Laparoscopic Surgical Management of Interstitial Ectopic Pregnancy: The Retrograde Milking Technique

Abstract

Study Objective

To review the classification and surgical management options for interstitial ectopic pregnancy (IEP) and demonstrate a novel approach to the management of distal IEP, the myometrium-sparing laparoscopic retrograde milking technique.

Design

One patient underwent surgical management of distal IEP using the laparoscopic retrograde milking technique followed by routine salpingectomy. She was seen for routine 6-week postoperative follow-up.

Setting

The patient was positioned in dorsal lithotomy with legs in stirrups and arms tucked. A 10mm 30-degree laparoscope and three 5-mm accessory ports were used.

Patients or Participants

One patient with distal IEP was selected and provided informed consent for video recording of her surgery to be used for educational and research purposes.

Interventions

The laparoscopic retrograde milking technique, an emerging technique for management of distal IEP that avoids myometrial incision, was used to milk the pregnancy into the tubal ampulla. Routine salpingectomy was then performed.

Measurements and Main Results

The patient had an uncomplicated surgery and recovery. Her beta-HCG was followed weekly until negative.

Conclusion

Distal IEPs may be safely and effectively managed with the laparoscopic retrograde milking technique followed by routine salpingectomy. Surgeon skill remains paramount to the surgical management of IEPs due to the risk of intraoperative rupture. Providers performing the milking technique should be prepared to urgently convert the procedure to a cornuostomy or wedge resection and be comfortable with laparoscopic suturing. If myometrial incision can be avoided through use of the milking technique, advantages may include reduced operative time, decreased blood loss, faster recovery, and the possibility of vaginal delivery in subsequent pregnancies by avoiding a myometrial incision, an option typically not recommended after laparoscopic cornuostomy or cornual wedge resection. Although theoretically this technique does not breach the myometrium, patients should be counselled about the lack of evidence regarding risk of uterine rupture during trial of labour after salpingectomy using this technique.