ABSTRACT

The objective of this report is to describe the possible use of intramiometrial vasoconstrictive agents for laparoscopic management of interstitial pregnancy and the consequences in anatomical results and reproductive outcomes. Cornual resection can be performed by laparoscopy, but the high vascularization of this area may result in profuse bleeding and laparoscopic suturing under these conditions might be impossible for the majority of the surgeons. We present a case that describes the possible use of intramiometrial instillation of a solution of diluted epinephrine and levobupivacaine under laparoscopic guidance that permitted a bloodless cornual excision with complete reconstruction. Vasoactive agents might have potentially serious cardiovascular side effects and the correct election of the active principle and the dosage is essential to reduce the risk of the surgery and obtain good anatomical results and reproductive outcomes. In conclusion, unruptured interstitial pregnancies can be managed successfully with intramyometrial instillation of epinephrine and bupivacaine. This simple technique is particularly attractive as it facilitates anatomical reconstruction of the cornual area, gives enough time to perform a complete suture of the defect and reduces the risk of laparotomic conversion.

1. INTRODUCTION

2. MATERIAL AND METHODS

We report our experience in a patient with a cornual pregnancy who was successfully managed with a simple inexpensive technique that included infiltration of a solution with diluted epinephrine and levobupivacaine and right cornual wedge resection with salpingectomy. Anatomical reconstruction of the cornual area was achieved by a two-layer intracorporeal suturing under laparoscopic guidance.

We also conducted a MEDLINE search from January 1970 to December 2010 using combinations of the medical subject headings “cornual”, “interstitial”, “intramural”, and “ectopic pregnancy”, retrieving a total of 126 articles and reviews. Only pertinent articles that related with the specific laparoscopic management and different techniques for reducing bleeding at the cornual area were considered. Additional reports, including those referring specifically to the use of vasoconstrictive agents in gynecology were also considered.

3. RESULTS

A 38-year-old woman with no previous surgical procedures attended our unit, with abdominal pain and spotting 8 weeks after her last menstrual period. At presentation the patient’s general condition was good and hemodynamically stable. The patient had no comorbid conditions and she referred no previous surgery. Abdominal examination revealed tenderness and intestinal peristalsis was identified on auscultation. Gynecological examination revealed painful cervix mobilization and augmented right adnexa. The ultrasound exam showed a right adnexal mass of 3 × 4 cm with an embryo of 7 mm that presented positive heart beating that appeared to be located at the proximal portion of the right tube. Routine blood tests were taken showing no signs of anemia or infection. Serum B-hCG was 3238 mU/mL. A laparoscopic removal of the ectopic pregnancy was indicated. Laparoscopic access was performed using a visual port insertion with Ternamian endotip trocar (Karl Storz, Tuttlingen, Germany). At examination there was an unruptured mass of 4 × 3 cm that seemed to origin from the right horn of the uterus. The right salpinx and the right ovary were normal. Left ovary and tube were also normal. The uterus was enlarged and plump. It was normal except for some dense adhesions in the posterior uterine surface. Intramyometrial instillation of a 50 mL solution with diluted epinephrine and levobupivacaine was used in order to permit a bloodless cornual excision. The solution was prepared by an assistant in a 50-mL syringe connected to a laparoscopic cannula. The syringe contained 50 mL of Levobupivacaine chloride 0.25% (Chirocane Sol. iny. 0.25%, Abbot Lab. SA, España) and 0.25 mL of epinephrine ([1/4] vial of 1mg/mL). The infiltration was performed deeply inside the cornual myometrium, medially to the limit of the ectopic pregnancy, to avoid the direct infiltration inside the chorial tissue. Repeated aspirations were performed to prevent intravascular injection before infiltration and the systolic and diastolic blood pressure and heart rate were accurately controlled by the anesthesiologist. An elliptic incision was made above the base of the cornual pregnancy, leaving enough serosa and myometrium for closure the defect and a wedge resection at the cornual area was performed. Very scant bleeding was noted during removal of the products of gestation, which facilitated the anatomical reconstruction. The defect was first sutured with a two-layer introflecting stitch in order to prevent slippage. Coagulation was avoided in order to preserve the quality of the uterine scar and to avoid damaging the endometrium. A nitrocellulose barrier (Gynecare Interceed, Johnson & Johnson, NY, USA) was left in the surgical area in order to prevent adhesions. The products of gestation were removed laparoscopically using an endoscopic bag (Endocatch Gold, 10 mm; Covidien, Norwalk, CT, USA).

During the next two days of hospitalization the patient was in a good general condition without any pain in the abdomen. The routine palpatory and auscultatory examinations revealed no abnormalities. The postoperative period was uneventful. Hemoglobin drop was 0.8 g/dL and control serum beta-hCG 24 hours after surgery was 943 mU/ml, and was repeated weekly after neutralization 14 days later. The patient was discharged 48 hours after the laparoscopic procedure without further complications. Postoperative gynaecological examination performed one month later was normal and at the present the patient is not seeking pregnancy.

4. DISCUSSION

Bupivacaine and levobupivacaine are local anesthetics that cause vasodilatation at clinical doses, but lower doses appear to cause vasoconstriction. Levobupivacaine has shown to have vasoconstrictive activity in concentrations of ≤0.25%, with duration of its action between 4 and 24 h when used for local infiltration [24]. In addition, levobupivacaine has similar potency to bupivacaine with a lower risk of cardiovascular and nervous toxicity, which makes it a good election for its anesthetic and vasoconstrictive properties [25]. Clinical studies have tested the efficacy of levobupivacaine in a wide spectrum of operations, such as surgical wound infiltration or intraperitoneal instillation after laparoscopic procedures [26, 27]. We decided to use a combination of levobupivacaine and low dose of epinephrine in order to minimize the cardiovascular effects of the latest without interfering in the vasoconstrictive effects on hemostasis.

5. CONCLUSION

In conclusion, our experience suggests that unruptured interstitial pregnancies can be managed successfully with intramyometrial instillation of epinephrine and levobupivacaine under laparoscopic guidance. This technique is particularly attractive as it facilitates anatomical reconstruction of the cornual area, gives enough time to perform a complete suture of the defect and reduces the risk of laparotomic conversion.

CONFLICT OF INTEREST

None declared.

REFERENCES

NOTES

^*Corresponding author.