Ectopic pregnancy, ruptured or unruptured, will usually require surgical intervention. Salpingectomy (removal of the fallopian tube) is uniformly effective, safe, simple, fast, and well within the capabilities of an abdominal surgeon. Its only important disadvantages are that it results in the loss of the tube.
After opening the abdomen (lower midline incision is fast and gives excellent exposure), identify the fallopian tube containing the ectopic. Grasp the tube with Babcock clamps and elevate the tube. This spreads out the mesosalpinx (the blood supply of the tube). Using hemostats, clamp across the mesosalpinx, starting at the fimbriated end and working toward the uterus. Clamp across the tube where it enters the uterus. Then remove your specimen and suture the clamped tissue with 0 or 2-0 Vicryl, Chromic or other such material.
Evacuate from the abdomen any large clots and close the abdomen.
In the face of a large ectopic pregnancy and significant bleeding, this approach of salpingectomy is probably the wisest course. With smaller ectopics, you may conserve some or all of the tube performing a “segmental resection” in which only the middle portion of the tube is removed. This offers the advantage of conserving some of the tube for tubal reconstruction at a later date if necessary.
Another technique which works well for small ectopic pregnancies (2-3 cm in diameter) is the “linear salpingostomy.” A scalpel makes a linear incision along the antimesenteric border of the tube, directly over the ectopic pregnancy. The pregnancy is extruded through the incision and the tube observed for further bleeding. Often, the bleeding will simply stop. The tube may be reclosed with very fine absorbable suture or simply left open (the defect will close spontaneously.)
While a linear salpingostomy may be preferable in some fully-equipped and fully-staffed medical facilities, there are important drawbacks to its use in isolated settings, primarily the limitations of diagnostic techniques to follow these patients over time. Surgeons in these isolated settings might be better advised to perform the definitive therapy (salpingectomy, partial or complete) which will assure hemostasis and avoid the possible need for reoperation.
See also Hysterectomy
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