[Gynecological Laparoscopy] Laparoscopic fallopian tube interstitial pregnancy surgery

Interstitial fallopian tube pregnancy (interstitial tuhal nreonancv) is relatively rare, accounting for only 2% to 4% of fallopian tube pregnancies. The interstitial part is the convergence area of uterine blood vessels and ovarian blood vessels with rich blood supply, and symptoms rarely occur in the early stage.

Once ruptured, cervical intra-abdominal bleeding often occurs within a very short period of time. In recent years, with the improvement of laparoscopic surgery technology and proficiency, the success rate of abdominal pick treatment for fallopian tube interstitial pregnancy has been significantly improved, and laparoscopy has become the preferred option for the treatment of fallopian tube interstitial pregnancy.

【Indications】

The vital signs of patients with fallopian tube interstitial pregnancy are stable or the lesions have not ruptured and caused massive bleeding.

【Contraindications】

Patients with interstitial pregnancy rupture, massive hemorrhage and shock are relative contraindications to laparoscopic surgery.

Preoperative preparation

1.For patients with massive hemorrhage from interstitial pregnancy rupture, a double-tube venous channel should be established as soon as possible. While actively replenishing fluids, blood transfusions, and correcting shock, preoperative examinations and preparations should be quickly completed, and changes in vital signs should be closely monitored.

2.Actively improve the necessary preoperative examinations including blood routine, urine routine, blood type, coagulation function, electrolytes, blood β-hCG, bedside B-ultrasound and electrocardiogram, etc.

3.Preparation of abdominal and vulvar skin.

4.Bowel preparation: Enema should be avoided to avoid rupture of ectopic pregnancy lesions or worsening of bleeding in those who have already ruptured.

5.Catheterize and leave a urinary catheter before surgery.

6.Transfuse blood or prepare autologous blood transfusion.

Surgical steps and techniques

1. First clean up the blood and clots in the pelvic and abdominal cavity.

2. Fully expose the pelvic cavity. Under the microscope, it can be seen that the uterine horn on the affected side is enlarged and appears as a purple-blue protrusion.

It needs to be differentiated from uterine horn pregnancy, mainly based on the relationship between the enlarged part and the round ligament. The embryo of interstitial pregnancy grows outside the uterine cavity, and the enlarged part is located outside the round ligament.

3. To avoid major bleeding, first inject neurohypophysin 6U + 50ml of normal saline into the uterus (Figure 2) to promote uterine contraction, and then perform purse-string sutures on the basal edge of the enlarged part of the gestational sac with No. 1 Vicryl suture The purse string sutures the seromuscular layer, and the suture border should be slightly far away from the gestational sac. It is best to perform two sutures.

4. While tightening the sutures, incise and remove the pregnancy rib lesions. After tying the knot, you will see that the pregnancy area is in a knotty state. Use a monopolar electric hook to incise the seromuscular layer above it and clean out the pregnancy objects and blood clots.

5. Remove the fallopian tube on the affected side to the proximal end of the isthmus, clean up the pregnancy objects in the interstitium (Figure 5, Figure 6), and suture the uterine corners intermittently with No. 1 micro-suture.

6. After the suturing is completed, 50 mg of methotrexate is injected into the underlying muscle layer of the dry disease to prevent persistent ectopic pregnancy, and 5 ml of sodium hyaluronate gel is applied to the wound surface to prevent adhesion.

7. Put the specimen into a retrieval bag and take it out through the white Trocar hole. Pay attention to cleaning up the tissues scattered in the pelvic cavity and on the sigmoid colon, and give a large amount of normal saline to flush the abdominal cavity to avoid residual villi, which may cause persistent ectopic pregnancy.

Intraoperative risks and prevention

For interstitial fallopian tube pregnancy, surgery should be performed before rupture to avoid potentially life-threatening bleeding. The operation should be wedge-shaped resection of the uterine horn and fallopian tube resection on the affected side, and the uterus should be removed if necessary.

1. Massive bleeding: The interstitial part of the fallopian tube has rich blood supply. In order to avoid massive bleeding during the operation, you can inject pituitaryin before removing the pregnancy site, and then apply purse-string suture technique. Purse-bag suture can not only overcome the shortcomings of easy slippage of direct ligation, but also This can avoid massive bleeding that may be caused by direct electrocoagulation incision. At the same time, after cleaning the pregnancy lesions, the uterine corners are sutured intermittently, which can not only better stop bleeding, but also strengthen the uterine corners, facilitate local healing, and prevent uterine rupture in another pregnancy.

2. Remaining pregnancy products: Injecting 50 mg of methotrexate into the basal seromuscular layer of the lesion during the operation can effectively prevent persistent ectopic pregnancy.

3. The surgeon is required to have certain experience in laparoscopic surgery, especially proficiency in endoscopic suturing technology, which is the key to ensuring the success of the operation.

Postoperative precautions

1. For patients with severe pelvic bleeding, a rubber drainage tube can be placed in the recto-uterine fossa and taken out through the right lower abdomen. 2. Closely monitor changes in blood 3-hCG after surgery, and recheck blood B-hCG 24 hours after surgery. If the drop is >50%, monitor once every 3 days until normal; if blood 3-hCG levels drop 24 hours after surgery, <50%, give mifepristone tablets 50 mg orally once every 12 hours for a total of 5 days.