Trans-umbilical single-port laparoscopic excision of intramural pregnancy

Introduction

Background

Ectopic pregnancy is a sort of abnormal pregnancies on behalf of implantation of yolk sac outside the uterine cavity, such as fallopian tube, cervix, ovary and abdominal sites. Typical symptoms of ectopic pregnancy include pelvic or abdominal pain, abnormal uterine bleeding and hemorrhagic shock as a severe complication. Intramural pregnancy (IMP) is a rare type of ectopic pregnancy, with an incidence of 1% of all ectopic pregnancies (1,2). Intramural pregnancies need to be differentiated from uterine horn pregnancies as well as tubal interstitial pregnancies.

Rationale

Due to the lack of typical clinical manifestation, it is not easy for IMP to be diagnosed at the early pregnancy period, which lead to potentially fatal complications, such as uterine rupture, acute and severe hemorrhage, shock, etc. (3). Precipitating factors include uterine surgery, tubal surgery, induced abortion, embryo implantation and other surgeries. Preoperative sonography helps in the diagnosis of IMP. Laparoscopic surgery is used successfully as a main treatment in most cases, while some cases are treated with combination with hysteroscopic surgery.

Objective

We are hereby presenting a case of intramural pregnancy and describing the use of trans-umbilical single-port laparoscopy for surgical management of this rare condition. We present this article in accordance with the SUPER reporting checklist (available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-32/rc).

Preoperative preparations and requirements

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this study and accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

The patient was admitted to the hospital with “44 days of menopause”. She had undergone left salpingo-oophorectomy for ectopic pregnancy 1-year before. Ultrasonography showed that there was no definite gestational sac in the uterus, and a gestational sac-like echo measuring about 1.6 cm × 1.2 cm × 1.6 cm was detected in the left intermuscular wall, with yolk sac-like echoes visible within it, which appeared to have no obvious relationship with the uterine cavity. Serum β-human chorionic gonadotrophin (hCG) levels result in 35,378.2 mIU/mL. There were no specific clinical symptoms, such as abdominal pain, vaginal bleeding. The patient requested surgery for fear of uterine rupture as well as bleeding.

Preoperative computed tomography (CT) scanning was used to determine the specific location of gestation (shown in Figure 1). Adequate preoperative blood mixing is ready for preventing intraoperative hemorrhage.

Figure 1 Gestational sac inside in the left intramuscular wall. (A) Abdominal CT scanning; (B) ultrasonography. CT, computed tomography.

Step-by-step description

• The patient was placed in a lying position with urethral catheter indwelled after general anesthesia.
• A puncture hole approximately 2 cm in diameter was made in the umbilicus. The skin, subcutaneous fat, fascia and peritoneum were incised to enter the abdominal cavity and a specialized single-PORT (Disposable Incision Dilator by Hangzhou Kangji Medical Instrument Company) was placed through the umbilicus to create an artificial pneumoperitoneum.
• The patient was placed in the head-down-foot-up position, and pelvic adhesions were broken down.
• Diluted pituitrin (6 U, containing vasopressin and oxytocin) was injected through a long needle (by Zhengjiang Tiansong Medical Instrument Company) into the myometrial wall (as shown in Figure 2).
  

  Figure 2 Diluted pituitrin (6 U) was injected into the myometrial wall.
• The plasma membrane of the uterus was incised with Harmonic by Ethicon Endo-Surgery, LLC, and the pregnancy tissues were completely excised and placed into a specimen bag for removal.
• Electrocoagulation by Biclamp Lap forceps (by ERBE Elektromedizin GmbH) was performed for wound hemostasis.
• Myometrial plasma layer was closed continuously with absorbable sutures, leaving no gap in the subplasma layer (as shown in Figure 3).
  

  Figure 3 Myometrial plasma layer were closed continuously with absorbable sutures.
• Close the puncture hole in the abdominal wall.

The whole procedure is shown in Video 1. The duration of surgery was 80 minutes with a blood loss of 10 mL.

