Exophytic interstitial ectopic pregnancy removal: novel use of Endoloop for uterine cavity preservation.

Objective: 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.

Design: Case report with intraoperative surgical footage.

Setting: 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.