Laparoscopy is one of the most important for the development of diseases of the uterus and fallopian tubes. The surgery in the management of benign adnexal that progress, carpentry, ovarian cystectomy, unilateral or bilateral ovaries and fallopian tubes, laparoscopy-assisted vaginal hysterectomy (LAVH) with or without unilateral or bilateral salpingo-ovarian.
The risk of ectopic pregnancy is higher among white women. Increases three to four times in women 35-44 compared to bicycles of 15-24 years. About 64% of ectopic pregnancies in a bubble, where fertilization takes place. The recent rise in the incidence of ectopic pregnancies has been attributed to the higher prevalence of sexually transmitted infections, delay the age, the sexual organ of the previous surgery successful clinical detection. Any condition that prevents or inhibits the migration of the fertilized ovum in the uterine cavity may predispose women to ectopic pregnancy.
Figure: tubal pregnancy
An ectopic pregnancy usually occurs in 99% of the fallopian tube. You can find it in :
- Warts (64%)
- Isthmus (25%)
- Bell (9%)
- Landlines (2%)
- Ovary (0.5%)
- Cancer of the cervix (0.4%)
- Stomach (0.1%)
- Intraligamental (0.05%)
Major risk factors associated with ectopic pregnancy are:
- Current use of intrauterine devices 11.5%
- The use of clomiphene citrate 10%
- Before surgery tubal 5.6%
- Pelvic inflammatory disease 4.0%
- Infertility 2.9%
- Induced abortion 2.5%
- Accessions 2.4%
- abdominal surgery 2.3%
- Cancer T-shaped 2%
- Myomata 1.7%
- Progestin-only contraceptives 1.6%
If laparoscopy is planned, the location, size and nature of tubal pregnancy be determined. If the bleeding can be arrested or detained, respectively, of rupture of tubal pregnancy can be effectively treated endoscopically. After controlling the bleeding, the products of conception and blood clots will be removed. If more than 1500 cc hemoperitoneum, laparoscopic-cons is indicated. salt heparin should be used in cases of large hematomas. Require large extracorporeal connection ectopic.
10 mm suction instrument is used to clean the abdominal cavity. forced irrigation with saline solution should remove the clot and the fabric of peritonitis chorionic trophoblast, with minimal damage to the genital structures.
Figure: salpingotomy ectopic pregnancy in the intact
For intact tubal pregnancy oviducts was identified and mobilized to reduce bleeding, 5 to 8 ml of the diluted solution containing 5 units vasopressin in 20 ml of saline is injected into the spinal needle 20 or by laparoscopy. Should be granted in mesosalpinx just below and above the surface of the section tubal ectopic pregnancy antemesentric containing the product. Needles do not add to the depth of intravascular blood vessels, because they can cause acute injection of hypertension, bradycardia, and one day can be fatal.
Figure: salpingotomy ectopic pregnancy in the intact
After stabilization of the manifold in one hand and microelectrodes in the other, linear incision is made on the antimesenteric surface of the extension 1:59 cm in the thinnest parts of the tube. Fine needle should be used in cutting mode, and should barely touch the surface of the fabric. With electrosurgery, heat may spread if large tips are used on large surfaces in contact with the tissues. It is important to be aware of the existence or location of key structures in the neighborhood. If you're not careful gynecologists can not be a chance for injury to adjacent organs.
Figure: suck intact trophoblast to ectopic pregnancy
Pregnancy normally protrude through the incision and slid slowly out of the pipe. You can gently teased to cut electricity or laparoscopic atraumatic forceps. Sometimes a strong opening of irrigation in the fallopian tubes can be removed from the establishment of pregnancy. What is pregnancy or extruded from the tube, some products of conception may request the siting of a ligamentous structure containing blood vessels. Using bipolar coagulation of this structure before removing the tissue. Depending on the size of the product even if the concept of an ectopic is usually removed 10 mm trocar sleeve.
Resection of the segment containing the tubal pregnancy is more salpingostomy isthemic pregnancy or pipe rupture or hemostasis is difficult to obtain. Segmental resection of the fallopian tubes is performed using a bipolar forceps or the harmonic scalpel. Automatic stapling or suturing designs can be used for bloodless resection of the fallopian tubes. Mesosalpinx if the bleeding should be cauterized with a bipolar, attention to the branch curve ovarian and uterine arteries anatomizing. Total salpingectomy is made by gradual coagulation and cutting mesosalpinx the proximal end of the fimbriae. It is separated from the uterus using bipolar coagulation and scissors. isolated segment of the fallopian tube containing the pregnancy removed intact or waste by the handle 10 mm trocar. The product design can be placed in a plastic bag and removed. Multifire stappeling salpingectomy devices require 10 mm trocar. If the fabric large and can not be processed by the cannula, endobag can be used to collect tissues.
Membership or other pathological processes such as endometriosis can be treated simultaneously in the removal of an ectopic pregnancy without significant extension of the action. Less than a week of hCG beta should return to baseline values, ie very low or undetectable.
If the pregnancy is the pore may be associated with a traumatic rupture, hemorrhagic shock and there is an increase of twice the maternal mortality compared to other tubal pregnancies. Delayed diagnosis and increased vascularity of laparoscopy are difficult to do. 2-4% are interstitial ectopic. Anatomy of an ectopic pregnancy, is a growing recognition of its end. Traditional management is better for those words salpingectomy with or without resection of the cornea, and in some cases it may be difficult to remove the uterus. interstitial pregnancy may be suspected during laparoscopy, where large uterus and asymmetric line.
The majority of patients are carried out within 48 hours. A rate higher fertility rates of intrauterine pregnancy in subsequent pregnancies with laparoscopic techniques.
Laparoscopic surgery is a good option for extra-uterine rupture and ectopic does not necessarily guarantee a laparotomy. If the patient is hemodynamically stable and preliminary studies indicate laparoscopic moderate blood loss, it may be possible to control the bleeding and to maintain certain laparoscopic procedures. If the patient is in Phase II or Stage III of shock, which has a large hemoperitoneum, laparotomy is the best choice. The management of ectopic pregnancy require a pelvic examination, the ectopic localization, aspiration and blood clots, location and control of bleeding points, or perform salpingectomy and in rare cases, ovaries are performed simultaneously.
Control of bleeding is the most critical procedures, methods, and many can try to achieve hemostasis in turn:
- Identification of bleeding after careful consideration, dry electro pole
- Administration of vasopressin in mesosal-pinx,
- Electro desiccation mesosalpinx,
- If the bleeding does not stop at these measures salpingectomy whole or in part, as part of the tube and the patient's desire for fertility.
After a good laparoscopic management of ectopic pregnancy, the patient can be discharged the next day. You should come to new FT-hCG in the serum one week after surgery to determine the end of an ectopic pregnancy. Ft-hCG level should be very low or undetectable one week after surgery. If it is above 20 mIU / ml, the blood test re-ordered two weeks later, when the FT-hCG was undetectable.