Endometriosis
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Laparoscopic Surgical Management of Interstitial Ectopic Pregnancy: The Retrograde Milking Technique

Laparoscopic Surgical Management of Interstitial Ectopic Pregnancy: The Retrograde Milking Technique
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Video Description

To present a unique case presentation featuring the laparoscopic placement of a secondary cervico-isthmic abdominal cerclage during a trichorionic triamniotic (TCTA) pregnancy. Notably, the procedure reveals an incidental finding of uterine dehiscence, subsequently addressed through the placement of a uterine omental patch. This video provides a comprehensive overview of the pertinent anatomy and key surgical steps involved in placing a transabdominal cerclage during a 12 week TCTA pregnancy through narrated illustrations and video footage. Uterine dehiscence and extrusion of placenta from triplet A is identified and repaired. The procedure was uncomplicated and the patient delivered 3 healthy infants by cesarean-hysterectomy at 33 weeks gestation. The laparoscopic placement of a uterine omental patch represents a novel technique for repair of uterine dehiscence during pregnancy. Its consideration should be based on the patient’s reproductive history, and acknowledgment for the limited long-term studies regarding this technique.

Presented By

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Dr. Sarah Freeman
Dr. Meghan McGrattan
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Dr. Mostafa Atri
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Dr. Ally Murji
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Affiliations

Mount Sinai & Women’s College Hospital

University of Toronto

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What is Laparoscopic Surgical Management of Interstitial Ectopic Pregnancy: The Retrograde Milking Technique?

The laparoscopic surgical management of interstitial ectopic pregnancy using the retrograde milking technique is a minimally invasive procedure to treat ectopic pregnancies that occur in the interstitial portion of the fallopian tube, where the tube connects to the uterus. Here’s how it works:

  • Interstitial Ectopic Pregnancy: This type of ectopic pregnancy occurs when a fertilized egg implants in the interstitial part of the fallopian tube. This area has a rich blood supply, making these pregnancies particularly high-risk for severe bleeding and uterine rupture as the pregnancy grows.

  • Laparoscopic Approach: Laparoscopy is a minimally invasive technique that uses small incisions, a camera, and specialized instruments to access the fallopian tube and uterus. This approach minimizes recovery time, reduces infection risk, and provides a clear view of the surgical site.

  • Retrograde Milking Technique: This technique involves gently compressing the interstitial portion of the fallopian tube in a “milking” motion, guiding the ectopic pregnancy tissue back toward the end of the tube for removal. This avoids cutting into the uterine wall and preserves as much of the reproductive anatomy as possible.

  • Benefits of the Technique: Retrograde milking allows for the removal of the ectopic tissue without requiring a full resection of the affected fallopian tube or uterine wall. It’s a conservative method that aims to preserve fertility and reduce risks associated with more invasive interventions.

This technique provides an effective, fertility-preserving option for managing interstitial ectopic pregnancies, using minimally invasive surgery to treat a high-risk condition safely.

What are the Risks of Laparoscopic Surgical Management of Interstitial Ectopic Pregnancy: The Retrograde Milking Technique? 

The laparoscopic surgical management of interstitial ectopic pregnancy using the retrograde milking technique carries specific risks due to the delicate nature of this type of ectopic pregnancy. Here are the main risks:

  • Uterine Rupture: The interstitial area, where the fallopian tube meets the uterus, is highly vascular. Manipulating this region can weaken the uterine wall, leading to a risk of rupture either during or after the procedure, which may require additional surgery.

  • Severe Bleeding: This area has a rich blood supply, increasing the risk of significant bleeding during or after surgery. Blood loss can be challenging to control and may necessitate blood transfusion or conversion to open surgery.

  • Incomplete Removal: There’s a risk of leaving some ectopic tissue behind, which may continue to grow, potentially leading to persistent symptoms or complications, and may require further intervention.

  • Tubal Damage or Infertility: Handling the fallopian tube and uterus during the procedure can lead to scarring or tubal damage, which may impact future fertility.

  • Infection: As with any surgical procedure, infection at the surgical site or within the pelvic region is a potential risk, potentially complicating recovery.

  • Postoperative Adhesions: Manipulation of the reproductive organs can lead to scar tissue formation, or adhesions, which may cause chronic pelvic pain or future fertility issues.

Careful surgical planning and technique are essential to reduce these risks and ensure effective, safe management of an interstitial ectopic pregnancy.

Video Transcript: Laparoscopic Surgical Management of Interstitial Ectopic Pregnancy: The Retrograde Milking Technique

Laparoscopic surgical management of interstitial ectopic pregnancy, the retrograde milking technique. The authors have no conflicts of interest to disclose. This video will review the classification and surgical management options for interstitial ectopic pregnancy, IEP, and demonstrate a novel approach to the management of distal IEP, the myometrium-sparing laparoscopic retrograde milking technique.

