Theoretically, total salpingectomy eliminates the risk of an ipsilateral tubal pregnancy. However, total salpingectomy is difficult to achieve using endoloops alone. We describe a situation where this resulted in an ipsilateral recurrence of tubal pregnancy which required emergency intervention and removal of the tubal remnants.
Despite major advances in its early diagnosis and treatment, ectopic pregnancy continues to account for a significant number of maternal deaths. A World Health Organization analysis of maternal deaths showed ectopic pregnancy to be responsible for 4.9% of all and 6.1% of direct maternal deaths in developed countries [
A woman, aged 28, gravida 4, para 0, presented at 5 weeks gestation with lower abdominal pain and mild vaginal bleeding. She had 2 terminations of pregnancy and her last pregnancy had been ectopic, managed laparoscopically by a left salpingectomy using endoloops. Transvaginal ultrasound showed an empty uterus, no evidence of ectopic pregnancy, and a moderate amount of peritoneal fluid.
Four days after the methotrexate administration,
Ectopic pregnancies occurred in 1.1% of pregnancies and caused 10 maternal deaths between 2003 and 2005 in the UK, with no evidence of these having become less important as a cause of direct maternal death over the last 20 years [
In this case, it took 15 days between the initial presentation and the definitive emergency treatment. At her first referral to hospital, the patient fulfilled all criteria commonly considered as conditional for methotrexate treatment and she was followed up appropriately. However, the further evolution with an acute abdomen and the need for emergency intervention is reminiscent of the times before the advent of vaginal ultrasound and
There is a great deal of variation in surgical treatments of tubal pregnancies [
There is an extensive literature on the use of endoloops in laparoscopic surgery most of it related to gastrointestinal procedures. In gynaecology, endoloops became popular mainly for laparoscopic tubal ligation, mimicking the classical open surgery Pomeroy approach, as an alternative to fallopian rings and clips [
We are aware of only one report on the long-term outcome of the endoloop approach for treatment of ectopic pregnancy and this related specifically to cornual (i.e., interstitial) ectopic pregnancies [
Salpingectomy, while not necessarily eliminating all ipsilateral ectopics, certainly prevents a tubal recurrence on that side. However, our case illustrates that it is fallacious to assume that total salpingectomy is always as total as the word implies. In fact, it is inherently difficult to achieve a total salpingectomy when using nothing but endoloops. Such cases and others that leave a tubal remnant may well need to be considered as akin to salpingostomy in terms of the risk of recurrence. Whilst few generalisations can ever be made from a case report, it is important for clinicians to be aware of this inherent problem, especially as it is not the only consequence. Hydrosalpinges can develop in tubal stumps, resulting in decreased fertility and an occasional need for further surgical intervention.
In conclusion, it is unwise to discount ipsilateral tubal pregnancies too quickly. Surgical variations in what is purported to be salpingectomy are sufficiently large and their consequences important enough for clinicians to remain vigilant.