Table of Contents
- Procedure Summary
- Authors
- Youtube Video
- What is Laparoscopic Approach to Conservative Management of Ovarian Ectopic Pregnancy?
- What are the Risks of Laparoscopic Approach to Conservative Management of Ovarian Ectopic Pregnancy?
- Video Transcript
Video Description
Summary: This video outlines and reviews the surgical steps in performing a laparoscopic technique for tissue dissection and removal of rare ovarian ectopic pregnancies. This method demonstrates a conservative approach to management with aim to preserve ovarian function and fertility.
1. Overview of the background, clinical presentation and relevant pre-operative considerations
2. Instruction for surgical approach through a clinical case
3. Discussion of the post-operative care
Presented By
Affiliations
University of Toronto
Watch on YouTube
Click here to watch this video on YouTube.
What is Laparoscopic Approach to Conservative Management of Ovarian Ectopic Pregnancy?
The laparoscopic approach to conservative management of ovarian ectopic pregnancy is a minimally invasive technique aimed at treating pregnancies that develop on an ovary, a rare and potentially dangerous condition. This procedure involves small incisions in the abdomen to remove the ectopic tissue while preserving ovarian health and the patient’s future fertility. Laparoscopy offers advantages such as reduced recovery time, less post-operative pain, and lower risk of adhesions compared to open surgery. It’s particularly valuable for women wishing to maintain their fertility. The decision to use laparoscopy depends on factors like the size of the ectopic pregnancy and the patient’s overall condition. This approach minimizes tissue damage and helps in faster recovery, making it a preferred method for managing this complex reproductive health issue.
What are the Risks of Laparoscopic Approach to Conservative Management of Ovarian Ectopic Pregnancy?
The laparoscopic approach to conservative management of ovarian ectopic pregnancy, while minimally invasive and fertility-preserving, carries certain risks:
- Injury to Surrounding Organs: The procedure may inadvertently harm nearby organs such as the bladder, intestines, or blood vessels.
- Bleeding: There is a risk of significant bleeding during or after surgery, which may require further intervention.
- Infection: Surgical procedures increase the risk of infection, which can range from local at the surgical site to widespread within the pelvis.
- Incomplete Removal of Ectopic Tissue: There’s a possibility that not all ectopic pregnancy tissue will be successfully removed, potentially leading to persistent ectopic pregnancy.
- Risk of Recurrence: Patients who have had one ectopic pregnancy may have a higher risk of experiencing another ectopic pregnancy in the future.
- Adhesions: The development of scar tissue post-surgery can lead to pelvic pain, fertility issues, or bowel obstruction.
Despite these risks, laparoscopic surgery is often preferred for its benefits, including reduced recovery time and preservation of fertility. It’s crucial for patients to discuss potential risks and benefits with their healthcare provider to make an informed decision tailored to their specific health situation.
Video Transcript: Laparoscopic Approach to Conservative Management of Ovarian Ectopic Pregnancy
Laparoscopic approach to conservative management of ovarian ectopic pregnancy. This method demonstrates a conservative approach to successful removal of ovarian ectopic that maximises future ovarian function and fertility by preserving ovarian tissue, limiting the need for oophorectomy.
Ovarian ectopic pregnancy is rare. Reported incidents after natural conception ranges from one in 7000 to one in 40000 natural pregnancies, and accounts for 3% of all ectopic pregnancies. However, there are reports of an increase in incidents relative to both tubal and term pregnancies.
In contrast to tubal pregnancy, there is a lack of consensus on aetiology. Ovarian pregnancy is neither associated with pelvic inflammatory disease or infertility. Few to no reported cases of recurrent ovarian pregnancy suggests this may be a chance phenomenon. The most common associated risk factor is use of intrauterine device, but increasing incidents with infertility and assisted reproductive technologies is now being reported.
Presenting signs and symptoms of this conditions minimally deviate from that of the typical presentation of tubal or rupture of tubal ectopic, which can make establishing the diagnosis challenging. Approximately 75% of cases will terminate in the first trimester, and are often misdiagnosed as corpus luteal haemorrhage or ovarian cyst, unless they undergo early ultrasound and beta-hCG for symptomatic pelvic pain.
