Laparoscopic cornuotomy using temporary tourniquet suture in Interstitial pregnancy. Young-Sam Choi M.D. Kwang-Sik Shin M.D. Jin Choi M.D. Dae-Sook Eun M.D. Dept. of Obstetrics & Gynecology, Eun Hospital Kwang-Ju, South Korea

Interstitial pregnancy very rare form of ectopic pregnancy can bring about catastrophic events Catastrophic events life-threatening hemorrhage uterine rupture in subsequent pregnancy Introduction

Conventional managements ● Hysterectomy ● Cornual wedge resection with / without ipsilateral salpingectomy through a laparotomy perfect method for terminating the pregnancy but they were invasive and not desirable in patients who wish to preserve their fertility History

Introduction of conservative managements ● Medical approach Tanaka et al. in 1982 ● Laparoscopic approach Reich et al. in 1988 ● Hysteroscopic approach Meyer et al. in 1989 History

Methotrexate (systemic or local) KCl Hypertonic dextrose Prostaglandins Actinomycin D Advantage: non-invasive Disadvantage: need for prolonged, close follow-up some patients require adjuvant treatment and it has some adverse effects Medical managements

Hemostatic techniques Diluted vasopressin injection Electrocauterization Fibrin glue Ultrasonic cutting and coagulating device Ascending uterine artery ligation Advantage: minimal invasive Disadvantage: not always sufficient to control hemorrhage Laparoscopic approach

Suture techniques Encircling suture or endoloop ligation Square suture Automatic stapler Advantages: more effective more reliable at hemostasis Disadvantage sacrifice the tube and cornu Laparoscopic approach

Not cornuostomy But Cornuotomy Schema of Technical tip 1 st Diluted vasopressin injection 2 nd Tourniquet suture apply (Cornual Island) 3 rd Additional vasopressin injection These resulted in a “ Cornual Island ” that isolated the region from the blood supply. Laparoscopic Cornuotomy

Schema of Technical tip 4 th Transverse incision on cornu 5 th Evacuation of conceptus 6 th Repair of incision (cornuotomy) 7 th Removal of tourniquet suture (temporary) Laparoscopic Cornuotomy

TVUS & color Doppler flow of IP (A) Empty endometrial cavity, thin myometrial mantle, extremely eccentrically located gestational sac are revealed (B) “Solid ring of fire” pattern is revealed on color Doppler flow, implying peritrophoblastic, highly vascular implantation

Laparoscopic Cornuotomy

Results (n=9) Variables Number of patients (n=9) Operation time (min)58±16 Estimated hemorrhage (ml)50±22 Resolution of β ‑ hCG (days) 27±8 Postoperative adjuvant therapy0 Blood transfusion0

HSG image 3 months after operation Both tubes are patent (arrowheads) and that contrast material spills into the peritoneal cavity (open arrow). Small external dimpling (straight arrow) is revealed on the affected proximal cornu, but is negligible in terms of the overall tubal patency

MRI images 3 months after operation Axial view in the T2-weighted imageCoronal view in the T2-weighted image The arrowhead and open arrow indicate the affected cornu. Note that there are no significant differences in the thickness of the affected and unaffected cornu, and no defects in terms of the overall cornual contour.

Uterotubal patency & Cornual integrity Variables Number of patients (n=9) Tubal patency (on HSG) (n=7) 2 patients were excluded owing to lost to follow-up and had undergone prior ipsilateral salpingectomy Patent 5 Non-patent 2 Cornual integrity (on MRI) (n=8) 1 patient were excluded owing to lost to follow-up No defect 8 Defect 0

Pregnancy outcomes ● 3 multiparous women had conceived 12&17 months after the surgery and were safely delivered by vaginal route at full-term. ● 1 nulliparous woman conceived 30 months after surgery and she is in the 32 weeks of pregnancy now.

Laparoscopic cornuotomy ● Perfect for hemostasis ● No adjuvant treatment ● Probaility of preservation of cornua & tube ● Possibility of vaginal delivery in subsequent pregnancy Conclusions

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