This video demonstrate Laparoscopic Management of Chronic Ectopic and Myomectomy in same patient at same session. Chronic ectopic pregnancy is a form of tubal pregnancy in which salient minor ruptures or abortions of an ectopic pregnancy instead of a single episode of bleeding, incites an inflammatory response often leading to the formation of a pelvic mass. Ectopic pregnancy presents diagnostic dilemmas in the absence of classical symptoms. MRI and laparoscopy are important tools in such cases. If patient has fibroid uterus it can be operated at same session.

The field of minimally invasive gynecological surgery has witnessed remarkable advancements over the past decades. Laparoscopy not only provides superior visualization but also offers quicker recovery, less postoperative pain, and better cosmetic results compared to traditional open surgery. Managing complex gynecological conditions like chronic ectopic pregnancy alongside uterine fibroids in a single operative session requires skill, careful planning, and a multidisciplinary approach.

Introduction

Chronic ectopic pregnancy (CEP) is a rare but challenging condition in gynecology. Unlike acute ectopic pregnancies, CEP is characterized by delayed symptoms, adhesions, and sometimes, a pseudo-tumor formation due to repeated bleeding from the implantation site. Concurrently, uterine fibroids (leiomyomas) are common benign tumors that may require surgical intervention if symptomatic, causing menorrhagia, infertility, or pain.

Performing a laparoscopic myomectomy simultaneously with the management of a chronic ectopic pregnancy presents unique technical challenges, but with meticulous preoperative assessment and advanced laparoscopic techniques, it is feasible and beneficial for patients.

Preoperative Considerations

1. Patient Evaluation

   • Detailed history focusing on pain, menstrual irregularities, infertility, and prior surgeries.

   • Laboratory investigations including β-hCG levels to assess ectopic activity.

   • Imaging studies: Transvaginal ultrasound is essential to identify ectopic gestation and characterize fibroids; MRI can be considered in complex cases.

2. Surgical Planning

   • Consent should cover both procedures, including potential risks such as hemorrhage, conversion to laparotomy, and adhesion formation.

   • Preoperative optimization includes correction of anemia if present, and ensuring the patient’s fitness for general anesthesia.

Laparoscopic Technique

1. Patient Positioning and Port Placement

   • Standard lithotomy position with Trendelenburg tilt.

   • Typically, a 10mm umbilical port for the camera and 3–4 accessory ports for instruments.

2. Management of Chronic Ectopic Pregnancy

   • Identification of the ectopic site, which is often surrounded by dense adhesions.

   • Careful adhesiolysis to expose the fallopian tube and ectopic mass.

   • Salpingectomy or salpingostomy depending on tubal status and patient’s fertility desire.

   • Hemostasis achieved using bipolar coagulation or suturing.

3. Myomectomy Procedure

   • Uterine incision made over the fibroid using energy devices or cold scissors.

   • Enucleation of the fibroid with minimal trauma to the surrounding myometrium.

   • Layered closure with absorbable sutures to maintain uterine integrity.

   • Retrieval of fibroid tissue via morcellation or mini-laparotomy as appropriate.

4. Final Steps

   • Thorough irrigation to remove blood clots and prevent adhesion formation.

   • Placement of anti-adhesion barriers if needed.

   • Hemostasis confirmed and ports closed.

Postoperative Care

• Early mobilization and pain management.

• Monitoring for signs of infection or bleeding.

• Follow-up imaging if indicated to ensure uterine and tubal healing.

• Counseling regarding future fertility and conception timing.

Advantages of Combined Laparoscopic Approach

• Single anesthesia exposure and hospital stay.

• Reduced overall recovery time and faster return to daily activities.

• Minimization of adhesion formation compared to staged surgeries.

• Preservation of fertility whenever feasible.

Conclusion

The laparoscopic management of chronic ectopic pregnancy along with myomectomy in the same patient is a safe and effective approach in experienced hands. Proper patient selection, meticulous surgical technique, and comprehensive preoperative planning are essential for optimal outcomes. With the growing expertise in minimally invasive gynecologic surgery, more complex cases can be managed laparoscopically, improving patient satisfaction and postoperative recovery.