Laparoscopic cornuotomy using temporary tourniquet suture in Interstitial pregnancy.

Young-Sam Choi M.D.

Kwang-Sik Shin M.D.Jin Choi M.D.

Dae-Sook Eun M.D.

Dept. of Obstetrics & Gynecology, Eun HospitalKwang-Ju, South Korea

Interstitial pregnancyvery rare form of ectopic pregnancycan bring about catastrophic events

Catastrophic events life-threatening hemorrhage

uterine rupture in subsequent pregnancy

Introduction

Conventional managements● Hysterectomy● Cornual wedge resection with / without ipsilateral salpingectomy through a laparotomy

perfect method for terminating the pregnancybut they were invasive and not desirable in patients who wish to preserve their fertility

History

Introduction of conservative managements

● Medical approach Tanaka et al. in 1982

● Laparoscopic approach Reich et al. in 1988

● Hysteroscopic approach Meyer et al. in 1989

History

Methotrexate (systemic or local)KClHypertonic dextroseProstaglandinsActinomycin D

Advantage: non-invasive

Disadvantage: need for prolonged, close follow-up some patients require adjuvant treatment and it has some adverse effects

Medical managements

Hemostatic techniquesDiluted vasopressin injectionElectrocauterizationFibrin glueUltrasonic cutting and coagulating deviceAscending uterine artery ligation

Advantage: minimal invasiveDisadvantage: not always sufficient to control hemorrhage

Laparoscopic approach

Suture techniquesEncircling suture or endoloop ligationSquare sutureAutomatic stapler

Advantages: more effective more reliable at hemostasisDisadvantage sacrifice the tube and cornu

Laparoscopic approach

Not cornuostomy But Cornuotomy

Schema of Technical tip

1st Diluted vasopressin injection

2nd Tourniquet suture apply (Cornual Island)

3rd Additional vasopressin injection

These resulted in a “Cornual Island” that isolated the region from the blood supply.

Laparoscopic Cornuotomy

Schema of Technical tip

4th Transverse incision on cornu

5th Evacuation of conceptus

6th Repair of incision (cornuotomy)

7th Removal of tourniquet suture (temporary)

Laparoscopic Cornuotomy

TVUS & color Doppler flow of IP

(A) Empty endometrial cavity, thin myometrial mantle, extremely eccentrically located gestational sac are revealed

(B) “Solid ring of fire” pattern is revealed on color Doppler flow, implying peritrophoblastic, highly vascular implantation

Laparoscopic Cornuotomy

Results (n=9)

VariablesNumber of patients

(n=9) Operation time (min) 58±16 Estimated hemorrhage (ml)

50±22

Resolution of β‑hCG (days)

27±8

Postoperative adjuvant therapy

0

Blood transfusion 0

HSG image 3 months after operation

Both tubes are patent (arrowheads) and that contrast material spills into the peritoneal cavity (open arrow).

Small external dimpling (straight arrow) is revealed on the affected proximal cornu, but is negligible in terms of the overall tubal patency

MRI images 3 months after operation

Axial view in the T2-weighted image Coronal view in the T2-weighted image

The arrowhead and open arrow indicate the affected cornu. Note that there are no significant differences in the thickness of the affected and unaffected cornu, and no defects in terms of the overall cornual contour.

Uterotubal patency & Cornual integrity

VariablesNumber of patients

(n=9)

Tubal patency (on HSG)(n=7)

2 patients were excluded owing to lost to follow-up and had undergone prior ipsilateral salpingectomy

Patent 5

Non-patent 2

Cornual integrity (on MRI)(n=8)

1 patient were excluded owing to lost to follow-up

No defect 8

Defect 0

Pregnancy outcomes

● 3 multiparous women had conceived 12&17 months after the surgery and were safely delivered by vaginal route at full-term.

● 1 nulliparous woman conceived 30 months after surgery and she is in the 32 weeks of pregnancy now.

Laparoscopic cornuotomy

● Perfect for hemostasis

● No adjuvant treatment

● Probaility of preservation of cornua & tube

● Possibility of vaginal delivery in subsequent

pregnancy

Conclusions

If you have any questions,

please contact me by E-mail.

Thank you very much for your attention.

yschoimd@yahoo.co.kr