Use of Laparoscopic Slip Knot with Purse-String Suture in Surgical Management of Unruptured Heterotopic Interstitial Pregnancies

Abstract

BACKGROUND The aim of this study was to investigate the advantages and disadvantages of using laparoscopic slip knot with purse-string suture technique in the surgical management of unruptured heterotopic interstitial pregnancies compared with other surgical strategies. MATERIAL AND METHODS We retrospectively analyzed data on 13 patients with unruptured heterotopic interstitial pregnancies who underwent laparoscopy in our hospital between May 2012 and August 2018. The control group consisted of 10 patients who underwent cornual resection or cornuostomy with conventional sutures and knots. The study group consisted of 3 patients whose surgical plans involved use of the slip knot with purse-string suture technique followed by cornuostomy. We evaluated the surgical records and video to comparatively analyze their operation duration, intraoperative blood loss, and pregnancy outcomes. RESULTS The average volume of intraoperative blood loss was 76.67±25 ml in the study group and 215.00±110 ml in the control group. On average, the intraoperative blood loss volume in the study group was 138 ml less than in the control group and the difference was statistically significant (P<0.05). There was no statistically significant difference in the live birth rate and operation time between the 2 groups (P>0.05). The duration of hemostasis in the study group was 11 min shorter than in the control group, while the duration of cornual electrocoagulation in the study group was 18.5 s shorter. Both groups achieved thorough hemostasis without the help of vasopressin and avoided use of embryo-killing drugs such as methotrexate. Neither group required second surgery or developed postoperative complications such as uterus rupture or persistent ectopic pregnancy. CONCLUSIONS This strategy is safe and reliable for gestational sac clearance while simultaneously preventing any potential harm to the intrauterine embryo. It is particularly suitable for unruptured HIP patients who have a strong desire to preserve their intrauterine embryos.

Figure 1

(A) Transvaginal ultrasound view: white arrow indicating the interstitial pregnancy (HIP) lesion 25×24×27 mm, CRL 6mm, fetal cardiac activity can be seen, yellow arrow indicating the intrauterine embryo, 18×13×16 mm, CRL 5 mm, primitive cardiac pulsation can be seen; (B) Laparoscopic finding of HIP of the patient.

Figure 2

Steps of laparoscopic purse-string suture. (A) The first and second stitches entered from right to left. (B) The third stitch entered from anterior of the uterus cornual and passed through the coverings of the broad ligament. (C) The fourth stitch was executed with the left hand holding the instruments as the needle entered from left to right. (D) Final outcome of the laparoscopic purse-string suture.

Figure 3

(A–G) Steps in making a slip knot; corresponding to Steps 1 to 9 in the main text; (G) The arrow shows the direction of force to pull the suture; (H) Uterus after the operation, with thorough hemostasis; (I) Postoperative ultrasonography checkup showed a surviving embryo.

Figure 4

Cornual resection. (A) The arrow points to the excised uterine cornual. (B) The uterine cornual was removed and the round ligament was severed.