Ectopic pregnancy remains one of the most challenging conditions in gynecology. While acute ectopic pregnancy is well known for its sudden onset of abdominal pain and internal bleeding, there exists another form—chronic ectopic pregnancy—which is less common but diagnostically more difficult. Advances in minimally invasive surgery have made laparoscopy the treatment of choice for both acute and chronic ectopic pregnancies. Laparoscopic management provides accurate diagnosis, effective treatment, and fertility-preserving solutions, all with minimal surgical trauma.

Understanding Chronic Ectopic Pregnancy

Unlike acute cases, chronic ectopic pregnancy develops insidiously. It results from the gradual leakage of trophoblastic tissue from the fallopian tube into the peritoneal cavity, leading to recurrent bleeding and the formation of pelvic adhesions. The ectopic gestation may not progress, and instead of a ruptured tube with active bleeding, the body reacts to persistent trophoblastic tissue with inflammatory changes and hematoma formation.

Clinical Presentation:
Patients often present with vague and persistent symptoms rather than dramatic collapse. These include:

Chronic lower abdominal or pelvic pain.

Irregular or prolonged vaginal bleeding.

Low-grade fever or malaise.

Occasionally, a palpable adnexal mass.

Because symptoms overlap with other gynecological and pelvic inflammatory conditions, diagnosis can be delayed.

Diagnostic Challenges

Chronic ectopic pregnancy is often difficult to confirm before surgery. Investigations typically include:

Ultrasound: May show complex adnexal masses with heterogeneous echogenicity, but no definitive gestational sac.

Serum beta-hCG: Levels are usually low or plateauing, unlike the high or rising levels in acute ectopics.

MRI/CT scan: Sometimes used in complex cases to differentiate from ovarian cysts, tubo-ovarian abscesses, or endometriomas.

Due to its atypical features, chronic ectopic pregnancy is often confirmed only during laparoscopy.

Role of Laparoscopy

Laparoscopy is both a diagnostic and therapeutic tool in managing chronic ectopic pregnancy. It allows direct visualization of the pelvis, identification of the affected tube, and treatment in the same sitting. Compared to laparotomy, laparoscopy offers faster recovery, less postoperative pain, and minimal adhesion formation—an important factor in women desiring fertility.

Surgical Approach

The laparoscopic procedure involves several carefully planned steps:

Patient Preparation
The patient is placed under general anesthesia in lithotomy position. Pneumoperitoneum is created, and trocars are inserted, usually three or four ports.

Exploration
The pelvis is examined to identify the affected fallopian tube, pelvic adhesions, and the extent of hematoma or mass formation. Chronic ectopics often appear as a swollen, thickened tube with surrounding adhesions and organized clots.

Surgical Options

Laparoscopic Salpingectomy:
The most common approach in chronic ectopic pregnancy. Since the tube is usually extensively damaged, removal of the affected tube is often necessary. Bipolar cautery or advanced energy devices are used to coagulate and divide the mesosalpinx, followed by excision of the tube.

Laparoscopic Salpingostomy:
In rare cases where the tube is less damaged and the patient strongly desires fertility preservation, a linear incision may be made on the tube to remove residual trophoblastic tissue. However, because of scarring and recurrent risk, salpingostomy is less commonly performed in chronic ectopic cases compared to acute ones.

Adhesiolysis:
Surrounding adhesions are carefully released to restore normal pelvic anatomy, which is critical for fertility.

Hemostasis and Irrigation:
All bleeding points are secured, and clots are irrigated from the peritoneal cavity to prevent postoperative adhesions.

Specimen Retrieval
Tissue is retrieved in an endoscopic bag to prevent spillage of trophoblastic material.

Postoperative Care

Patients typically recover quickly after laparoscopic surgery. Oral intake can resume within hours, and mobilization is encouraged the same day. Hospital stay is generally short, around 24–48 hours.

Key aspects of follow-up include:

Beta-hCG Monitoring: To ensure complete resolution of trophoblastic tissue. Persistent or rising levels may indicate incomplete removal.

Pain Management: Postoperative discomfort is minimal and managed with oral analgesics.

Fertility Counseling: Women are advised to wait 3–6 months before attempting conception, depending on the surgical outcome. Assisted reproductive techniques may be discussed if the remaining tube is damaged or absent.

Advantages of Laparoscopic Management

Precise diagnosis when imaging is inconclusive.

Simultaneous treatment in the same procedure.

Shorter hospital stay and faster return to normal activities.

Reduced adhesion formation compared to open surgery.

Fertility-preserving approach in selected cases.

Superior visualization of pelvic structures.

Conclusion

Chronic ectopic pregnancy is a rare but significant clinical entity that presents diagnostic and therapeutic challenges. Unlike the dramatic emergency of acute ectopic pregnancy, chronic cases often remain elusive until laparoscopy is performed. Laparoscopic management not only confirms the diagnosis but also offers definitive treatment with minimal morbidity. Salpingectomy remains the most common surgical solution, while conservative procedures are reserved for carefully selected patients. Ultimately, laparoscopy provides the safest, most effective, and fertility-conscious management for women with chronic ectopic pregnancy, reaffirming its role as the gold standard in modern gynecology.