Postoperative considerations and tasks

The urinary catheter was removed 12 hours postoperatively and the patient had normal spontaneous urination. The patient resumed voluntary activity out of bed 24 hours after surgery and discharged 48 hours after surgery, with a significant decrease in hCG levels from 31,465.8 mIU/mL before surgery to 2,371.40 mIU/mL at discharge. The serum hCG level was monitored weekly until it turned negative. Strict contraception was required at least two years after the surgery.

Tips and pearls

Preoperative imaging modality such as sonography is important to get an accurate diagnosis.

Intraoperative use of pituitrin can reduce bleeding during surgery.

The use of absorbable surgical suture with barbs can make it easier to suture in trans-umbilical single-port laparoscopic approach.

Discussion

Surgical highlights

In intramural pregnancy, laparoscopic surgery alone or combination with hysteroscopic surgery is used usually as a main treatment, leaving behind several scars in the lower-abnormal skin. Here we report a more minimally-invasive method as trans-umbilical single-port laparoscopy, making the postoperative scars nearly invisible.

Strengths and limitations

The principal tool for the diagnosis of IMP is ultrasound (4). Sometimes, it was difficult to make a definite early diagnosis of IMP before surgery via sonography, and in that cases IMP could be diagnosed through further modalities such as CT, magnetic resonance imaging (MRI) or surgical intervention such as hysteroscopy or laparoscopy (5,6). In this study, preoperative sonography revealed a gestational sac-like echo detected in the left intermuscular wall, which was further determined by abdominal CT scanning.

Based on the preoperative imaging modalities, trans-umbilical single-port laparoscopy with a tiny puncture, rather than traditional laparoscopy, was performed, which greatly reduce the patients’ trauma, increase cosmetic effects and leave no more complications.

During the surgery, low-dose pituitrin was used, inducing uterine contractions and decreasing uterine blood loss.

The new improved method as trans-umbilical single-port laparoscopy makes the surgery more minimally-invasive, but more cost due to the specific equipment including PORT and absorbable surgical suture with barbs.

Comparison with other surgical techniques and researches

It was reported that conservative surgical management such as laparotomy (7) or laparoscopy (8) can be achieved to remove the intramural pregnancy with preservation of the uterus and myometrial reconstruction. Operative hysteroscopy (9) for the management of intramural ectopic pregnancy was also reported, with a potentially increased risk of uterine perforation.

In this study, trans-umbilical single-port laparoscopy can reduce the patients’ trauma and increase cosmetic effects.

In patients with high risk of bleeding, if necessary, interventional embolization of uterine arteries may help reduce bleeding.

Implications and actions recommended

If an intramural pregnancy is suspected in early pregnancy, CT scanning makes for the detailed location of gestation sac. Trans-umbilical single-port laparoscopic excision of gestation lesions is advised and can be a safe surgical modality. Low-dose pituitrin can enhance uterine contractions and reduce bleeding during surgery.

At last, there are certain requirements for surgical techniques in the excision of intramural pregnancy. The surgeons should be familiar with uterine vessels anatomy and skillful in single-port laparoscopic suture technique, which also were important for the successful operation.

Conclusions

Preoperative ultrasound, CT or MRI may assist in the diagnosis of intramural pregnancy. Based on the results of the imaging, an appropriate surgical procedure, such as exploratory single-port laparoscopic surgery, is selected to help the patient get a good treatment. Intraoperative use of pituitrin or oxytocin can reduce intraoperative bleeding.

Acknowledgments

The video was awarded the second prize in the Fourth International Elite Gynecologic Surgery Competition (2024 Masters of Gynecologic Surgery).

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gynecology and Pelvic Medicine for the series “Award-Winning Videos from the Fourth International Elite Gynecologic Surgery Competition (2024 Masters of Gynecologic Surgery)”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-32/rc

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-32/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-32/coif). The series “Award-Winning Videos from the Fourth International Elite Gynecologic Surgery Competition (2024 Masters of Gynecologic Surgery)” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this study and accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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