Morshedi Bijan, Woo Jeffrey J
Eastern Virginia Medical School, Norfolk, Virginia.
Eastern Virginia Medical School, Norfolk, Virginia.
Fertil Steril. 2023 Feb;119(2):336-338. doi: 10.1016/j.fertnstert.2022.10.019. Epub 2022 Nov 18.
To demonstrate the unique use of Endoloop during laparoscopic removal of an exophytic interstitial ectopic pregnancy to ensure hemostasis, provide counter traction against a uterine manipulator, and reduce the likelihood of entry into the endometrium.
Case report with intraoperative surgical footage.
Tertiary care referral center operating room.
PATIENT(S): Single patient case report.
INTERVENTION(S): A single patient with an ectopic pregnancy suspected using ultrasound and confirmed during surgery.
MAIN OUTCOME MEASURE(S): Laparoscopic removal of the interstitial ectopic pregnancy via a wedge resection cornuectomy without endometrial involvement using a monopolar hook, Endoloop, and a William's cystoscopic needle for the injection of vasopressin.
RESULT(S): The patient was a 32-year-old G7P1051 with a history of a left tubal ectopic pregnancy status post a laparoscopic left salpingectomy, 1 full-term vaginal delivery, 2 elective terminations, 2 early pregnancy losses, smoking (1 pack per day), and marijuana use (6 blunts per day). She initially presented in November 2020 with intermittent but worsening left lower quadrant abdominal pain and was found to have a left adnexal mass, raising concern for an ectopic pregnancy in the setting of a β-human chorionic gonadotropin (β-hCG) level of 6,411 mIU/mL, and no intrauterine pregnancy identified using transvaginal ultrasound. She was counseled on medical vs. surgical management and she elected to receive an injection of methotrexate in the emergency department (ED) before discharge with a scheduled follow-up visit at the clinic for standard β-hCG trends. The patient did not attend her scheduled day 4 and 7 visits for β-hCG levels or her 2-week appointment for ultrasound; so, she was called over the phone and asked to come to the ED as soon as possible for evaluation. Approximately 3 weeks after the injection of methotrexate, the patient was still experiencing intermittent left lower quadrant abdominal pain. A repeat ultrasound in the ED showed no intrauterine gestational sac, an endometrial thickness of 0.6 cm, a normal right ovary, a normal left ovary with a corpus luteum cyst, a small amount of free fluid in the cul-de-sac, and a left adnexal extraovarian complex cystic structure measuring 2.9 × 2.4 cm with a fetal pole. The fetal pole corresponded with a gestation period of 6 weeks and 3 days, based on a crown-rump length of 0.59 cm, and lacked cardiac activity. The β-hCG level at this time was 1,124 mIU/mL, and the patient strongly desired surgical management for her ongoing abdominal pain and unresolved ectopic pregnancy. The patient's vital signs and complete blood count were within normal limits. The patient desired future fertility. A repeat transvaginal ultrasound before surgery showed the extraovarian nature of the ectopic pregnancy but could not specify whether it was intrauterine or intra-abdominal in the left adnexa; so, the decision was made to proceed with a diagnostic laparoscopy. After laparoscopic entry through Palmer's point using the Veress needle and then insertion of a 5-mm trocar under direct visualization, the left exophytic interstitial ectopic pregnancy was discovered, as depicted in the video. Given the patient's desire for future fertility, a wedge resection cornuectomy without the involvement of the endometrium was the ideal surgical approach. Subsequent trocar placement consisted of a 10-mm trocar in the umbilicus and a 5-mm trocar in the left lower quadrant. The Endoloop was initially inserted into the umbilical 10-mm trocar to allow for placement around the interstitial ectopic pregnancy to achieve hemostasis and act as a tourniquet. The Endoloop suture was passed into the abdomen and then pulled laterally using an atraumatic grasper through the left lower quadrant trocar to provide counter traction against a uterine manipulator that was deviating the uterus to the patient's right side. This created an excellent plane for dissection along the myometrial base of the interstitial pregnancy to prevent the removal of excess uterine tissue and decrease the likelihood of entry into the endometrial cavity. Injection of 4 units vasopressin (20u in 50 mL of normal saline) using a William's cystoscopy catheter through the umbilical port further ensured hemostasis along the base of the ectopic pregnancy during removal using a monopolar hook. The cystoscopy catheter was chosen for its length and flexible body to maximize maneuverability. Electrocautery was used as needed for hemostasis. After the removal of the ectopic pregnancy using the monopolar hook, the myometrium and serosa were reapproximated in a running 2-layered fashion using a V-Loc suture. The ectopic pregnancy was removed from the abdomen in a specimen retrieval bag through the 10-mm umbilical port. The 10-mm port was closed using a standard fascial closure device and then the skin of all the port sites was reapproximated using 4-0 Monocryl suture. Two important factors that favored this surgical technique over hysterectomy or standard cornuectomy included the patient's strong desire for future fertility and the exophytic nature of the interstitial pregnancy. Nevertheless, as the pregnancy increases in distance from the cornua, so does the likelihood that the pregnancy will be a normal intrauterine pregnancy, which greatly impacts counseling and management if the pregnancy is desired. Postoperative care was routine and the recommendation was made to wait at least 3 months to attempt another pregnancy and to undergo saline-infused sonography for the evaluation of the endometrial cavity; however, the patient never followed up.