Sonographic diagnostic criteria on ultrasound that have been suggested include wide echogenic ring, internal echo on the ovarian surface, presence of ovarian cortex around the mass, and echogenicity of the ring greater than that of the ovary itself, or ring of fire sign.
For those who present with rupture and haemodynamic instability, preoptic diagnosis is not easily made with imaging. It is twice as likely to be diagnosed at surgery, mostly incidentally at the time of presumed tubal ectopic, or following the pathological diagnosis.
Spiegelberg criteria were developed in attempt to establish diagnosis. These criteria, however, still often fail to be satisfied by known cases. Therefore, the diagnosis is frequently clinically based on location of pregnancy at the time of removal. As most patients present with a ruptured sack in a haemodynamically compromised state, medical management is usually not feasible.
Ovarian ectopic pregnancy can be broadly classified into two types, intra and extraovarian. A plane of division may be found between the ectopic pregnancy and the ovary in an extraovarian, allowing for its excision, unlike the intraovarian type, which may need wedge resection, or even oophorectomy.
Steps to the procedure in a stepwise approach include, number one, confirming the diagnosis. Following entry into the abdomen, evacuation of hemoperitoneum, and visualisation of ovarian ectopic to confirm diagnosis as intra or extraovarian pregnancy. Number two, incision and dissection. The creation of a linear oophorostomy and careful tissue dissection. Number three, ensuring adequate haemostasis. Number four, removal. Retrieval of the specimen, and closure.
We present a case of an otherwise healthy 33-year-old G2 P1 patient at approximately eight weeks gestation by last menstrual period. She spontaneously conceived, and presented with severe pelvic pain to the emergency room. Vitals are within the normal limits. Examination findings are pertinent for severe rebound tenderness. Her haemoglobin is 97 from a baseline of 120, and her beta-hCG is 3240.
Ultrasound findings revealed no evidence of an intrauterine pregnancy. Hemoperitoneum, and vascular ring-shaped structure of 1.9 by 1.7 cm thick walled, inseparable from right ovary, with peripheral flow. Not typical for tubal pregnancy, and differential would include haemorrhagic cyst.
Intraoperative findings were as follows. Following abdominal entry with a Veres needle technique and placement of intraabdominal ports, hemoperitoneum was evacuated with a large suction irrigator for 700 ml of blood, for ease of evacuation through a 12 mm right lower quadrant port.
Careful examination of the pelvis was conducted for any signs of ongoing bleeding or haemorrhage. Findings included right ovarian ectopic pregnancy about 2 cm in size, otherwise normal fallopian tubes and contralateral left ovary. Diagnosis was confirmed, and the decision was made to proceed with conservative management, with linear oophorostomy in order to preserve the ovary.
With the monopolar scissors and electrocautery, we incised the overlying ovarian tissue to extend the ectopic pregnancy opening laterally by approximately 2 cm. Then, with blood tissue dissection, ectopic tissue was able to be grasped, and pregnancy easily removed from the surrounding ovarian tissue in a single piece.
The specimen was set aside in the anterior cul-de-sac, while we turned attention to performing thorough irrigation and inspection. This was done to ensure all products of conception had been removed, and only normal appearing ovarian tissue remained. Use of microbipolar was then employed when necessary, and haemostasis was achieved and ensured with minimal use of cautery.
Once any areas of bleeding were cauterised, the intraovarian bed was inspected, showing ovarian stroma throughout. With large 10 mm suction irrigator to help dislodge any potential trophoblastic tissues. Final irrigation and inspection of the pelvis was then completed.
A specimen retrieval bag was then placed into the abdomen, and the products of conception were removed without difficulty through the right lower quadrant port, and sent for pathology. All instruments were then removed, and we proceeded with closure. The procedure was overall uncomplicated.
The patient recovered well postoperatively, and serial beta-hCG was performed weekly to ensure no persistence of trophoblastic tissues. 74 on day seven, and ten on day 14 respectively. She’ll continue to be followed until result is negative.
This simple stepwise procedure highlights a safe and effective approach to treatment of intraovarian ectopic. Similar laparoscopic approaches have been described by some studies to result in similar tubal patency and future fertility rates when compared with medical treatment, in the case of extrauterine pregnancies. And this is what we aim to facilitate in our…