Laparoscopy Versus Laparotomy

The first laparoscopic treatment of this condition was reported in 1973 by Shapiro.11 Although several series have since been published,12 the technique took some time to gain general acceptance. There were predictable surgical complications and significant problems with training.

There were initial concerns about tubal patency and adhesion formation after laparo-scopic treatment versus traditional laparotomy for ectopic pregnancy. However more recently these concerns have been resolved. Virtually all studies have shown that laparoscopic surgery is superior to laparotomy. Lower cost, shorter hospital stay, less operative time, less blood loss, reduced analgesia requirements and shorter convalescence have been demonstrated in the laparoscopic group.13 Table 11.3 shows the rates of subsequent intrauterine pregnancy were 62% after laparotomy and 59% after laparoscopy, and the rates of ectopic pregnancies were 16% and 12% respectively. These data suggest that there are no significant differences in reproductive outcome following laparoscopy or laparotomy. The issue of adhesion formation was addressed by Fayad et al. Two groups were investigated in this study,14 396 women had a laparotomy, and 546 women underwent operative laparoscopy. This study concluded that there was no therapeutic advantage to the use of Ringers solution (instilled into the abdominal cavity) for the prevention of postoperative pelvic adhesion formation, but in the laparoscopy group no adhesions developed in women who had pelviolysis or fimbrioplasty.14

Despite the fact that women with a tubal pregnancy in their only fallopian tube are a very high-risk group, it is possible to restore

Table 11.3. Outcome after laparoscopy or

laparotomy treatment of ectopic pregnancy

Authors

Year

No

% IUP

% EP

DeCherney

1987

69

52

16

Donnez

1990

138

51

10

Pouly

1990

223

67

12

Paulsen

1992

48

54

31

Total

478

59

12

laparoscopy

Timonen

1967

185

53

12

Sherman

1982

47

83

6

Querleu

1988

129

52

30

Tuomivaara

1988

86

66

14

Makinen

1989

42

69

29

Langer

1990

118

70

11

Total laparotomy

607

62

16

tubal function in a high proportion of cases. In one report 16 of 21 women who subsequently conceived were treated with laparotomy and microsurgery to the remaining fallopian tube.15 However, tubal function following an ectopic pregnancy is a significant problem as there may be pre-existing pathology. Approximately 50% of 76 women with a history of previous pelvic inflammatory disease and a laparotomy for ectopic pregnancy were found to have a nonpatent contralateral tube on follow up hystero-salpingography. In the same study a subgroup of 13 women were managed by linear salping-otomy. In only six cases was the treated tube subsequently found to be patent.16

The laparoscopic approach for the treatment of ectopic pregnancy is believed to be associated with improved fertility - perhaps because of reduced adhesion formation. In one study, 105 women with ectopic pregnancy were randomized to laparoscopy or laparotomy. Women who underwent a laparotomy developed significantly more adhesions than women who underwent a laparoscopy.17 In a further three studies which compared laparoscopy and laparotomy for the treatment of ectopic pregnancy, all concluded that if surgery was performed, the laparoscopic approach should be used.1819

Newborn Scaphoid Abdomen
Figure 11.3 Laparoscopic view of an ampullary ectopic pregnancy. (See also colour plate)
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