Robotic-Assisted Laparoscopic Excision of C-Section Scar Ectopic Pregnancy with Bipolar Coagulation of Uterine Vessels

Abstract

Video Objective To describe a technique of robotic-assisted laparoscopic excision of c-section scar ectopic pregnancy (CSP) with bipolar coagulation of uterine vessels. Setting CSP occurs when a gestational sac (GS) is located in the anterior uterine wall with diminished myometrium between the sac and the bladder, and a discontinuity in the anterior wall of the uterus adjacent to the GS, with an empty uterus and cervical canal. It is estimated that 4.2% of ectopic pregnancies are CSP. Laparoscopic bipolar coagulation of uterine vessels is mostly described in myomectomies: it aids in decreasing blood loss, preserves the uterus, and there are pregnancies and term pregnancies post-procedure reported in the literature, with approximately 40% early miscarriage rate. This is a video case report of a 35yo G6P3023 7weeks pregnant with CSP on sonogram, failed multidose regimen methotrexate and developed lower abdominal pain with vaginal bleeding. She was counseled on surgical treatment of CSP. Interventions In this video, we describe the surgical approach opted for this patient. The minimally invasive surgery was recommended considering decreased blood loss, postoperative pain and hospital stay. Considering her history of prior 3 c-sections, the robotic approach would offer better visualization for lysis of adhesions and greater instruments range of motion. In anticipation of bleeding of difficult control, bipolar coagulation of uterine vessels was planned preoperatively. Preoperative imaging was also crucial. It was noted firm adhesions from the bladder to the lower uterine segment, carefully dissected off until identification and removal of GS, confirmed with frozen section. The hysterotomy was repaired with barbed suture. Excellent hemostasis with minimal blood loss (EBL 20ml) noted. Patient did well postoperatively, with beta HCG followed to zero. Conclusion Robotic-assisted laparoscopic excision of CSP should be considered as a valuable treatment option, and preparedness is paramount.