Laparoscopic treatment of ectopic pregnancy.

Over the last decade and a half the success and safety of endoscopic surgery for ectopic pregnancy has been established. Shapiro and Adler (1973) reported laparoscopic salpingectomy using electrocoagulation followed by excision. Soderstrom (1981) followed with the snare technique of salpingectomy. Valle and Lifchez (1983) reported tubal patency rates approaching and attaining 100% following salpingostomy in the sole oviduct during laparotomy encouraged continued laparoscopic approach. DeCherney (1981) described linear salpingostomy via a cutting current in 18 women with an intrauterine pregnancy rate of 50% 1 year afterwards. No spontaneous abortions or repeat ectopics were reported. Pouly et al (1986) described laparoscopic salpingostomy in 321 women with a resultant 64% intrauterine pregnancy and 22% repeat ectopic rate. These studies support the realization that previous surgical approaches per laparotomy for ectopic pregnancy may be achieved endoscopically, but intraoperative and postoperative complications have occurred. As noted by Kelly et al (1979) and Richards (1984) these consist mainly of persistent or delayed haemorrhage along with continued trophoblastic growth. Haemorrhage is most often a result of failed salpingostomy in larger ectopics. Continued trophoblastic development requiring repeat surgical exploration due to incomplete removal of tissue has been reported by Pouly (1986) in as many as 5% of cases. This rare but reported consequence signals the importance of following quantitative HCG concentrations into the negative range. Occasionally HCG levels remain elevated more than 30 days postoperatively with eventual resolution; Cartwright et al (1986) claim that tubal patency rates appear to be unaffected by this prolonged clearance of tissue. Despite infrequent morbidity, laparoscopic treatment of ectopic pregnancy, in comparison to laparotomy, significantly shortens hospital stays, operating time, convalescence and postoperative analgesic requirements (Brumsted et al, 1988). Endoscopic surgery also reduces postoperative formation of pelvic adhesions (Fayez and Schneider, 1987). As familiarity and technical expertise with endoscopy continues to increase, exploratory laparotomy may be considered too radical an approach to ectopic pregnancy treatment regardless of the procedure performed.