New concepts in the surgical management of tubal pregnancy and the consequent postoperative results

Abstract

The success following reconstructive tubal pregnancy can only be measured in terms of live births. Because the fallopian tube is not a simple conduit and has numerous complex functions, many women fail to conceive despite successful reconstructive surgery. The most effective way to prevent reocclusion or peritubal adhesion is to minimize tissue trauma. Magnification permits accurate excision and hemostasis. In this review, it has been demonstrated that tubal conservation is technically possible and safe. It is effective in increasing the number of live births postoperatively in women interested in fertility and does not increase the risk of the repaired tube for a repeat tubal gestation more than the uninvolved tube, although one of five subsequent pregnancies are again ectopic. They seem to occur equally as often in the contralateral tube as in the repaired tube. It has been shown that salpingotomy can restore tubal patency and maintain fertility. The second question was whether the number of viable pregnancies increase after conservative surgery. This question can be answered only if the repaired tube remains and the patient subsequently delivers at term. Such data have already demonstrated this outcome. Conservative operations in selected cases of tubal pregnancy seem feasible and safe and do not further impair tubal function. Because intrauterine pregnancy is more apt to occur than is repeat ectopic pregnancy, it seems logical that the involved tube should be saved whenever fertility is desired (Fig. 2). In unruptured isthmic pregnancy, Stangel and Gomel prefer segmental excision and end-to-end anastomosis during the same intervention. Gomel advocates segmental excision of the conceptus whether ruptured or not when the pregnancy is located in the isthmus or proximal half of the ampulla, and end-to-end anastomosis undertaken later as an elective procedure if necessary (Fig. 2). An ampullary gestation may be successfully treated by salpingotomy; and in the case of distal ampullary location, a tubal abortion may be performed (Fig. 2). When extensive destruction of the tube occurs, salpingectomy becomes necessary. In cases of early diagnosis of tubal gestation, conservative surgical management may be carried out via laparoscopy (Fig. 1).