Preoperative preparation, access, and anesthesia
Any surgical intervention for tubal pregnancy requires strict conditions. The patient is placed on the operating table in the supine position. The most important aspect is the choice of anesthesia: the surgery is performed exclusively under general anesthesia. The use of local, regional, or spinal anesthesia is excluded in this case.
To enter the abdominal cavity, the surgeon uses one of two standard approaches. This can be a classical lower midline laparotomy, providing a wide overview, or a Pfannenstiel incision.
Technique of radical surgery (salpingectomy)
Radical surgery, or salpingectomy, involves the complete removal of the affected uterine tube. The procedure consists of several sequential steps:
- Bringing the uterus into the wound. To provide convenient access to the appendages, special catgut stay sutures are passed through the uterine fundus. Alternatively, the surgeon may grasp the uterine fundus with Museux forceps. After this, the uterus along with the affected tube and ovary are carefully brought directly into the surgical wound.
- Placement of hemostatic clamps. To prevent bleeding, two main clamps are applied. The first clamp is strictly fixed to the uterine end of the tube (rather than the ampullary section, isthmus, or abdominal end). The second clamp is applied to the suspensory ligament of the ovary, positioning it parallel to the tube itself.
- Transection of the uterine tube. The tube is transected along the line of its mesentery—mesosalpinx. As the scissors advance, the surgeon sequentially applies 2–3 more hemostatic clamps to the tissues of the mesentery.
- Wedge resection of the uterine cornu. To guarantee the complete removal of the entire tube without residue, its end near the uterine cornu is excised in a wedge shape. It is extremely important to observe the depth of this excision: it must be strictly no more than 5 mm (not 2 mm and not 10 mm).
Hemostasis, peritonealization, and completion of salpingectomy
After organ removal, it is necessary to ensure reliable hemostasis. 2–3 interrupted catgut sutures are applied to the resulting wound of the uterine cornu. Areas of the mesentery (mesosalpinx) that were previously clamped are thoroughly suture-ligated using interrupted catgut sutures as well.
The next stage is peritonealization, which is necessary to cover the wound surfaces. It is performed using a continuous catgut suture. The suture begins from the peritoneal covering, moving to the anterior and posterior leaflets of the mesosalpinx. For reliable peritonealization of the uterine cornu region, the surgeon may use the round ligament of the uterus.
There is also a modification of the technique leaving the tubal stump. In this case, wedge resection of the uterine cornu is not performed, and the broad ligament of the uterus is used to peritonealize the remaining stump.
The surgery concludes with a thorough cleansing of the abdominal cavity: the surgeon removes all accumulated clots and liquid blood. A visual inspection of the appendages on the contralateral side is mandatory. After this, the abdominal wall is closed in layers.
Conservative (organ-preserving) surgeries
If the condition of the uterine tube is assessed as satisfactory and allows its preservation, surgeons resort to conservative interventions.
The technique of such surgery consists in carefully removing the fertilized ovum through a longitudinal incision in the tubal wall. The main goal of this stage is to perform the manipulation without compromising the future patency of the organ.
In situations where the surgeon has doubts about maintaining patency, a special technique is used. A polyethylene catheter is inserted into the lumen of the operated uterine tube. This catheter is left inside for a long period—from 6 to 8 weeks (rather than 1–2 or 3–4 weeks), while its other free end is necessarily brought outward.
Briefly: answers to topical questions
What are the strict contraindications to conservative (organ-preserving) surgeries in tubal pregnancy?
In the provided sources, a separate list of strict contraindications to conservative (organ-preserving) surgeries in tubal pregnancy is not formulated.
The indications for radical surgery—salpingectomy—are explicitly stated:
- Recurrent pregnancy in a uterine tube that has previously undergone organ-preserving surgery.
- Cicatricial changes in the uterine tube.
- The patient's unwillingness to have future pregnancies.
- Rupture of the fallopian tube.
- Gestational sac diameter greater than 3 cm.
- Localization of the gestational sac in the intramural (interstitial) segment of the fallopian tube.
It is also stated that organ-sparing surgeries are performed if the condition of the tube allows for its preservation.
What types of conservative interventions are used for tubal pregnancy besides longitudinal incision (linear salpingostomy)?
In addition to salpingotomy (longitudinal incision of the fallopian tube), the following conservative-plastic surgeries are performed to preserve reproductive function:
- «Milking» the gestational sac (milking) — used only for localization in the ampullary section.
- Segmental resection of the fallopian tube — performed when appropriate conditions are met.
In cases where doubts remain regarding tube patency after removal of the gestational sac, a polyethylene catheter is inserted into its lumen for a period of 6–8 weeks.
To remember the depth of the wedge resection of the uterine horn, use the association with an excellent grade: the surgeon must do everything to a "5" — the depth must strictly not exceed 5 mm.
Class and exam questions
What type of anesthesia is used for surgeries regarding ectopic pregnancy?
The intervention is performed exclusively under general anesthesia. Regional, local, or spinal anesthesia are not used in this case.
Where are the clamps applied at the initial stage of tube removal?
The first clamp is applied strictly to the uterine end of the tube, and the second one to the suspensory ligament of the ovary, positioning it parallel to the tube.
How does the surgical technique differ when leaving a stump?
In this modification, the end of the tube near the uterine horn is not excised in a wedge shape; instead, the broad ligament of the uterus is used to reperitonealize the remaining stump.
What is done before layered closure of the abdominal wall?
The surgeon is obligated to remove all clots and liquid blood from the abdominal cavity, as well as perform a thorough visual inspection of the appendages on the contralateral side.
What else to study on this topic
- Topographic anatomy of the fallopian tubes and ovaries
- Blood supply to the uterine appendages and risk zones during clamp placement
- Technique for Pfannenstiel incision and lower midline laparotomy
- Features of continuous catgut suture placement during reperitonealization
- Properties of catgut and the use of suture materials in gynecological surgery
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