Laparoscopic cornuotomy using temporary tourniquet suture in Interstitial pregnancy.

1
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
Hospital Kwang-Ju, South Korea
2
Introduction
Interstitial pregnancy very rare form of
ectopic pregnancy can bring about catastrophic
events Catastrophic events life-threatening
hemorrhage uterine rupture in subsequent
pregnancy
3
History
Conventional managements ? Hysterectomy ?
Cornual wedge resection with / without
ipsilateral salpingectomy through a
laparotomy perfect method for terminating the
pregnancy but they were invasive and not
desirable in patients who wish to preserve their
fertility
4
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
5
Medical managements
Methotrexate (systemic or local) KCl Hypertonic
dextrose Prostaglandins Actinomycin D
Advantage non-invasive Disadvantage need
for prolonged, close follow-up some patients
require adjuvant treatment and it has some
adverse effects
6
Laparoscopic approach
Hemostatic techniques Diluted vasopressin
injection Electrocauterization Fibrin
glue Ultrasonic cutting and coagulating
device Ascending uterine artery ligation
Advantage minimal invasive Disadvantage not
always sufficient to control hemorrhage
7
Laparoscopic approach
Suture techniques Encircling suture or endoloop
ligation Square suture Automatic stapler
Advantages more effective more reliable
at hemostasis Disadvantage sacrifice the tube
and cornu
8
Laparoscopic Cornuotomy
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.
9
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)
10
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
11
Laparoscopic Cornuotomy
12
Results (n9)
Variables Number of patients (n9)
Operation time (min) 5816
Estimated hemorrhage (ml) 5022
Resolution of ß-hCG (days) 278
Postoperative adjuvant therapy 0
Blood transfusion 0
13
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
14
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.
15
Uterotubal patency Cornual integrity
Variables Number of patients (n9)
Tubal patency (on HSG) (n7) 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) (n8) 1 patient were excluded owing to lost to follow-up
No defect 8
Defect 0
16
Pregnancy outcomes
? 3 multiparous women had conceived 1217 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.
17
Conclusions
Laparoscopic cornuotomy ? Perfect for
hemostasis ? No adjuvant treatment ? Probaility
of preservation of cornua tube ? Possibility of
vaginal delivery in subsequent pregnancy
18
Thank you very much for your attention.
yschoimd_at_yahoo.co.kr
If you have any questions, please
contact me by E-mail.