Interstitial pregnancy is a rare form of ectopic pregnancy in which implantation occurs in the fallopian tube, where it passes through the myometrium. Representing 2% of all ectopic pregnancies, IEPs are associated with a 2.5% mortality rate, necessitating clear diagnosis and prompt, skilful intervention. Establishing the precise location of the pregnancy is essential to surgical decision-making.

Traditionally, we have thought of IEPs as being centrally implanted within the interstitium. However, the interstitium measures 10 mm in length, allowing for implantation sites that may be more proximal or distal within this region, abutting either the fallopian tube or the endometrial cavity. We propose that IEPs can be classified into three subtypes according to their location, central, proximal and distal.

These subtypes will have different appearances on imaging and at the time of surgery, allowing us to differentiate between them. Typically, the management of IEP has involved laparoscopic cornuostomy or cornual wedge resection. This remains the mainstay of treatment for centrally implanted interstitial pregnancies, but is associated with risk of bleeding and uterine rupture in future pregnancies. Recently, myometrium-sparing alternatives have been proposed for some types of IEPs.

For distally implanted IEP, the surgeon may employ a laparoscopic retrograde milking technique, followed by salpingectomy. Hysteroscopically assisted laparoscopic salpingectomy has also been described. For a proximally implanted IEP, laparoscopically assisted hysteroscopic removal is described. If myometrial incision can be avoided, advantages may include reduced operative time, decreased blood loss, faster recovery and the possibility of vaginal delivery in subsequent pregnancies by avoiding a myometrial incision.

An option typically not recommended after a laparoscopic cornuostomy. Our case is a 38-year-old, otherwise healthy woman, who presented at 11 plus one weeks gestational age with four days of vaginal bleeding. Imaging revealed an ectopic pregnancy that was situated more in the tubal portion than within the interstitium, in keeping with a distal IEP. We will now demonstrate the laparoscopic retrograde milking technique for resection of distal IEP.

The steps are as follows. One, confirm the distal location of the interstitial pregnancy. Two, inject vasopressin. Three, milk the pregnancy distally. Four, perform the salpingectomy. Five, ensure haemostasis. At any point, the surgeon must be prepared for rupture of the pregnancy and possible need to change operative plans, which may include laparoscopic suturing of the myometrium to achieve haemostasis.

Step one, confirm the distal location of the IEP. It can be difficult, even on pre-operative imaging, to distinguish a proximal tubal ectopic pregnancy from a distal IEP. When the myometrium is distended around the most proximal portion of the fallopian tube, as you can see here, then the retrograde milking technique can be considered. Step two, inject vasopressin into the myometrium for enhanced haemostasis.

A dilution of 20 units of vasopressin in 100 cc of normal saline is used to facilitate redosing of vasopressin without exceeding the safe threshold of 12 pressor units. Step three, perform the retrograde milking technique. The pregnancy is carefully and gradually milked into the tubal ampulla in a sweeping motion, using the second hand as a backstop to prevent the pregnancy from re-entering the interstitium. Flat atraumatic blunt gaspers are used to reduce the risk of rupture.

Notice how the pregnancy tissue advances farther and farther into the tubule ampulla as the milking is continued. Step four, perform the salpingectomy. Beginning at the cornual end, the milking technique is repeated to ensure the pregnancy remains contained within the ampulla. We then proceed with salpingectomy. Here, we use a blunt-tipped bipolar sealing device to desiccate and cut across the highly vascular cornual aspect of the tube, using additional milking as needed.

As you can see, additional haemostasis is required as we desiccate through this area of dense vasculature. We ultimately enter the mesosalpinx, where the remainder of the salpingectomy can be performed with ease in the usual fashion, until the fimbria ovarica is reached, taking care to avoid the infundibulopelvic ligament. Step five, ensure haemostasis and examine the tubal stump. The pelvis is copiously irrigated, haemostasis is ensured and the tubal stump is examined to ensure the myometrium is intact and no suturing is required.

The specimen is then removed in a bag. The procedure is now complete. The patient had an uncomplicated recovery and was discharged home from the post-operative care unit following her procedure. Pathology confirmed an ectopic pregnancy. Beta-HCGs were followed weekly until negative. For patients undergoing a salpingectomy for IEP using the retrograde milking technique, we recommend trending beta-HCGs weekly to ensure no retained products of conception remain in the interstitium.

Although, theoretically, this technique does not breach the myometrium, patients should be counselled about the lack of evidence regarding risk of uterine rupture during trial of labour after salpingectomy with this technique. They should also be counselled regarding increased risk of ectopic pregnancy in the future and need for early pregnancy ultrasound to confirm intrauterine gestation. In conclusion, distal IEPs may be safely and effectively managed with the laparoscopic retrograde milking technique, followed by routine salpingectomy.

Surgeon skill remains paramount to the surgical management of IEPs due to the risk of intraoperative rupture. Providers performing the milking technique should be prepared to urgently convert the procedure to a cornuostomy or wedge resection and be comfortable with laparoscopic suturing.