Laparoscopic Management of Heterotopic Istmocornual Pregnancy: A Different Technique

To present a modified technique for laparoscopic cornual resection for the surgical treatment of heterotopic istmocornual pregnancy.

A step-by-step explanation of the surgery using video (Canadian Task Force Classification III-c).

Heterotopic pregnancy is the coexistence of pregnancy in both the intrauterine and extrauterine sides. The incidence is 1 in 30 000 in spontaneous pregnancies; however, the incidence increased to 1 in 100 to 1 in 500 pregnancies with the increasing number of artificial reproductive technologies [1,2]. Although management is controversial, there are 2 main approaches classified as surgical and nonsurgical. The administration of potassium chloride, methotrexate, and/or hyperosmolar glucose is a nonsurgical intervention; however, there are some limitations such as systemic side effects and the possible adverse effect on a live fetus [1-3]. For this reason, surgical intervention involving cornual resection is the main treatment option.

A 32-year-old patient was admitted to our clinic with sudden-onset pain at the left groin. She was at the 11th week of gestation. She had a diagnosis of infertility for 7 years, and she became pregnant after an in vitro fertilization cycle. At sonographic examination, 2 gestational sacs were detected, 1 with a live fetus settled into the uterus and the second (20-mm length) on the left cornual side without a yolk sac and embryo and the left adnexa accompanied with coagulated blood. Immediate laparoscopic surgery was planned. At the laparoscopic exploration, left istmocornual pregnancy that was ruptured and bleeding were observed. We performed a modified technique for laparoscopic cornual resection in which the uterine corn was tightened with the noose twice, and the corn was sutured circularly to avoid excessive bleeding. Initially, the mesosalpinx was coagulated and transected with bipolar energy. Afterward, the uterine corn was tightened with the noose twice, and the fallopian tube was removed. To reduce the bleeding during remnant cornual tissue extraction, a permanent 0 monofilament suture was passed deep into the myometrium and tightened to achieve better hemostasis. Then, the remnant cornual tissue was extracted with harmonic scissors, and the uterine wound was repaired with continuous suture to reduce the risk of uterine rupture during the ongoing pregnancy. Depot progesterone was administered just before the surgery and the day after. She was discharged on the first postoperative day. At the follow-up, she did not experience any problems during pregnancy, and she was delivered with cesarean section at 39 weeks' gestation.

In conclusion, laparoscopic surgery is a safe and feasible option for the treatment of heterotopic pregnancy, and control of bleeding can be achieved better with our modified technique.