Laparotomy for Ectopic Pregnancy

1. Read the bedletter thoroughly, as for all operations
2. Have a plan for the operation – salpingectomy, or tubal conservation
3. Find out if the patient has considered tubal ligation (i.e. if a fully conscious 33 year old, Para 3, with an unwanted pregnancy consented for sterilization)
4. Do a Pfannenstiel incision only if the diagnosis is certain & no problems are expected. Otherwise, midline
5. Clear the operating field after opening the abdomen – scoop out blood, lift structures aside & gently pack if necessary. Enlarge the incision if necessary
6. If there is vigorous bleeding, clamp the offending bleeder as soon as it can be easily isolated (often the bleeding is slow)
7. Peritubular adhesions can be put on the stretch & then divided, if present, to free up the tube. Consider this for the other tube if fertility is an issue
8. A single Maingot clamp, diagonally placed across the tube & along the mesosalpinx, is usually adequate. If the ovary cannot be separated, the infundibulopelvic ligament must be separately divided & the ovary removed
9. If adhesions are troublesome, ligate & cut the round ligament & open the broad ligament, to approach the ectopic from outside in. This shows the position of the ureter beneath the infundibopelvic ligament.  Oophorectomy may occasionally become necessary
10. For tubal conservation, incise the anti-mesenteric edge of the tube for 3 cm with cutting diathermy, empty the tube digitally, diathermise bleeders & leave the defect open
11. If the contralateral tube is a hydrosalpinx & fertility is hoped for, cut a cruciate terminal salpingotomy with a diathermy, & divide simple peritubular adhesions only
12. If the patient has requested sterilization do a modified Pomeroy tubal ligation on the contralateral tube
13. Minimise trauma to the tissues to ensure less complications & quicker recovery
14. Ensure good haemostasis & leave the abdomen free of blood

Ectopics should be performed laparoscopically if possible. The operation remains the same. 3 ports should suffice. Suck the blood out to improve vision. Salpingectomy or salpingotomy are acceptable. Tissue retrieval can be into a 10mm 2⁰ port with a ‘toilet seat’ to pass a grasper or with an artery clamp passed directly through the skin at the 2⁰ port site or with a bag.