrosalpinx before a previous IVF attempt). Duration of pregnancy is 6 weeks and 5 days, a transvaginal ultrasound revealed an embryo with a positive foetal heartbeat, located in the left cornuum. As no conservative treatment option could be followed, we proceeded with laparoscopic removal of ectopic pregnancy through cornual resection. Since a specific surgical methodology has not yet been established, presenting more step-by-step surgical approaches that can be used in clinical practice is of high importance. We present a step-by-step surgical approach that we have implemented in cases of cornual pregnancy in our department.

INTRODUCTION

Interstitial and cornual pregnancies are dangerous, yet rare, forms of ectopic pregnancy, accounting for 2%–4% of all ectopic pregnancies.[1] Cornual pregnancy refers to the implantation and following development of a gestational sac in the upper and lateral portions of the uterus.[1] On the other hand, an interstitial pregnancy occurs when a gestational sac implants in the proximal and intramural portion of the fallopian tube (which is enveloped by myometrium).[1]

Interstitial and cornual pregnancies remain the most difficult types of ectopic pregnancy to diagnose and treat.[2] The ’classic triad’ of ectopic pregnancy symptoms and signs (amenorrhea, abdominal pain and vaginal bleeding) occurs in <40% of patients.[3] Moreover, the site of implantation, in particular, makes this clinical entity difficult to differentiate from an intrauterine pregnancy on ultrasound and sometimes requires expert advice and the use of three-dimensional ultrasonography scans and even magnetic resonance imaging for an accurate early diagnosis of interstitial pregnancy if suspected from two-dimensional ultrasonography scans.[3]

Conventionally, the treatment of interstitial pregnancy has been interventional: a surgical approach that may even extend to a hysterectomy or uterine cornual resection through laparotomy.[4] Recently and hopefully increase more conservative approaches have been suggested through laparoscopy.[4]

CASE REPORT

The case presented is about a 38-year-old female, para 1, gravida 3, with a history of a previous successful delivery after in vitro fertilisation (IVF) treatment cycle in the past. The patient had undergone a salpingectomy performed elsewhere for treating a hydrosalpinx before a previous IVF attempt, before another failed IVF cycle and before the successful one. Duration of pregnancy is 6 weeks and 5 days, a transvaginal ultrasound revealed an embryo with a positive foetal heartbeat (FHB), located in the left cornuum. Unfortunately, as expected due to the positive FHB, no conservative treatment option could be followed, and thus, we decided to proceed with a laparoscopy after an extended patient consent to treat the patient with a medical plan to maintain her future fertility.

We used Hasson's technique to create pneumoperitoneum and we gave the patient 1 g of tranexamic acid after her intubation. Intra-abdominal pressure was set at 15 mmHg after insertion of trocars. In the case presented, we used two lateral 5 mm and one 10 mm suprapubic port, with the patient in the Trendelenburg position. As presented in the supplemental videos, we followed the following surgical technique steps:

First step: We moved out the small bowel from the pelvis along with a very careful systematic inspection of the abdomen [Video Part 1]

Second step: A careful inspection of the cornual ectopic pregnancy followed. (In that case, we clearly saw an unruptured left cornual ectopic pregnancy in the patient) [Video Part 1].

Third step: The left broad ligament was opened and the pelvic sidewall structures were meticulously dissected. The left ureter was identified. Careful dissection was performed to open the medial left paravesical and pararectal spaces. The left uterine artery was fully skeletonised. We performed this as a protective measure to control possible intraoperative bleeding which could be very severe [Video Part 2].

Fourth step: We injected argipressin (1 ml of solution diluted in 100 ml of natural saline 0.9%) in the uterus around the ectopic pregnancy [Video Part 3].

Fifth step: Then, we put ’purse’ sutures (using a Vicryl 0 suture) around the ectopic pregnancy to perform further bleeding control and haemostasis. (partial rupture of the sac was noted after that step) [Video Part 3].

Sixth step: Then, we removed the ectopic pregnancy with a minimal part of healthy uterine muscle using the harmonic scalpel. Blood loss was minimal [Video Part 4].

Seventh step: A continuous stitching of the uterus using 180 V-Loc 2-0 suture followed [Video Part 5].

Eighth step: We finally removed the ectopic through the suprapubic port [Video Part 5].

Ninth step: Careful inspection and thorough haemostasis was performed [Video Part 5].

The patient was delivered 2 years after the procedure, after another successful IVF cycle and through a caesarean section, a healthy full-term baby without any clinical sign of rupture of the uterine wall.

DISCUSSION

Many cases of laparoscopic cornual resection have been reported in the literature, but a specific surgical methodology has not yet been established.[1] Although patients who present as critically ill and unstable (hypotension, severe abdominal pain or heavy vaginal bleeding) are likely to receive an emergency laparotomy, recent advances in laparoscopy have made the laparoscopic approach the gold standard of surgical treatment.[3] We present a step-by-step surgical approach that we have implemented in cases of cornual pregnancy in our department.

Declaration of patient consent

The authors certify that they have 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 her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.