Problem: risks for hemorrhage and infertility

Clinical and ultrasound examinations raised suspicion for an ectopic pregnancy in a 42-year-old woman. She had a history of right salpingectomy because of a tubal pregnancy.

Our solution

Intraabdominal inspection revealed an interstitial or cornual pregnancy in the right uterine cornu. Laparoscopy was performed.

After the broad ligaments were opened and the ureters were identified, both uterine arteries were isolated. To reduce bleeding during the removal of the ectopic pregnancy, we ligated the uterine arteries using extracorporeal knots. For the same reason, ovarian vessels were isolated on both sides, and infundibulopelvic ligaments were tied with the same technique. During all of these steps, the course of the ureters was kept under direct visual control bilaterally.

The uterine wall was opened with bipolar coagulation and scissors, and the pregnancy was excised and removed from the abdomen with a 10-cm endobag ( Video clip 1 ). The myometrium was then closed with the use of 3 interrupted size 0 absorbable monofilament sutures. Meticulous hemostasis at the level of the uterine incision was performed with bipolar forceps. In addition, we applied FLOSEAL Hemostatic Matrix (Baxter Healthcare Corporation, Deerfield, IL) on the hysterotomy. Finally, the vascular sutures were removed without any bleeding ( Video clip 2 ).

The patient was discharged on the second postoperative day; her recovery was free of complications. At the 2-month postoperative visit, she confirmed her desire for future childbearing. Given the extensive use of electrocautery and the single-layer closure of the hysterotomy during her surgery, we strongly recommended elective cesarean section as the best delivery option should she carry an intrauterine pregnancy to term.