CONCLUSION(S): This video demonstrates the unique use of Endoloop and vasopressin through a William's cystoscopy injection needle during the laparoscopic removal of an exophytic interstitial ectopic pregnancy. The Endoloop helped to ensure hemostasis, provide counter traction against the uterine manipulator, and optimize visualization to reduce the likelihood of endometrial involvement in a patient who desired future fertility.
展示Endoloop在腹腔镜下切除外生性间质部异位妊娠中的独特用途，以确保止血，对抗子宫操纵器提供反向牵引，并降低进入子宫内膜的可能性。
带有术中手术影像的病例报告。
三级医疗转诊中心手术室。
单病例报告。
一名患者经超声怀疑异位妊娠，并在手术中得到证实。
通过楔形切除子宫角切除术在不涉及子宫内膜的情况下，使用单极钩、Endoloop和威廉氏膀胱镜针注射血管加压素，腹腔镜切除间质部异位妊娠。
患者为32岁女性，孕7产1（G7P1051），有左侧输卵管异位妊娠病史，此前接受过腹腔镜左侧输卵管切除术，有1次足月阴道分娩、2次选择性终止妊娠、2次早期妊娠丢失，吸烟（每天1包），吸食大麻（每天6支）。她于2020年11月首次就诊，主诉左下腹间歇性腹痛且逐渐加重，检查发现左侧附件区有包块，β-人绒毛膜促性腺激素（β-hCG）水平为6411 mIU/mL，经阴道超声未发现宫内妊娠，怀疑异位妊娠。她接受了关于药物治疗和手术治疗的咨询，选择在急诊科接受甲氨蝶呤注射，出院前安排在诊所进行标准的β-hCG水平随访。患者未按预约进行第4天和第7天的β-hCG水平检查，也未参加2周后的超声检查；因此，通过电话联系她，要求她尽快到急诊科进行评估。在注射甲氨蝶呤约3周后，患者仍有间歇性左下腹疼痛。急诊科复查超声显示宫内未见妊娠囊，子宫内膜厚度0.6 cm，右侧卵巢正常，左侧卵巢有黄体囊肿，盆腔少量游离液体，左侧附件区有一2.9×2.4 cm的卵巢外复杂囊性结构，内见胎芽。根据头臀长0.59 cm，胎芽符合6周3天孕周，且无心跳。此时β-hCG水平为1124 mIU/mL，患者因持续腹痛和异位妊娠未解决，强烈希望接受手术治疗。患者生命体征和血常规正常。患者希望未来生育。术前再次经阴道超声显示异位妊娠为卵巢外性质，但无法确定其位于左侧附件区的子宫内还是腹腔内；因此，决定进行诊断性腹腔镜检查。通过Veress针经Palmer点进入腹腔，然后在直视下插入5 mm套管针，如视频所示，发现左侧外生性间质部异位妊娠。鉴于患者希望未来生育，理想的手术方法是进行不涉及子宫内膜的楔形切除子宫角切除术。随后在脐部插入10 mm套管针，在左下腹插入5 mm套管针。首先将Endoloop插入脐部10 mm套管针，围绕间质部异位妊娠放置以实现止血并起到止血带作用。Endoloop缝线经腹部穿出，然后通过左下腹套管针用无损伤抓钳向外侧牵拉，以对抗将子宫向患者右侧牵拉的子宫操纵器，提供反向牵引。这为沿着间质部妊娠的肌层底部进行解剖创造了良好的平面，可防止切除过多子宫组织并降低进入子宫内膜腔的可能性。通过脐部端口使用威廉氏膀胱镜导管注射4单位血管加压素（20 u溶于50 mL生理盐水中），在使用单极钩切除异位妊娠期间，进一步确保沿异位妊娠底部止血。选择膀胱镜导管是因其长度和可弯曲的主体，以最大限度地提高操作灵活性。根据需要使用电灼止血。使用单极钩切除异位妊娠后，用V-Loc缝线以连续双层方式重新缝合肌层和浆膜。通过10 mm脐部端口将异位妊娠放入标本回收袋中取出。使用标准筋膜闭合装置关闭10 mm端口，然后用4-0 Monocryl缝线重新缝合所有端口部位的皮肤。与子宫切除术或标准子宫角切除术相比，这种手术技术更具优势的两个重要因素是患者强烈希望未来生育以及间质部妊娠的外生性。然而，随着妊娠距离子宫角的距离增加，妊娠为正常宫内妊娠的可能性也增加，如果希望保留妊娠，这将对咨询和管理产生重大影响。术后护理常规进行，建议至少等待3个月再尝试怀孕，并进行盐水灌注超声检查以评估子宫内膜腔；然而，患者从未进行随访。
本视频展示了在腹腔镜切除外生性间质部异位妊娠过程中，Endoloop和血管加压素通过威廉氏膀胱镜注射针的独特应用。Endoloop有助于确保止血，对抗子宫操纵器提供反向牵引，并优化视野，以降低希望未来生育的患者子宫内膜受累的可能性。
