da Vinci robotic system saves fertility after reanastomosis following segmental resection of tubal ectopic pregnancy.

Clinical pearls:

• da Vinci-guided reanastomosis after segmental resection of tubal pregnancy is feasible for salvaging tubal patency and fertility in patients with absent or defective contralateral tubal function.

Patients with a single functional fallopian tube can be benefited by use of da Vinci robotic system for segmental resection and end to end reanastomosis of tubal ectopic pregnancy with higher chances of recovering the tubal patency after surgery.

The prevalence of ectopic pregnancy in women attending the emergency department with first trimester pain and bleeding is 6 to 16%.[i] The last CDC statistic quote the prevalence at 20 per 1000 pregnancies while the NHS shows that there are 11,000 ectopic pregnancies in U.K each year. [ii]

The occurrence of ectopic pregnancy in one tube increases the patients chance of getting ectopic in contralateral tube by 6-7-fold because both tube share similar pathology. Conventional option that are in frequent use includes methotrexate (MTX) therapy, salpingotomy, and milking of the ectopic implant. However, these options are not used very commonly due to delay in diagnosis of most ectopic pregnancies. They are diagnosed at a stage when rupture is imminent, thus limiting the use of options that can preserve the tube.

Researchers at the Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea reported results of a retrospective study of 17 patients who underwent segmental resections of tubal pregnancy followed by end-to-end reanastomosis over a period of 1.5 years. The paper was published in the October issue of Journal of Medicine.[iii]

The inclusion criteria for patients in the study are those diagnosed with tubal pregnancy actively seeking to conceive afterwards with stable vital signs, ages under 40 years, those with spontaneous or post-MTX rupture, presence of fetal heartbeat, and serum hCG levels initially over 5000 mIU/mL or elevated hCG levels despite MTX therapy. 

Exclusion criteria were pregnancy very near to corneal end or occupying fimbria, severe pain with tachycardia ,hypotension due to hemoperitoneum greater than 500 mL, size of ectopic pregnancy more than 5 cm and those patients suitable for MTX therapy ( without rupture and  preoperative serum hCG levels of less than 1500 mIU/mL)  as well as those with declining hCG level of more than 50% after 48 hours.

Out of 17 patients initially recruited, 14 patients underwent the procedure with 3 patients had to undergo salpingectomies due to intraoperative findings.

All surgeries were performed by team skilled in Robotic, Minimal Invasive Gynecological surgery as well as laparoscopic tubal anastomosis following tubal recanalization using the da Vinci robotic system (Intuitive Surgical, Mountain View, CA).[iv]

These patients were followed up for a period of 2 years for recovery of tubal patency, surgical complications, pregnancy and live births rates. 

Out of 14 patients who underwent surgery, only 11 were included in the final follow-up, as two patients were confirmed at surgery to have patent contralateral tube, and one did not desire immediate conception.

A HSG performed at 6 months’ follow-up showed 100% patency.

The cumulative pregnancy rate at 24 months was 63.64% (7/11) with no repeat tubal pregnancy. Follow-up beyond 24moths led to additional intrauterine pregnancies but they were not included in the study statistics.

The researchers stressed the need for additional future trials with larger number of patients to accumulate solid data on end to end reanastomosis after tubal resection surgery.

The authors concluded “tubal reanastomosis after segmental resection of tubal pregnancy using the da Vinci system is a feasible means of salvaging fallopian tube integrity and fertility in those with a single viable fallopian tube, demonstrating natural pregnancy rates compatible with that of conventional reanastomosis for tubal ligation.”

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[i] http://www.uptodate.com/contents/ectopic-pregnancy-incidence-risk-factors-and-pathology

[ii] http://www.nhs.uk/conditions/Ectopic-pregnancy/Pages/Introduction.aspx

[iii] http://journals.lww.com/md-journal/Fulltext/2016/10110/Robot_assisted_segmental_resection_of_tubal.5.aspx

[iv] http://www.davincisurgery.com/da-vinci-gynecology/