This video demonstrate Laparoscopic Management of Chronic Ectopic Pregnancy performed by Dr R K Mishra at World Laparoscopy Hospital. 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. A pregnancy test may or may not be positive. CULDOCENTESIS is the confirmatory test for rupture of a chronic ectopic pregnancy, The early diagnosis and minimally invasive management of ectopic pregnancy are usually possible because of the development of highly sensitive urine pregnancy tests and ultrasonography. We herein report a rare case of chronic ectopic pregnancy which was difficult to diagnose before laparoscopic surgery.

Chronic ectopic pregnancy is a rare and challenging variant of ectopic pregnancy, characterized by the slow leakage of trophoblastic tissue into the surrounding pelvic structures. Unlike acute ectopic pregnancies, chronic ectopics often present with vague and nonspecific symptoms, making diagnosis difficult. Traditional management involved laparotomy, but with the advancement of minimally invasive techniques, laparoscopic management has become the preferred approach due to its precision, reduced morbidity, and faster recovery.

Understanding Chronic Ectopic Pregnancy

A chronic ectopic pregnancy occurs when a tubal pregnancy progresses slowly, with repeated minor ruptures or leakage of blood and trophoblastic tissue. The body attempts to contain this bleeding, often forming dense adhesions and an organized hematoma, which may mimic other pelvic pathologies. Common clinical features include:

• Chronic lower abdominal pain

• Irregular vaginal bleeding

• Adnexal mass

• Sometimes mild anemia due to ongoing slow bleeding

Laboratory findings often show slightly elevated or declining β-hCG levels, which can further complicate diagnosis. Imaging with transvaginal ultrasound may reveal a heterogeneous adnexal mass with cystic and solid components, but diagnosis is frequently confirmed intraoperatively.

Advantages of Laparoscopy

Laparoscopy offers several advantages over traditional open surgery in managing chronic ectopic pregnancies:

1. Minimally Invasive: Smaller incisions result in less postoperative pain and quicker recovery.

2. Enhanced Visualization: High-definition cameras allow for precise identification of adhesions, hematomas, and ectopic tissue.

3. Reduced Blood Loss: Careful dissection under magnified view minimizes intraoperative bleeding.

4. Fertility Preservation: Laparoscopy allows for tubal-sparing procedures when feasible, improving future reproductive potential.

5. Shorter Hospital Stay: Patients often return home within 24–48 hours.

Laparoscopic Surgical Approach

Preoperative Preparation

• Complete blood count, coagulation profile, and serum β-hCG levels

• Pelvic ultrasound or MRI to delineate the lesion

• Blood products on standby in case of significant bleeding

Surgical Steps

1. Port Placement: Standard laparoscopic ports are placed: a 10 mm umbilical port for the camera and 5 mm ports in the lower quadrants for instruments.

2. Exploration: The pelvis is carefully inspected. Adhesions and the chronic ectopic mass are identified.

3. Adhesiolysis: Dense adhesions surrounding the ectopic pregnancy are carefully dissected using sharp and blunt techniques.

4. Excision of Ectopic Tissue: The ectopic pregnancy is excised while preserving as much of the fallopian tube as possible. In cases with extensive tubal damage, salpingectomy may be necessary.

5. Hemostasis: Meticulous hemostasis is ensured, using bipolar coagulation or hemostatic agents.

6. Specimen Retrieval: The ectopic tissue is placed in an endoscopic retrieval bag and removed through the umbilical port.

Postoperative Care

• Early ambulation and pain management

• Serial monitoring of β-hCG levels to ensure complete removal of trophoblastic tissue

• Follow-up ultrasound to confirm resolution of hematoma or residual lesions

Outcomes and Considerations

Studies have shown that laparoscopic management of chronic ectopic pregnancy results in:

• Lower intraoperative blood loss

• Shorter operative time compared to laparotomy

• Reduced postoperative complications

• Preservation of fertility in selected cases

However, surgery can be technically challenging due to dense adhesions and distorted anatomy. Therefore, surgeons must be skilled in advanced laparoscopic techniques, including intracorporeal suturing and careful hemostasis.

Conclusion

Chronic ectopic pregnancy, though rare, presents unique diagnostic and surgical challenges. Laparoscopy provides a safe and effective minimally invasive approach, allowing for precise excision, reduced morbidity, and preservation of reproductive potential. With careful patient selection, preoperative planning, and surgical expertise, laparoscopic management is now the gold standard for treating chronic ectopic pregnancies.